Every finding on record at Hebrew Center For Health And Rehabilitation

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #2) reviewed for a medication errors, the facility failed to ensure a medication to treat Parkinson's disease (Sinemet) was transcribed timely, and failed to ensure medication was administered in accordance with physician orders. The Sinemet was not administered for nineteen (19) days, in accordance with physician orders, which resulted in significant medication error and a significant decline in the resident's physical condition. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (brain disorder when brain cells stop producing a chemical(dopamine) that helps movement, casing stiff muscles, shaking and slow movement). A hospital discharge summary and interagency referral form (W-10) dated 6/9/2026 directed to administer Carbidopa-Levodopa (generic name for Sinemet) 25-100 milligrams (mg) per tablet (drug that changes into chemical Dopamine used to treat Parkinson associated symptoms), administer two (2) tablets, four (4) times a day. The Summary identified the last dose administered was on 6/9/2026 at 1:03 PM. A follow up appointment was scheduled on 6/29/2026 with neurology. APRN #1 admission note dated 6/10/2026 at 9:00 AM identified evaluation was completed for orders after admission from the hospital. The note directed to continue all medications as listed on the hospital W-10 (review of the W-10 identified page 7 directed Carbidopa-Levodopa 25-100 mg, take two (2) tablets four (4) times a day at 7 AM, 11 AM, 3 PM and 7 PM). An admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/12/2026 identified Resident #2 had Brief Interview for Mental Status (BIMS) of fourteen (14), indicated Resident #2 was alert and oriented, and required set up for personal hygiene with moderate assistance for transfer and walking 10 feet with a walker. An APRN note dated 6/16/2026 (7 days after admission) identified Resident #2 complained of a stiff neck that had worsened since admission, and was now unable to move his/her neck to the left and right. The APRN noted resting tremors unchanged from previous assessment. Tylenol 650 mgs, three (3) times a day and use of a daily Lidocaine patch (topical local anesthetic used to numb irritated nerves and relieve local pain) was initiated. An APRN note on 6/18/2026 (9 days after admission) identified Resident #2 requested to see the APRN as Resident #2 felt he/she was not receiving sufficient therapy. Physical therapy (PT) also requested APRN to see Resident#2 due Resident #2 declined to participate in therapy until he/she spoke to a doctor. Resident #2 identified his/her current therapy was not improving his/her deconditioning (loss of physical strength and function due to illness). A resident care plan (RCP) dated 6/23/2026 identified Resident # 2 had a deficit in self-care and in functional mobility with weakness. Interventions directed partial assistance of one (1) staff completing less than half of the effort for transfers, and ambulation with rolling walker within room. A social service note dated 6/23/2026 (14 days after admission) identified therapy reported Resident #2 now required assistance of two (2) staff for standing and completion of activities of daily living (ADLs) and was now non-ambulatory due to current functional status. APRN note dated 6/24/2026 (15 days after admission) identified she was asked to evaluate Resident #2 by Physical Therapy urgently due to acute weakness and significant functional decline. PT #2 reported Resident #2 had a significant change as he/she was unable to stand up and was extremely weak. Neurological examination was non-focal although Resident #2 was overall weak. New orders were placed for labs and x-ray to rule out infection. APRN follow-up note dated 6/25/2026 (16 days after admission) identified Resident #2 reported no pain but was limited by weakness and an inability to walk. PT and occupational therapy (OT) to evaluate other interventions, and plan to continue to monitor for further functional decline. Record review identified all prescribed medications were reviewed by the APRN with each visit. Additional record review failed to identify Resident #2 was receiving the Carbidopa-Levodopa 25-100 mg as directed on the hospital W-10 discharge summary; no physician order was located that the order was written and included in the admission orders at the facility. A neurology consult dated 6/29/2026 identified Resident #2 had become significantly weaker, and his/her Parkinson's disease was worsened. Recommendations directed to not discharge Resident #2 from rehabilitation services until he/she is able walk with walker again. A facility reportable event (RE) dated 6/29/2026 (20 days after admission) at 6:00 PM identified a medication error of clinical significance. The RE indicated during an outpatient (neurology) appointment it was identified Resident #2's Sinemet had been omitted during the transition process from the hospital to the facility; Resident #2 had not received the ordered Sinemet since admission on [DATE]. The medication was started immediately, and the neurologist was updated that an order was placed. APRN order dated 6/29/2026 (20 days after admission) directed Carbidopa-Levodopa (Sinemet) 25-100 milligrams (mg) per tablet, give two (2) tablets, four (4) times a day. APRN note dated 6/30/2026 identified Resident #2 was seen by a neurologist with recommendations to restart Sinemet. Resident #2 continued to be weak on exam, had difficulty lifting his/her head and had frequent drooling. Orders directed to continue Sinemet. APRN note dated 7/2/2026 (3 days after the Sinemet was restarted) identified Resident #2 had improved and able to hold up head much better with less drooling. Improvement was consistent with expected response to Sinemet medication. A review of the facility nursing schedule revealed RN #1 was the day supervisor on 6/10/2026. RN #1 was unavailable for interview during the survey. Interview and record review with RN #3 on 7/23/2026 at 1:15 PM identified she was the day shift manager for Resident #2's unit. RN #3 stated she did not complete an additional medication reconciliation of Resident #2's medications to compare orders with the hospital W-10 to ensure all medications were ordered. RN #3 stated she just didn't get to it. Interview and record review with APRN #1 on 7/29/2026 at 2:00 PM identified she could not recall Resident #2, but she did the best she could when she verified the orders. Record review and interview with PT #1 and the Assistant Administrator on 7/29/2026 at 12:00 PM identified Resident #2 was admitted for short-term rehabilitation focusing on a goal to safely climb up/down six (6) steps to enable access into the home after discharge. Staff identified Resident #2 regressed in mobility; upon admission he/she had been able to sit on the side of bed with no back support with partial assistance of one (1) staff and was able to ambulate with walker up to 300 feet independently. A therapy reassessment on 6/21/2026 (7 days after admission) identified a decreased ability to walk independently, and was only able to walk 100 feet with partial to moderate assistance with the walker. On 6/24/2026 (15 days after admission), Resident #2 could not initiate a step after maximum assistance of one (1) staff to stand on the parallel bars, was unable to advance his/her legs, and required therapy to provide physical assist to maintain stability. Interview identified after the Sinemet was re-started on 6/30/2026, Resident #2 experienced an improvement and required supervision/touch assistance for transfers, was able to walk 150 feet with supervision, and was able to negotiate six (6) steps. Interview with MD #1, Resident #2's attending physician, on 7/29/2026 at 11:33 AM identified that not providing the Sinemet from admission to the facility until it was identified by the neurologist on 6/29/2026 (20 days after admission) had a significant impact on Resident #2's medical condition contributing to Resident #2's worsening Parkinson's symptoms, as identified by the neurologist during Resident #2's outpatient appointment. Interview identified Resident #2 should have received the medication as ordered by the discharging hospital on 6/9/2026. Interview and record review with the DON on 7/29/2026 at 2:00 PM identified RN #1 had not transcribed Resident #2's medication as ordered per the hospital W-10 into Resident #2's medical record on admission upon 6/9/2026. The DON stated on admission or readmission the shift supervisor would review the W-10 medications and transcribe them into the resident's electronic medical record (EMR). The RN supervisor would then reconcile the transcribed medications back to the W-10 to ensure accuracy. The expectation was this reconciliation occurred prior to contacting the physician/APRN for verification of the orders. Additionally, the physician/APRN who verified the orders would also have a copy of the medications listed on the W-10 so she/he could double check as the staff reviewed the orders with him/her. The DON identified RN #1 and APRN #1 who verified Resident #2's medications had missed Resident #2's Sinemet medication that was listed on the hospital W-10. RN #1 did not enter the medication into the EMR when Resident #2 was admitted on [DATE]. The DON stated she did not know why RN #1 and APRN #1 missed Resident #2's Sinemet order. The DON stated a second medication reconciliation was also expected to be completed on the next shift by the RN supervisor utilizing the medication reconciliation worksheet, and document the comparison of the EMR medications to the W-10 from the hospital. Further, the DON stated that RN #2 did identify the medication error on 6/10/2026, however the error was not addressed and corrected at that time. The DON stated the error should have been corrected when RN #2 identified it, and she did not know why it was not done. Interview with RN #2 on 7/23/2026 at 12:45 PM identified she had completed Resident #2's second medication reconciliation during the 11:00 PM to 7:30 AM shift on 6/9/2026 and revealed she did not have time to contact the physician/ARPN that night. RN #2 stated at the end of her shift she notified the day shift of the need to obtain a physician order for Resident #2's Sinemet, and she could not recall who she reported the information to, and RN #2 was unable to provide documentation that the information was communicated. The facility Medication Reconciliation Policy dated 4/2023 directed in part, that the medication reconciliation process was completed by nursing staff at admission, readmission and discharge. The purpose was to identify clarifications and discrepancies that need to be resolved with the medical provider to ensure residents' safety and prevent negative outcomes related to medication management. The Policy directed nursing staff to complete the medication reconciliation evaluation in the EMR prior to calling the healthcare provider for initial verification of orders. If discrepancies are identified, contact the provider and obtain orders as needed. The facility admission and Discharge Policy dated 6/2025 directed in part, to complete a medication reconciliation in the EMR by the licensed nurse. Orders are reviewed and discrepancies resolved with the healthcare provider when validating admission or readmission orders. Facility documentation review identified staff education was initiated on 7/2/2026 for facility licensed nursing staff regarding verification of new orders and a mandatory second licensed nurse double check of all new admission and re-admission orders against the hospital transfer/discharge documentation before the Medication Administration Record (MAR) is finalized. Education included a process if a discrepancy was identified. A QAPI was developed and meeting held on 6/30/2026 and audits were initiated. Based on review of facility documentation, past non-compliance was identified on 7/2/2026.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of four residents (Resident #1) reviewed for medication errors, the facility failed to ensure a medication was discontinued timely in accordance with physician orders. The facility failed to ensure a medication was discontinued after readmission from a hospital causing two (2) of the same type of heart medications (calcium channel blockers) to be administered for five (5) days. The findings include: Resident #1s diagnoses included cardiomyopathy (enlarged heart), chronic obstructive pulmonary disease (COPD), diabetes mellitus, and chronic kidney disease. A resident care plan (RCP) dated 4/9/2026 identified Resident # 1 had an altered cardiac status. Interventions directed to administer medications as ordered. A quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/13/2026 identified Resident #1 had Brief Interview for Mental Status (BIMS) of eleven (11), indicating moderately cognitively impaired and required moderate assistance for personal hygiene and transfers. Record review identified Resident #1 was transferred to the hospital on 6/19/2026 for chest pain and was readmitted to the facility on [DATE]. A hospital discharge summary and interagency referral form (W-10) dated 6/20/2026 directed Resident #1 to start Nifedipine extended release (XL) (calcium channel blocker that treats high blood pressure and chest pain) 60 milligrams (mg) daily, and to stop taking Amlodipine 10 mg tablet (calcium channel blocker that treats high blood pressure and chest pain). A nursing note dated 6/20/2026 at 8:42 PM identified Resident #1 was readmitted from the hospital, and all orders were approved by provider. A physician order dated 6/20/2026 directed Nifedipine extended release (ER) 60 mg one time a day for hypertension. A physician order dated 6/21/2026 directed Amlodipine Besylate 10 mg tablet daily (order was entered by RN #1). A facility reportable event (RE) dated 6/29/2026 at 10:30 AM identified a medication error of clinical significance. Resident #1 was inadvertently given an overlap of medications for five (5) days with no ill effects. Resident #1 was transferred to the hospital for a separate event, and the medication error was discovered during a chart review. Record review identified Resident #1 was transferred to the hospital on 6/28/2026 for chest pain. A facility RE summary dated 7/3/2026 identified on 6/29/26, it was noted Resident #1 had received Amlodipine in error. A medical work up included an EKG, laboratory work and a chest x-ray with no adverse effects noted. Interview and record review with RN #5 on 7/23/2026 at 1 PM identified he completed the second reconciliation on the 11:00 PM to 7:30 AM shift on 6/20/2026 and did not recall details of the review. Interview and record review with RN #4 on 7/23/2026 at 12:20 PM identified she was the shift manager on the 7 AM to 3 PM shift on 6/20/2026 when Resident #1 was readmitted . RN #4 stated she did not complete an additional reconciliation of Resident #1's medication to the hospital W-10 when Resident #1 was readmitted because she just didn't get to it. Interview with Pharmacist #1 on 7/23/2026 at 1:20 PM identified that although Nifedipine extended release (ER) 60 mg and Amlodipine besylate 10 mg both had the same mechanism to address hypertension (calcium channel blockers) they were not likely to cause any negative effect on Resident #1. Interview and record review with the DON on 7/29/2026 at 2:00 PM identified RN #1 had not followed the hospital W-10 directions to discontinue the Amlodipine when Resident #1 was readmitted on [DATE]. The DON stated on admission or readmission, the shift supervisor should review the W-10 medications and transcribe them into the resident's electronic medical record (EMR). The RN supervisor would then reconcile the transcribed medications back to the W-10 to ensure accuracy. The DON stated she expected the reconciliation to occur prior to contacting the physician/APRN for verification of the orders. The DON stated an error occurred when RN #1 did not identify the W-10 directed to no administer Amlodipine, and the error was not identified with subsequent checks of the orders for accuracy (a second check on the next shift and an additional check on the next day shift were due to be completed). The DON stated she did not know why the orders were not transcribed correctly, or why the additional order checks were not completed accurately. RN #1 was not available for interview during the survey. The facility Medication Reconciliation Policy dated 4/2023 directed in part, medication reconciliation process was to be completed at admission and readmission to identify discrepancies. Nursing staff complete the medication reconciliation in the EMR prior to calling the healthcare provider for initial verification of orders. If discrepancies are identified, the provider is contacted and orders were obtained as needed. The facility's admission and Discharge policy dated 6/2025 directed in part, a medication reconciliation was to be completed in the EMR by the licensed nurse. Orders are reviewed and discrepancies resolved with the healthcare provider when validating admission or readmission orders. Facility documentation review identified staff education was initiated on 7/2/2026 for facility licensed nursing staff regarding verification of new orders and a mandatory second licensed nurse double check of all new admission and re-admission orders against the hospital transfer/discharge documentation before the Medication Administration Record (MAR) is finalized. Education included a process if a discrepancy was identified. A QAPI was developed and meeting held on 6/30/2026 and audits were initiated. Based on review of facility documentation, past non-compliance was identified on 7/2/2026.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for behaviors, the facility failed to notify the on call provider when the resident's behaviors and altered mental status began to escalate following a fall until approximately six (6) hours later and failed to immediately transfer the resident following an APRN assessment which identified the resident required transfer to the Emergency Department (ED) for an urgent psychiatric and medical evaluation until approximately three (3) hours later. The findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances, Post Traumatic Stress Disorder (PTSD), depression, muscle weakness, and unsteadiness on feet.Review of the facility census identified Resident #1 was sent to the hospital on 3/31/26 and readmitted to the facility on [DATE] to a different room than the room occupied prior to the 3/31/26 transfer.The Nursing readmission Evaluation dated 4/29/26 identified Resident #1 was alert to person and place only, had cognitive and hearing impairments, and had an unsteady gait due to a right toe amputation.The Resident Care Plan (RCP) dated 4/29/26 identified Resident #1 had impaired cognitive functioning, impaired thought processes, and a history of wandering and refusing care and treatments. Interventions included presenting one task at a time, cueing, reorienting and supervising as needed, offering diversional activities, monitoring behavioral episodes, determining underlying causes, and providing psychiatric evaluation and treatment as needed.An Elopement Risk Evaluation dated 4/29/26 identified Resident #1 was not at risk for elopement.A nurse's note by RN #1 dated 4/29/26 at 4:40 PM identified Resident #1 arrived around 1:30 PM, was alert and oriented to self only, was wandering, and was going into the roommate's belongings. Resident #1 was placed on every fifteen (15) minute checks, fall mats were placed on both sides of the bed, and a request was made for the psychiatric APRN to evaluate Resident #1 due to behaviors.A nurse's note by LPN #1 dated 4/29/26 at 5:47 PM identified Resident #1 was alert, confused, and agitated upon arrival, ambulated to the roommate's side of the room, and was going through the roommate's belongings. Resident #1 was placed at the nurse's station for safety.A physician's order dated 4/29/26 directed trazodone 50 mg by mouth every 24 hours as needed for insomnia for five (5) days. A separate order directed every fifteen (15) minute monitoring.Review of the clinical record failed to identify an Elopement Risk Evaluation following documentation of wandering behaviors.Review of the April 2026 Medication Administration Record (MAR) identified trazodone was administered at 7:44 PM by LPN #2.A nurse's note by LPN #2 dated 4/29/26 at 8:53 PM identified Resident #1 was alert and confused at baseline, displayed no pain, was toileted before and after dinner and at bedtime, was medication compliant, and received trazodone with good effect.A nurse's note by RN #2 dated 4/30/26 at 4:41 AM identified that at 3:20 AM Resident #1 had an unwitnessed fall and was found sitting on the floor mat next to the bed and did not know how he/she got there. It identified no injuries, no pain, neurological signs within normal limits, and normal range of motion, and that Resident #1 was transferred with the assist of three (3) staff to a wheelchair and placed at the nurse's station. The note identified the on call APRN was notified and conducted a video visit and instructed staff to assess pain and monitor neurological vital signs per protocol and notify the provider of changes.An on call APRN note dated 4/30/26 identified Resident #1 had an unwitnessed fall, denied head strike, loss of consciousness, or pain, had no injuries, remained at baseline, and was in no acute distress. It directed staff to assess pain per protocol, maintain fall precautions, monitor neurological vital signs, and notify the provider of any change. The note failed to identify that any behaviors were reported to the provider.A nurse's note by LPN #3 dated 4/30/26 at 8:07 AM identified Resident #1 reported falling while attempting to use the bathroom. The NA assigned to Resident #1 (NA #1) reported Resident #1 was combative during care. LPN #3 identified Resident #1 was confused and restless but was resting in bed at the time of documentation.Review of the clinical record failed to identify that the on call provider was notified on the 11:00 PM to 7:00 AM shift of increased confusion, restlessness, or combativeness following the fall.A Situation Background Assessment and Recommendation (SBAR) note by RN #1 dated 4/30/26 at 7:49 AM identified Resident #1 had a change in condition with physical aggression, confusion, and restlessness. The note failed to identify if or when the provider was notified.A provider note by APRN #1 dated 4/30/26 identified she saw Resident #1 at 9:45 AM following reports of increased confusion, agitation, combativeness, and noncompliance with care and safety measures. It identified Resident #1 remained restless, confused, and difficult to redirect and due to acute behavioral changes, continued confusion, recent fall, and need for urgent psychiatric and medical evaluation, Resident #1 would be transferred to the ED.The Prehospital Care Report dated 4/30/26 identified Emergency Services was not alerted until 12:54 PM, more than three (3) hours after APRN #1 directed an urgent ED transfer. Emergency Services arrived at 1:06 PM. Resident #1 was found sitting in the wheelchair, alert but confused at baseline, calm and cooperative, and was transported to the ED.Interview with LPN #3 on 5/21/26 at 12:32 PM identified Resident #1 was awake throughout the night, restless, increasingly confused, and resistive to care following the fall but she could not recall notifying the nursing supervisor or the provider, stating she should have.Interview with NA #1 on 5/21/26 at 12:19 PM identified Resident #1 had no behaviors prior to the fall but was resistive to care and repeatedly trying to get out of bed afterwards.Interview with RN #2 on 5/21/26 at 2:55 PM identified staff did not report any behaviors or insomnia to her prior to the fall and did not report that behaviors escalated following the fall. She identified that had she been notified, she would have assessed the resident, reviewed as needed medications, and notified the on call provider.Interview with RN #1 on 5/21/26 at 1:14 PM identified Resident #1 was calm the evening of 4/29/26 after receiving trazodone. When RN #1 returned at 7:00 AM on 4/30/26, Resident #1 had extreme altered mental status and could not be redirected. RN #1 identified he should have notified the provider immediately but waited until APRN #1 arrived.Interview with APRN #1 on 5/21/26 at 1:33 PM identified upon evaluating Resident #1 on 4/30/26, Resident #1 was loud, restless, difficult to redirect, and significantly different from baseline. Due to acute changes after a fall, history of blood clots, and anticoagulant therapy, she ordered immediate ED transfer and identified that nursing should have notified the supervisor and provider immediately at the onset of restlessness, confusion, and escalating behaviors.Interview with the DON on 5/21/26 at 2:20 PM identified the hospital reported Resident #1 was stable without behaviors prior to readmission. Staff reported Resident #1 was restless, agitated, and combative upon return on 4/29/26. The DON identified the on call provider should have been notified overnight on 4/30/26 when behaviors escalated and that Resident #1 should have been transferred to the ED immediately following APRN #1's assessment.Review of the Change of Condition Notification policy dated 4/2023 directed that the provider must be notified when there is a significant change in the resident's physical, mental, or psychosocial status or when treatment must be altered. The policy required a complete assessment, documentation of symptoms, and documentation of provider notification.Review of the Behavior Management Program policy dated 10/2022 directed that the facility provide services to support the resident's highest practicable physical, mental, and psychosocial well being, review behavioral history prior to admission, identify antecedents, and implement appropriate interventions such as redirection, diversion, and re approach techniques.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for behaviors, the facility failed to permit the resident to return to the facility following a hospital Emergency Department (ED) visit, despite the resident's bed not yet being filled, and without documentation that readmission would endanger the health or safety of Resident #1 or other residents. The findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances, Post Traumatic Stress Disorder (PTSD), depression, muscle weakness, and unsteadiness on feet.Review of the facility census identified Resident #1 was transferred to the hospital on 3/31/26 and was readmitted on [DATE]. The Nursing readmission Evaluation dated 4/29/26 identified Resident #1 was alert to person and place only, had cognitive and hearing impairments, and had an unsteady gait related to a right toe amputation.The Resident Care Plan (RCP) dated 4/29/26 identified impaired cognition, dementia related behaviors, wandering, and refusal of care. Interventions included reorientation, cueing, offering diversional activities, supervising as needed, monitoring behavioral episodes, determining underlying causes, and psychiatric evaluation and treatment as indicated.An Elopement Risk Evaluation dated 4/29/26 identified Resident #1 was not at risk for elopement.Nursing documentation from 4/29/26 identified Resident #1 was confused, restless, wandering to the roommate's side of the room, and going through belongings. Staff redirected Resident #1 to the nurse's station for safety and administered as needed trazodone, which was documented as effective in calming the resident.Nursing documentation from later that evening identified Resident #1 remained confused but redirectable and displayed behaviors consistent with dementia. Staff interviews completed on 5/21/26 identified Resident #1 was confused and restless upon readmission but was easily redirectable, responded well to trazodone, did not wander into other residents' rooms, and did not display violent or dangerous behaviors.On 4/30/26, Resident #1 was transferred to the ED due to increased confusion and behavioral changes. Review of the Prehospital Care Report dated 4/30/26 identified Emergency Services found the resident alert but confused at baseline, calm, cooperative, and voicing no complaints.A nurse's note dated 4/30/26 at 1:33 PM identified the facility notified the APRN of altered mental status and obtained an order for hospital transfer. No documentation identified the resident posed a danger to self or others during this period.A Social Services note dated 5/1/26 identified the Administrator, DON, Admissions Director, and SW notified the responsible party that the facility would not readmit Resident #1 due to behavioral concerns and issued a discharge notice. The Notice of Transfer/discharge date d 5/1/26 stated Resident #1's health or safety, or the health and safety of others, would be endangered by readmission; however, the medical record did not contain documentation supporting that conclusion. Resident #1's bed remained unfilled until 5/2/26.Interviews conducted on 5/21/26 with LPN #1, LPN #2, NA #2, LPN #3, RN #2, and RN #1 identified they did not observe Resident #1 to be violent, aggressive toward staff or other residents, or wandering into other resident rooms. Staff consistently identified Resident #1's behaviors as consistent with dementia and redirectable.Interview with APRN #1 on 5/21/26 identified she was unaware of any dangerous behaviors or incidents involving Resident #1 that would have placed others at risk, and further identified she had not documented any assessment indicating Resident #1 posed a danger to others.Interview with the Admissions Director on 5/21/26 identified the facility decided not to readmit Resident #1 following the 4/30/26 ED visit. The Admissions Director reported Resident #1's bed was filled on 5/2/26 and that room rearrangement or alternative placement options within the facility were not explored prior to refusal of readmission.Interview with the DON on 5/21/26 identified there was no documentation supporting that Resident #1 was violent, wandering into other resident rooms, or posed a safety risk to others. The DON reported staff did not provide statements or documentation supporting danger to self or others and acknowledged that the facility did not explore alternative accommodations before denying readmission.Review of the Involuntary Discharge/Discharge/Transfer policy dated 6/2023 directed the facility to discharge or transfer residents only for permissible reasons, including when the health or safety of individuals in the facility is endangered, and required the basis for transfer or discharge to be documented in the resident's medical record. The policy required a physician statement indicating the discharge or transfer is not medically contraindicated. Review of the record failed to identify such documentation.Review of the Behavior Management Program policy dated 10/2022 directed the facility to identify behavioral antecedents and implement individualized interventions, including redirection, re approach, and diversion techniques, prior to discharge or transfer decisions. Review of the record failed to identify the use or consideration of such interventions prior to the refusal to readmit.Review of the Change of Condition Notification policy dated 4/2023 required staff to notify the provider of significant mental or psychosocial changes and required documentation of assessments, symptoms, and provider notification. Review of the record failed to identify documentation supporting that behavioral symptoms endangered others or that provider assessment supported involuntary discharge.Although requested, the facility did not provide a Consultative Discharge Process policy which outlines interdisciplinary review prior to refusal of readmission.

Based on review of the clinical record, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure medications were administered per physician's order and failed to notify the provider of missed doses. The findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances, hypertension, congestive heart failure, longstanding persistent atrial fibrillation, and deep vein thrombosis (DVT) of the left upper extremity.The Resident Care Plan (RCP) dated 4/29/26 identified Resident #1 had altered cardiac status, a DVT to the left upper arm, and was at risk for adverse effects related to anticoagulation therapy. Interventions included administering medications as ordered.A physician's order dated 4/29/26 directed apixaban 5 mg twice daily by mouth for DVT prophylaxis. Another physician's order dated 4/29/26 directed clopidogrel bisulfate 75 mg by mouth daily for blood clot prevention. A separate order directed hydralazine 50 mg by mouth every eight (8) hours for hypertension.Medication Administration Notes by LPN #3 dated 4/30/26 at 5:18 AM and 5:20 AM identified clopidogrel, apixaban, and hydralazine were not administered because the medications were not available.Review of the April 2026 Medication Administration Record (MAR) identified the three medications were scheduled for administration on 4/30/26 at 6:00 AM and were documented as Other/See Nurse Notes. Review of the MAR further identified apixaban and hydralazine had been administered as scheduled the evening prior.Interview with LPN #3 on 5/21/26 at 12:32 PM identified the ordered medications had not arrived from the pharmacy during the morning medication pass. LPN #3 reported she did not check the Pyxis automated dispensing system for emergency supply, could not explain why she failed to do so, and identified she did not notify the nursing supervisor or provider of the missed medication doses.Interview with APRN #1 on 5/21/26 at 1:33 PM identified licensed nurses are required to administer medications according to physician orders, check the emergency stock when medications are unavailable, and notify the provider when a dose is missed to obtain further instruction.Interview with the DON on 5/21/26 at 2:20 PM identified clopidogrel, apixaban, and hydralazine were stocked in the Pyxis on 4/30/26 and should have been removed and administered per order. The DON reported nursing staff are required to notify the nursing supervisor and provider when medications are unavailable or doses are missed.Review of the Medication Pass policy dated 10/2018 directed medications must be administered safely and timely per the physician's orders within one hour before or after the scheduled time and per the ten rights of medication administration, including right drug, right dose, right route, right time, and right documentation.

Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from neglect and a dependent resident was provided with care timely. The findings include: Resident #2's diagnoses included Alzheimer's, dementia and diabetes with chronic kidney disease. The Resident Care Plan (RCP) dated 1/8/2026 identified a self-care deficit, and bladder and bowel incontinence. Interventions directed extensive assistance with personal hygiene and toilet use, and provide incontinent care as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #2 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen, indicative of severe cognitive impairment, was frequently incontinent of bowel and bladder and required total care with ADLs. APRN (psychiatry) note dated 2/3/2026 indicated Resident #2 was nonverbal during evaluations, and due to severe cognitive impairment, information for the evaluation was obtained through a combination of direct clinical observation, chart review and a report from caregivers familiar with the resident's baseline behavior and functioning. Nurse Aide (NA) care card dated 2/8/2026 directed bladder/bowel incontinent check as required for incontinence, wash, rinse and dry perineum, change clothing as needed after incontinence episodes, dependent with bathing/showering and dressing, and extensive assistance of two (2) for bed mobility. Review of facility reportable event dated 2/9/2026 identified an allegation that Resident #2 was left out of bed and unchanged for extended period of time. The APRN was notified, and a full body audit was performed with no apparent injury or ill effects noted. The facility summary dated 2/16/2026 identified Resident #2 was repositioned while up out of bed in his/her tilt in space wheelchair and received all due care. Medications were administered by the nurse who stated Resident #2 appeared comfortable and free of odors and reported Resident #2 and his/her visitors did not express any concerns on 2/9/2026. The summary identified the facility did not substantiate the allegation of abuse. Interview and observation on 3/26/2026 at 11:18 AM with NA #1 identified she worked from 7 AM to 3 PM on 2/9/2026 and Resident #2 was on her assignment. NA #1 stated Resident #2 was one of the first residents she provided peri/incontinent care for and transferred Resident #2 out of bed about 7 or 7:30 AM. NA #1 stated her usual routine was to transfer Resident #2 out of bed for breakfast and then return Resident #2 to bed after the breakfast meal. NA #1 stated on 2/9/2026 she did not put Resident #2 back to bed after the breakfast meal, and about 10 AM she repositioned Resident #2's tilt-in-space wheelchair (TIS w/c). NA #1 stated she did not provide any incontinent care at that time and checked only for any odors; she did not touch the incontinent brief and stated she relies only on smell for Resident #2. NA #1 stated a family member visited around 11:00-11:30 AM and wanted resident to eat in the TV room; and at 1:00 PM she informed the visitor the resident needed to return to bed for care, but the visitor declined care to be provided at that time. NA #1 stated she did not return to re-offer care and she did not notify the nurse; NA #1 stated she should have re-attempted to provide care and she should have checked the brief every two (2) hours. Although NA #1 stated she notified the nurse at the end of her shift that Resident #2's family had refused care, she did not notify the nurse that the only care she provided for Resident #2 was before the breakfast meal was served approximately seven (7) hours prior. Interview and record review on 3/26/2026 at 1:28 PM with RN #1 identified she worked 7 AM to 3 PM on 2/9/2026, and she was not notified by NA #1 that Resident #2 had not received incontinent care since around 7 to 7:30 AM. RN #1 stated residents should be checked every two (2) hours to determine if they are wet or have had a bowel movement, and if so, the NA should put them back to bed and provide care. RN #1 stated staff should not check a resident for incontinence by using smell alone to determine if incontinence has occurred or if a brief needs to be changed. Interview and record review with NA #2 on 3/26/2026 at 12:56 PM identified she worked 3 to 11 PM on 2/9/2026, and stated incontinent care should be provided every two (2) hours, and Resident #2 was her patient. NA #2 stated that Resident #2 was out of bed in his/her TIS w/c. NA #2 returned Resident #2 to bed after the evening dinner meal and provided incontinent care at that time (approximately 12 hours after the morning care was provided before breakfast). NA #2 stated she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room, and stated she notified LPN #1 after dinner that she had been unable to provide the care. NA #2 further stated she was not informed by NA #1, the off-going day shift NA, or the nurse that Resident #2 had not received peri/incontinence care since approximately 7 or 7:30 AM. Interview and record review with LPN #1 on 3/26/2026 at 12:14 PM identified she worked from 3 to 11 PM on 2/9/2026 and Resident #2 was her patient. LPN #1 stated she was not notified that care was not provided for Resident #2 since before breakfast or that care was offered and declined by a family member. LPN #1 stated resident should be checked and changed every two (2) hours, and to check the brief by assessing the brief indicator (line on the brief that changes color when wet) and feeling the brief for wetness. Further, use of smell is an additional indicator that a resident may be soiled (example an odor from a bowel movement), but stated relying on smell alone was inappropriate. Interview and record review with Corporate RN #2, the Administrator, and the DNS on 3/26/2026 at 2:30 PM identified that Resident #2 had dementia and severe cognitive impairment, was nonverbal, transferred with a mechanical lift, and was dependent on staff for personal hygiene and incontinent care. interview identified Resident #2 received personal care and incontinent care about 7 or 7:15 AM, and NA #1 next attempted to provide care around 1 PM (approximately 6 hours after the care was last provided) but the visitor refused care. RN #2 stated care was not re-offered before the end of the shift at 3 PM, approximately seven (7) hours and 45 minutes after care was last provided. The evening NA did not provide inconvenient care until approximately 7 PM (approximately 12 hours after care was last provided). The DNS stated residents should be checked every two (2) to three (3) hours for incontinent, and that checking for incontinence by smell alone was not sufficient; checking for incontinence required checking the actual incontinent brief for soiling, wetness or checking the indicator line on the brief. The DNS stated NA #1 should have notified the nurse when care was not provided timely. Review of facility ADL: Eating dated 2/9/2026 indicated Resident #2's total intake of 960 milliliters of fluid. Additional interview with NA #2 on 3/26/2026 at 3:08 PM identified when she provided incontinent care for Resident #2 on 2/9/2026 about 7 PM, Resident #2's brief was heavily wet, and Resident #2 was also incontinent of a bowel movement. Review of the facility Abuse Policy & Procedure directed in part, that each resident had the right to be free from abuse and neglect. Neglect means the failure of employees to provide goods and services to a resident that are necessary. Review of Certified Nursing Assistant Job Description directed in part, to makes rounds on assigned residents at the beginning of each shift and every two (2) hours thereafter.

Based on observations, interviews, and facility policy review for ADL care, the facility failed to ensure that staff providing resident care maintained fingernails free of decorative items, including fake nails with decorations attached. The findings include: Interview and observation with NA #1 on 3/26/2026 at 11:18 AM identified NA #1 worked on a resident unit and provided residents with personal care (ADL care, incontinent care and meal service). NA #1 was observed to have gel-like fingernails between approximately 1/4 and 1/2 inch long with the tips neat and had straight edges across the tip of the nails. The gel-like fingernails were observed to have multiple round silver/white glitter rhinestone-like raised items, approximately 1/16th of an inch, attached to several fingernails on each hand that were firm to the touch and felt like bumps raised from the nail structure. Further, several fingernails had an attached silver-colored metal-like design that covered parts of the sides and tips of several fingernails. The silver metal-like design was raised from the nail surface and was a decorative design. NA #1 stated the glitter-like rhinestone-like items and the silver metal-like designs were glued onto the nails. Interview with DNS on 3/26/2026 at 11:58 AM identified that while staff may have gel fake nails, the nails should be at a comfortable length, and stated no attached jewels or sharp areas were allowed due to concern for infection. Interview with the DNS, Administrator and Regional RN #2 on 3/27/2026 at 3 PM identified the facility allowed staff to wear gel fingernails, Regional RN #2 stated the items attached to NA #1's fingernails were observed by her to be securely in place, and she thought the gel covered the top of the gems. Observation on 3/27/2026 at 10:40 AM of NA #1 identified the gel-like nails remaining in place with the silver/white glitter rhinestone-like raised items and the silver-colored metal-like design visible on multiple fingernails. Review of facility Personal Appearance and Dress Policy directed in part, fingernails are to be clean and well-manicured. For employees involved in direct resident/patient care or where infection control may be an issue, fingernails should not be so long that they compromise the resident's safety. Review of The World Health Organization (WHO) guidelines directed in part, to generally prohibit artificial nails and extenders for all healthcare workers in direct patient care, including nursing home settings, to prevent infection transmission. The guidelines further identified gel nails, being a form of artificial enhancement, are included in these prohibitions as they can harbor bacteria and are difficult to sanitize, even after alcohol gel use. Review of Centers for Disease Control (CDC) Hand Hygiene for Healthcare Workers directed in part, do not wear artificial fingernails or extensions when having direct contact with high-risk patients, germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and hand washing.

Based on review of the clinical record, facility documentation/policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for abuse, the facility failed to implement the comprehensive care plan which directed two-person staff assistance during care. The findings include:Resident #1 was admitted to the facility with diagnoses that included multiple sclerosis (MS), borderline personality disorder and generalized anxiety.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Interview for Mental Status score of 15), was always incontinent of bladder, frequently incontinent of bowel, required substantial/maximal assistance (staff does more than half the effort) with personal hygiene and bathing and was dependent on staff (staff does all of the effort) with toileting hygiene.The Resident Care Plan (RCP) dated 11/21/25 identified Resident #1 needed assistance with activities of daily living (ADL) due to a diagnosis of MS and progression of disease process. Interventions included two staff for dressing to assist Resident #1 to choose simple comfortable clothing that enhanced Resident #1's ability to dress self, substantial/maximal assist of two staff for bathing/showering, dressing, personal hygiene/oral care and toileting. The care plan further identified Resident #1 had bipolar disorder and antisocial behavior problems related to accusatory statements towards staff. Interventions included two staff to be present for extensive assistance with care and to monitor for target behaviors.A progress note by APRN #1 (psychiatric APRN) on 12/30/25 identified Resident #1 had diagnoses that included generalized anxiety disorder, borderline personality disorder, bipolar disorder and insomnia. The note identified Resident #1 had no acute psychiatric symptoms noted and to continue current medications and monitoring.A physician's order dated January 2026 directed to monitor for target behavior; accusatory to staff, delusions, verbal/physical aggression and manic behavior.Review of the Resident Care Card (RCC) (undated) identified Resident #1 required two staff for bathing, bed mobility, toileting, personal hygiene, dressing and transferring. The RCC further identified Resident #1 required two staff assistance for all care.Review of the bladder elimination flowsheet dated 1/24/26 identified at 5:30 AM Resident #1 was incontinent and provided care by NA #1.The Reportable Event form by the DNS dated 1/23/26 identified Resident #1 alleged the 11:00 PM to 7:00 AM nurse aid (NA #1) was rough during care. There were no injuries noted, the physician and police were notified.A statement completed by RN #1 dated 1/23/26 identified during wound rounds, Resident #1 reported he/she was being abused by NA #1. Resident #1 identified when NA #1 turned him/her, NA #1 was a little rough. Resident #1 stated he/she did not feel like he/she was abused and did not want a different NA.A statement completed by the ADNS dated 1/23/26 identified she saw Resident #1 on 1/23/26 at 10:00 AM. Resident #1 stated NA #1 rushed when providing incontinence care/turning/repositioning.Interview with the ADNS on 2/19/26 at 12:45 PM identified Resident #1 was an assist of two staff members for all care due to a history of psychosocial behaviors.Interview with NA #1 on 2/19/26 at 1:40 PM identified she was Resident #1's regular NA on the 11:00 PM to 7:00 AM shift. She identified on 1/23/26 during the 11:00 PM to 7:00 AM shift Resident #1 slept through the night. She identified she provided Resident #1 with water through the night. Around 5:15 AM NA #1 provided incontinent care for Resident #1 which included turning Resident #1 to his/her side, providing personal care and changing Resident #1's brief. NA #1 identified it was just herself providing care and no other staff members were present in the room. She identified she was aware Resident #1 was an assist of two staff members for care but provided care herself because Resident #1's care could be performed by one staff member. She further identified she checked the RCCs at times, and at times, she did not. Interview with NA #2 on 2/19/26 at 2:40 PM identified she was Resident #1's regular NA on the 7:00 AM to 3:00 PM shift. She identified Resident #1 required two staff members for transfers with a Hoyer lift. NA #2 further identified she provided incontinent care and repositioning for Resident #1 independently because she was able to do so.Interview with NA #3 on 2/19/23 at 2:50 PM identified she is Resident #1 regular NA on the 3:00 PM to 11:00 PM shift. She identified Resident #1 required two staff members for transfers with a Hoyer lift. She further identified Resident #1 was an assist of one for incontinent care, personal hygiene and repositioning. She further identified she had never seen two staff members provide ADL care for Resident #1.Interview with the DNS on 2/19/26 at 3:25 PM identified if a resident's care plan identified two staff members for ADLs, the resident should have two staff present for care. Resident #1 should have had two staff members present for care.Review of the ADL policy directed staff to provide assistance to complete ADL activities per the person centered evaluation and care plan.Review of the Baseline/Comprehensive Person Centered Care Plan policy identified the person-centered care plan is developed to include information necessary to properly care the resident. The comprehensive person-centered care plan will be implemented by qualified members of the facility staff. All clinical department heads are responsible to ensure that there is a system fo0r monitoring implementation of the resident care plans.

Based on clinical record reviews, facility documentation, facility policy, observations, and interviews for 2 of 2 residents (Resident #43 and #168) reviewed for environment and during observation of dining on 3 North and 3 South wings, the facility failed to provide a homelike environment. The findings included: 1.Resident #43 was admitted to the facility in June 2025 with diagnoses that included chronic kidney disease, anxiety, and depression. The admission MDS dated [DATE] identified Resident #43 had intact cognition. 2. Resident #168 was admitted to the facility in March 2022 with diagnoses that included chronic pain and chronic obstructive pulmonary disease. The quarterly MDS dated [DATE] identified Resident #168 had intact cognition. Review of the maintenance repair logbook dated 9/11/25 through 10/24/25 identified Resident #43 and Resident #168's room window shade needed to be repaired. On 10/24/25 Maintenance Technician #1 placed his initials and checked off that the shade was repaired. Review of the maintenance repair logbook dated 10/25/25 through 12/1/25 identified Resident #43 and Resident #168's room window shade needed to be repaired. Interview with Resident #43 on 1/5/26 at 12:55 PM identified the exterior window shade in the room had been missing for several months. Resident #43 indicated multiple times he/she complained to LPN #2 (charge nurse) and maintenance about the missing shade on the exterior window in his/her room. Resident #43 indicated he/she asked LPN #2 and maintenance to get a replacement shade for the window multiple times. Resident #43 indicated LPN #2 reported he entered it in the computer for maintenance, but the shade was never repaired. Resident #43 indicated that Maintenance Technician #1 had visited the room multiple times and said the shade needed to be ordered. Resident #43 indicated the shade was ordered approximately 3 months ago. Resident #43 identified without the shade the window was drafty, made the room cold, and allowed bright sunlight to interfere with television viewing. Interview with Resident #168 on 1/5/26 at 1:12 PM identified maintenance removed the broken shade approximately 3 months ago and said it would be replaced. Resident #168 indicated he/she notified LPN #2 multiple times and was told the shade had been ordered. Resident #168 identified the replacement had not occurred and the window remained drafty which is right next to his/her bed. Observation on 1/5/26 at 1:15 PM identified that the exterior window in Resident #43 and Resident #168's room lacked curtains or shade. Interview with Director of Maintenance on 1/5/26 at 2:00 PM identified two maintenance technicians review the maintenance logs on each unit multiple times a day. The Director of Maintenance stated maintenance checks off and initials the log once repairs are completed. Observation on 1/6/26 at 10:00 AM confirmed that the exterior window continued to lack curtains or shade. Interview with Maintenance Technician #1 on 1/8/26 at 1:45 PM identified he or another maintenance technician review the maintenance repair books daily on each unit. Maintenance Technician #1 identified he was aware the shade in Resident #43 and Resident #168 room required replacement. Maintenance Technician #1 identified he informed Resident #43 and Resident #168 the shade needed to be ordered and provided by the contractor. Maintenance Technician #1 stated on 10/24/25 he initialed the maintenance log and signed off on the log that Resident #43 and Resident #168's shade was replaced because it was reported to the contractor. Maintenance Technician #1 stated he did not go up to the resident's room to verify installation. Maintenance Technician #1 further stated he received three to four additional reports that the shade had not been replaced, and each time he had informed the contractors, but did not return to the room to verify completion. Interview with the Director of Maintenance on 1/8/26 at 1:50 PM identified on or around 10/24/25 a painter brought the broken shade from Resident #43 and Resident #168's shade to him. The Director of Maintenance indicated the next day he delivered the shade to the contractor for replacement because it was under warrantee. The Director of Maintenance identified the contractor reported he was all set, so he assumed it was done without verifying installation. The Director of Maintenance identified subsequent to surveyor inquiry he realized the shade in room had not been replaced on 10/24/25. The Director of Maintenance indicated he located a new shade labeled with the room number in the contractor's area, and the shade was installed on 1/7/26. The Director of Maintenance stated maintenance staff should not assume work is completed based on the contractor. The Director of Maintenance identified maintenance technicians are responsible for verifying completion prior to initialing maintenance logs and Maintenance Technician #1 should not have initialed the log on 10/24/25. Interview with RN #8 (corporate nurse) on 1/12/26 at 12:00 PM stated the facility did not have a policy addressing homelike environment or procedures for maintaining maintenance repair logs. Review of the facility Resident Rights policy identified the residents have the right to be treated with consideration, respect, full recognition of their dignity, receive quality care and services with reasonable accommodations of their personal needs and preferences, and to treat their living quarters as their homes. 3. a. An observation in the dining room on 3 North on 1/5/2026 at 12:05 PM identified 19 residents seated among 6 of 7 dining tables without the benefit of tablecloths or other linens. Each resident had been served beverages and then staff placed a meal tray in front of each resident removing the plate cover from the main meal and placing them in the middle of the dining table in a pile. An observation and interview in 1/8/2026 at 8:30 AM of the 3 North dining room identified no tablecloths on the tables and residents eating breakfast served on the dietary trays during meal arrival on the unit from the kitchen. An interview with Licensed Practical Nurse (LPN #1), in response to being asked if the residents were always served meals on trays s/he indicated sometimes residents ask to have the tray. An interview with Nurse Aide (NA#1) on 1/8/2026 at 8:40 AM indicated no residents had asked to have the tray placed on the table and she/he further indicated meals came from the kitchen with everything the resident needed. We would then place the tray in front of the resident. b. An observation was made of the 3 South dining room on 1/8/2026 at 8:55AM identified the residents eating in the dining room were served on meal trays. An observation and interview with LPN#2 indicated the residents are routinely served on meal trays as they come up from the kitchen on carts. LPN # 2 further indicated years ago the residents were served in the dining room using a steam table which stopped potentially due to the kitchen staff no longer assisting with dining. LPN #2 indicated that the residents are hungry and want to eat and providing meal trays is easier. An observation and interview in the 3 South dining room with NA#2 and NA#3 on 1/8/2026 at 8:58 AM, NA#2 indicated the meals arrive from the kitchen on a cart with everything needed and NA#3 indicated it was better using the trays as no time is wasted removing the food from the trays to the tables. An interview with the Director of Nursing Services (DNS) on 1/8/2026 at 1:52 PM indicated s/he would follow up on the dining room not having tablecloths and meals being served on trays and the meal covers being piled in the middle of each table. The DNS indicated the reason for having no tablecloths and meals served on dietary trays could be due to the change to the recent new dining room furniture. Although requested, a facility dining policy was not provided.

Based on review of facility policy, observations, and interviews the facility failed to ensure that food items were maintained at a palatable and appetizing temperature at time of serving. The findings include:On 1/5/2026 at 12:38 PM, observation in the 4 North Dining Room identified Resident #2, Resident #54, Resident #59, Resident #109, Resident #130, Resident #178, and Resident # 201 complained that their food was cold. Resident #54 requested their meal to be reheated.On 1/6/2026 at 12:35 PM, a test /temperature tray test was conducted with Director of Dietary #1, and the following was identified: At 12:35 PM the test tray was prepared and plated in the kitchen located on the basement floor. The test meal was plated on dish, placed in a plastic base, covered with a plastic dome, and put onto a meal tray. The meal tray was then placed in an open meal delivery truck with other resident trays. The meal delivery truck left the kitchen at 12:40 PM for its destination to the fourth-floor unit.At 12:41 PM (1 minute after leaving the dietary department), the open meal delivery cart arrived on the fourth- floor south unit. The open meal delivery cart was left in front of the nurse's station.At 12:46 PM (6 minutes after leaving the dietary department) LPN #6 was observed at the nurse's station and in the hallway the nurse aides were observed passing beverages from the beverage cart.At 12:49 PM (9 minutes after leaving the dietary department) Director of Dietary #1 informed LPN #6 the meal trays needed to be passed out.At 12:51 PM (11 minutes after leaving the dietary department) the Director of Dietary #1 and Director of Admissions began delivering meals trays to the residents.Interview with LPN #6 on 1/6/2026 at 12:51 PM identified meals trays are usually delivered to the residents' room by assigned nurse aide. LPN#6 indicated first the nurse aides pass beverages and then come back to pass the meal trays. LPN#6 indicated that for that unit, there are 4 nurse aides, one is assigned to each hallway, and the remaining two are assigned in the dining room.At 12:55 PM (15 minutes after leaving the dietary department) the last resident tray was delivered, and temperatures of the test tray were taken by the surveyor with a calibrated thermometer in the presence of the Director of Dietary #1 identifying the following:BBQ Beef internal temperatures were 138.1 degrees Fahrenheit (F) with the surveyor's thermometer and 136 degrees F with the Director of Dietary's thermometerOrzo internal temperatures were 124.6 degrees F with the surveyor's thermometer and 120 degrees F with the Director of Dietary's thermometer.Collard Greens internal temperatures were 129.3 degrees F with the surveyor's thermometer and 128 degrees F with the Director of Dietary's thermometer.Interview with Director of Dietary #1 on 1/6/2026 at 12:51 PM identified the temperatures of the should be approximately 140 degrees F. Director of Dietary #1 stated although the plates were warm, they had no other equipment to keep food warm while being delivered. The Director of Dietary #1 indicated administration had spoken about covered meal carts, but there were concerns with the number of carts needed and their storage when not being used. Interview with Director of Dietary #2 on 1/6/2026 at 2:30 PM identified the facility was aware of concerns with food temperatures and the facility was working on a quality project to address the concerns.A review of the facility policy for Food Temperature Measurement identified proper, safe, and appetizing temperatures were defined as temperatures that were both appetizing to residents and that minimized the risk for burns.

Based on observation, review of facility policy and interviews, failed to ensure dishware and cookware were cleaned in a sanitary manner when using the three-bay sink. The findings include:An observation with the Dietary Director #2 on 1/6/2026 at 12:25 PM, identified Dietary Aide #1 at the 3-bay sink washing a rubber spatula and a metal serving spoon over the wash sink and then placing the items in the sanitizing sink filled with sanitizing solution. Dietary Aide #1 was observed not rinsing the items before being washed. The rinse sink faucet was off, and the rinse sink had no water. Additionally, the rinse sink contained a large metal bowl with a large amount of brown colored food residue. The sanitizing sink contained a metal pot, multiple metal serving spoons and spatulas, and cooking utensils, including tongs and a whisk. Spots of soap residual were noted floating in the pink sanitizing solution.Interview with Dietary Aide #1 on 1/6/2026 at 12:25 PM identified she used the rinsing sink sometimes. Dietary Aide #1 stated it depended on how dirty the dishes were and the type of dishes. Interview with Dietary Director #2 on 1/6/2026 at 12:27 PM identified the dishes should be rinsed before being placed in the sanitizing solution. Dietary Director #2 then directed Dietary Aide #1 to rewash the dishes and replace the sanitizing solution.A review of the facility policy for Ware washing-Pot and Pan sink indicated that items should be washed in the first sink compartment, then rinsed in the middle compartment by immersing the items in the water. The policy further indicated that dishes should be thoroughly rinsed because detergent residue raises the pH of the sanitizer in the third compartment, reducing the sanitizing capacity.

Based on review of the facility infection control program, facility documentation, facility policy, and interview, the facility failed to ensure all staff were educated regarding the Covid-19 vaccine, offered the vaccine or provided with education on benefits and risks of the vaccine. The findings include:An interview and review of facility documents on 01/8/2026 at 10:25 AM with RN #1 the Infection Preventionist identified education was provided to all staff members regarding influenza vaccine. RN #1 indicated education for Covid 19 was only done by word of mouth and only staff member received the covid vaccine so far this year; however, the facility was unable to provide evidence that all staff members were educated on the risk and benefits of Covid 19 vaccine yearly. The facility policy Infection Prevention and control program provided onsite indicated education would be provided to all staff of the facility regarding Covid 19 vaccination.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #57) reviewed for Advanced Directives, the facility failed to implement advanced directives according to the resident's expressed wishes and obtain written consent from the resident's health care representative, signed in the presence of two witnesses, for a do not resuscitate (DNR) order, as required by facility policy. The findings include:Resident #57 had diagnoses that included dementia, depression, and high blood pressure.A consent form dated [DATE] identified Resident #57 elected cardiopulmonary resuscitation (CPR) and all life saving measures.The physician's order dated [DATE] directed do not resuscitate (DNR), do not intubate (DNI), no tube feeding, and Registered Nurse (RN) pronouncement of death (despite Resident #57's wishes on [DATE] to be a full code).The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 had moderately impaired cognition, required supervision or set up assistance for personal hygiene, toileting and was independent when ambulating.The Resident Care Conference (RCC) note dated [DATE] identified Resident #57's advanced directives were reviewed, and Resident #57 remained a full code. The note further indicated Social Services reviewed Resident #57's advanced directives with his/her health care representative and who confirmed the resident full-code status.The Resident Care Plan (RCP) dated [DATE] identified Resident #57 advanced directives directed a full code. Interventions directed to review the advanced directives quarterly and to include the resident and/or responsible party for guidance in order to honor the resident's wishes.A physician's order dated [DATE] directed DNR, DNI, no tube feeding, and Registered Nurse (RN) pronouncement of death.The RCP dated [DATE] identified Resident #57 had established advanced directives DNR/DNR, no tube feeding and an RN may pronounce. Interventions directed to review the advanced directives quarterly and to include the resident and/or responsible party for guidance in order to honor the resident's wishes.Review of the clinical record on [DATE] failed to identify any signed consent forms or documentation indicating that Resident #57 or the resident's health care representative approved the change from full code to DNR/DNI, no tube feeding, and RN pronouncement of death.Interview with Person #1 on [DATE] at 1:00 PM identified in [DATE], he/she recalled discussing Resident #57's DNI/DNR status with staff and agreed with the change. Person #1 indicated he/she did not sign any consent or forms authorizing the change in code status.Interview and clinical record review with RN #6 (unit manager) on [DATE] at 2:12 PM identified Resident #57's advanced directive consent form dated 1/6 (year not documented) directed DNR/DNI, included one witness signature, and indicated consent was obtained by telephone. RN #6 identified when residents are evaluated for their advanced directives and or wishes, if the resident is capable, they can sign the consent form or the family, power of attorney or conservator signs on the resident's behalf. RN #6 stated verbal consent may be obtained by an RN with two witness signatures for CPR or DNR/DNI. RN #6 could not explain the advanced directives form and consent form lacked the year or why it contained only one witness signature. Although, attempted an interview with APRN #1 was not obtained.Review of the facility Advanced Directive policy in part directed facility staff should immediately document discussions with the residents or resident's representative including a resident's wish to refuse CPR. At a minimum, a verbal declination of CPR by the resident or if applicable should be witnessed by 2 staff members. Surrogate decision making/HCP (health care proxy) consent for a DNR order must be in writing, signed in the presence of 2 witnesses [AGE] years of age or older who must sign the consent form.

Based on review of the clinical record, review of facility documentation, facility policy and interviews for 1 of 2 residents (Resident # 123) reviewed for abuse, the facility failed to ensure the resident was free from verbal and psychological abuse. The findings include Resident #123's diagnoses included heart failure (unspecified), spontaneous rupture of extensor tendons in the right lower leg, and polyneuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #123 as cognitively intact and required substantial assistance with showering/bathing and bed mobility and was dependent for transfers. No behavioral concerns were noted. The care plan dated 8/11/25 identified Resident #123 had Activities of Daily Living (ADL). Interventions included: using a Hoyer lift, noted non-ambulatory status, and assistance with bathing and dressing. A review of the grievance log dated 9/27/25 identified Resident #123 had a complaint of poor customer service by a Nurse Aide (NA#8) who told the resident to worry about her/himself when the resident was advocating for her/his roommate. NA #8 stated she was not going to break her back turning a fat crippled. When told she was being too rough, NA #8 overcompensated and hardly cleaned Resident #123 at all during incontinent care. When NA #8 was asked to leave the room by Resident #123, NA #8 was heard talking derogatorily about Resident #123 as she was leaving and out in the hallway. Action taken indicated NA #8 was no longer employed by the facility. On 9/28/25 at 12:51 AM, a nurse's note indicated: The patient had some complaints about her/his NA this shift, which made her/him emotional. The nursing supervisor was alerted, and the issue was resolved by the nursing supervisor. On 10/2/25, Resident #123 received mental health support from the facility psychiatric service.A review of progress notes for Resident # 123 failed to indicate the social work followed up with Resident #123 regarding the incident. A request for the last six months of Accidents and Incidents made on 1/7/26 at 12:20 PM identified the facility did not have any reports for the allegations made by Resident # 123 on 9/27/25. An interview with Resident #123 on 1/7/26 at 12:48 PM identified she/he was advocating for her/his prior roommate who had memory issues. Resident #123 reported NA #8 told her/him to mind her/his business. NA #8 came over to help Resident #123; however, she was grimacing and was scornful toward helping her/him. Resident #123 reported before leaving the room, NA #8 said something that made her/him feel horrible. She called Resident # 123 a name she/he did not want to repeat. Resident #123 reported informing the unit manager of the concern and stated NA #8 had not provided care to her/him since. An interview on 1/8/26 at 9:11 AM with Unit Manager Registered Nurse (RN #5) indicated she recalled the incident and immediately reported it to the unit supervisor and DNS; however, she was unsure of the outcome. An interview on 1/8/26 at 9:15 AM with DNS indicated she pulled the staff member from the schedule. She reported that based on the statements she received from Resident #123 and NA #8, she was unable to substantiate abuse. The DNS stated, Resident #123 did not directly say the words abuse. The DNS was unable to provide a clear answer as to who made the statement fat crippled, nor were there any other statements from witnesses. A review of NA # 8 employee file indicated she/he was hired on 8/4/25 and terminated on 11/16/25. The file identified that a background check was completed with no adverse results found. Further review identified NA # 8 last day of work was 9/27/25. The file indicated NA #8 was terminated due to poor job performance. The facility's Abuse Policy and Procedure provided to the surveyor onsite indicated, in part, that Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance. Staff will maintain a manner of courtesy and respect toward residents and their families. Staff will refrain from all actions that could be considered abuse, mistreatment, and/or neglect. The policy further indicated the reporting timeline for all allegations was: 1. Immediately to supervisors, 2. Within 24 hours to the Department of Public Health if the allegation did not result in serious bodily injury.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident # 123), reviewed for abuse, the facility failed to ensure allegation of verbal abuse was reported to the appropriate state agency timely. The findings include: Resident #123's diagnoses included heart failure (unspecified), spontaneous rupture of extensor tendons in the right lower leg, and polyneuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #123 as cognitively intact and required substantial assistance with showering/bathing and bed mobility and was dependent for transfers. No behavioral concerns were noted. The care plan dated 8/11/25 identified Resident #123 had Activities of Daily Living (ADL). Interventions included: using a Hoyer lift, noted non-ambulatory status, and assistance with bathing and dressing. A review of the grievance log dated 9/27/25 identified Resident #123 had a complaint of poor customer service by a Nurse Aide (NA#8) who told the resident to worry about her/himself when the resident was advocating for her/his roommate. NA #8 stated she was not going to break her back turning a fat crippled. When told she was being too rough, NA #8 overcompensated and hardly cleaned Resident #123 at all during incontinent care. When NA #8 was asked to leave the room by Resident #123, NA #8 was heard talking derogatorily about Resident #123 as she was leaving and out in the hallway. Action taken indicated NA #8 was no longer employed by the facility. On 9/28/25 at 12:51 AM, a nurse's note indicated: The patient had some complaints about her/his NA this shift, which made her/him emotional. The nursing supervisor was alerted, and the issue was resolved by the nursing supervisor. On 10/2/25, Resident #123 received mental health support from the facility psychiatric service.A review of progress notes for Resident # 123 failed to indicate the social work followed up with Resident #123 regarding the incident. A request for the last six months of Accidents and Incidents made on 1/7/26 at 12:20 PM identified the facility did not have any reports for the allegations made by Resident # 123 on 9/27/25. An interview with Resident #123 on 1/7/26 at 12:48 PM identified she/he was advocating for her/his prior roommate who had memory issues. Resident #123 reported NA #8 told her/him to mind her/his business. NA #8 came over to help Resident #123; however, she was grimacing and was scornful toward helping her/him. Resident #123 reported before leaving the room, NA #8 said something that made her/him feel horrible. She called Resident # 123 a name she/he did not want to repeat. Resident #123 reported informing the unit manager of the concern and stated NA #8 had not provided care to her/him since. An interview on 1/8/26 at 9:11 AM with Unit Manager Registered Nurse (RN #5) indicated she recalled the incident and immediately reported it to the unit supervisor and DNS; however, she was unsure of the outcome. Interview on 1/08/26 at 9:15 AM with DNS indicated based on the statements she received from Resident #123 and NA#8 she was unable to substantiate abuse, and a report was not submitted. A review of NA # 8 employee file indicated she/he was hired on 8/4/25 and terminated on 11/16/25. The file identified that a background check was completed with no adverse results found. Further review identified NA # 8 last day of work was 9/27/25. The file indicated NA #8 was terminated due to poor job performance. The facility's Abuse Policy and Procedure provided to the surveyor onsite indicated, in part, that Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance. Staff will refrain from all actions that could be considered abuse, mistreatment, and/or neglect. The policy further indicated the reporting timeline for all allegations was: 1. Immediately to supervisors, 2. Within 24 hours to the Department of Public Health if the allegation did not result in serious bodily injury.

Based on review of the clinical record, review of facility documentation, facility policy and interviews for 1 of 2 residents reviewed for abuse, the facility failed to conduct an investigation regarding an allegation of verbal and psychological abuse. The findings include Resident #123's diagnoses included heart failure (unspecified), spontaneous rupture of extensor tendons in the right lower leg, and polyneuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #123 as cognitively intact and required substantial assistance with showering/bathing and bed mobility and was dependent for transfers. No behavioral concerns were noted. The care plan dated 8/11/25 identified Resident #123 had Activities of Daily Living (ADL). Interventions included: using a Hoyer lift, noted non-ambulatory status, and assistance with bathing and dressing. A review of the grievance log dated 9/27/25 identified Resident #123 had a complaint of poor customer service by a Nurse Aide (NA#8) who told the resident to worry about her/himself when the resident was advocating for her/his roommate. NA #8 stated she was not going to break her back turning a fat crippled. When told she was being too rough, NA #8 overcompensated and hardly cleaned Resident #123 at all during incontinent care. When NA #8 was asked to leave the room by Resident #123, NA #8 was heard talking derogatorily about Resident #123 as she was leaving and out in the hallway. Action taken indicated NA #8 was no longer employed by the facility. On 9/28/25 at 12:51 AM, a nurse's note indicated: The patient had some complaints about her/his NA this shift, which made her/him emotional. The nursing supervisor was alerted, and the issue was resolved by the nursing supervisor. On 10/2/25, Resident #123 received mental health support from the facility psychiatric service.A review of progress notes for Resident # 123 failed to indicate the social work followed up with Resident #123 regarding the incident. A request for the last six months of Accidents and Incidents made on 1/7/26 at 12:20 PM identified the facility did not have any reports for the allegations made by Resident # 123 on 9/27/25. Review of the Department of Public Health Facility Licensing and Investigations Section (FLIS) Reportable events during the survey failed to identify any reports from facility related to allegation of verbal or psychological abuse reported on 9/27/2025. An interview with Resident #123 on 1/7/26 at 12:48 PM identified she/he was advocating for her/his prior roommate who had memory issues. Resident #123 reported NA #8 told her/him to mind her/his business. NA #8 came over to help Resident #123; however, she was grimacing and was scornful toward helping her/him. Resident #123 reported before leaving the room, NA #8 said something that made her/him feel horrible. She called Resident # 123 a name she/he did not want to repeat. Resident #123 reported informing the unit manager of the concern and stated NA #8 had not provided care to her/him since. An interview on 1/8/26 at 9:11 AM with Unit Manager Registered Nurse (RN #5) indicated she recalled the incident and immediately reported it to the unit supervisor and DNS; however, she was unsure of the outcome. An interview on 1/08/26 at 9:15 AM with DNS indicated she pulled the staff member from the schedule. She reported that based on the statements she received from Resident #123 and NA #8, she was unable to substantiate abuse. The DNS stated, Resident #123 did not directly say the words abuse. The DNS was unable to provide a clear answer as to who made the statement fat crippled, nor were there any other statements from witnesses. The facility's Abuse Policy and Procedure indicated, in part, that Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance. Staff will maintain a manner of courtesy and respect toward residents and their families. Staff will refrain from all actions that could be considered abuse, mistreatment, and/or neglect. The policy indicated: Immediate investigation into allegation (interview residents and other witnesses).

Based on clinical record reviews, review of facility policy and staff interviews for 1of 3 sampled residents (Resident # 6), reviewed for pressure ulcer development and for care meetings, the facility failed to revised the resident's care plan regarding a change in condition in the resident' s pressure ulcer develop and failed to ensure resident care planning meeting was scheduled timely .The findings included: 2.a.Resident #6's diagnosis included a pressure ulcer, heart failure and acute embolism and thrombosis of the deep vein of the left upper extremity. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 had severe cognitive impairment and was at risk for pressure ulcer but had no pressure ulcers. A Third Eye Health Note dated 11/10/2025 at 12:59 AM by the on-call Advanced Practice Registered Nurse (APRN) on 11/09/2025 at 3:47 PM indicated notification of a pressure injury to the left heel and an order for a dressing and a pressure-relieving boot were provided. The staff was also directed to follow up with wound physician. A nurse's note dated 11/10/2025 at 4:50 PM labeled E-Interact SBAR Summary for Providers indicated Resident #6's left heel was noted to be discolored with intact skin. Off-loading boots were applied, an RN assessment had been completed and family was present. A care plan updated on 11/10/2025 indicated Resident #6 had a stage 2 pressure ulcer( partial-thickness skin loss that appears as a shallow open wound or as a blister indicting damage to the top layers of skin) related to edema (swelling) with interventions to monitor for infection, notify the physician and family with changes, no shoe to the left foot until further orders and weekly wound evaluations. A wound physician consultation on 11/25/2025 indicated the left heel wound was a stage 2 pressure ulcer (blister) and the following week (12/5/2025) the wound physician consult indicated the left heel pressure ulcer worsened to a stage 3 pressure ulcer (full thickness loss of skin, looking like a crater).However, a review of Resident # 6's care plans during the survey failed to reflect the resident's care plan had been revised to reflect the change in the resident's pressure wound from a stage 2 to stage 3.An interview and clinical record review with the wound Nurse (RN #4) on 1/8/2026 at 1:05 PM indicated the weekly wound evaluation with pictures and the nursing care plan were not updated when the wound declined from a stage 2 to a stage 3 pressure ulcer on 12/5/2025 further indicating s/he would update the care plan now. The facility policy labeled Baseline/Comprehensive Person-Centered Care Plan indicated the comprehensive person-centered care plan will be kept current by all disciplines on an ongoing basis and upon any change in status.b. Resident #6's diagnosis included frequent falls and clavicle fracture.The significant change in condition Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had moderate cognitive impairment and required substantial to maximum assistance from staff to complete most activities of daily living (ADL).The Resident Care Plan (RCP) dated 10/26/2025 identified Resident #6 had a fracture of the left upper extremity. Interventions included: obtaining an orthopedic consultation, to provide medications as ordered and to obtain a therapy evaluation with treatment as indicated.An interview, clinical record review, and facility document review, with SW#1 on 1/12/2026 at 9:10 AM identified the process for completing the care planning schedule for residents was completed by several team members. SW#1 indicated the MDS nurses developed a schedule for the upcoming MDS assessments needing to be completed for the month which also required a care plan meeting to be scheduled for each resident with an invitation to participate in the meeting communicated to the resident and or his/her representative. SW #1 further indicated any additional assessments needing completion after the schedule was sent out for the month is emailed by the MDS nurses to inform the interdisciplinary team of the need for the assessment to be completed and a care plan meeting to be scheduled with invitations to the meeting sent by the receptionist and Resident Relations staff member.An interview and facility document review on 01/23/2026 at 9:30 AM with the front desk receptionist #1 identified the October and November 2025 care plan meetings had no care plan meetings scheduled for Resident #6.An interview, clinical record and facility document review with Resident Relations #1 on 1/12/2026 at 09:40 AM indicated not finding an email regarding the need to schedule a care plan meeting and invite the responsible party further indicating an upcoming care plan meeting for Resident #6 was scheduled in January 2026 and viewed the scanned copy of the invitation within Resident #6's electronic chart.An interview and facility document review with MDS Nurse #1 on 1/12/2026 at 9:50 AM provided an email sent to the interdisciplinary team members communicating the need to complete a significant change MDS assessment along with the care plan review dates. MDS Nurse identified a care plan meeting needed to be scheduled.An interview on 1/12/2026 at 11:50 AM with Social Worker (SW) 4, SW #1, and SW #3 in attendance identified SW #1 was assigned at the beginning of October 2025 the responsibility of being the Social Worker for the unit Resident #6 resided. SW # 1 indicated she/he sent an email indicating the need to schedule a care plan meeting but was overlooked. SW#1 further indicted the social worker for Resident #6 would have been responsible for scheduling an additional care plan meeting.Review of the facility Residents [NAME] of Rights policy; in part, identified residents had the right to make choices regarding aspects of their life that were significant to them and the facility policy labeled Baseline/Comprehensive Person Centered Care Plan indicated the resident and/or representative had the right to participate in the development/implementation/revision of the care planning process and the MDS Nurse was responsible to schedule the care plan meetings in accordance with regulation and resident/representative needs.

Based on review of clinical records, facility documentation, facility policies, observation, interviews, for 1 of 2 residents (Resident #17) reviewed for respiratory care, the facility failed to ensure an RN assessment was conducted when the resident had a change in respiratory status. The findings include: Resident #17's diagnoses included atherosclerotic heart disease, type 2 diabetes, and vascular dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 had a Brief Interview of Mental Status (BIMS) score of two (2) indicative of severe cognitive impairment, required maximal assistance with personal hygiene, and moderate assistance with rolling left and right. The Resident Care Plan (RCP) dated 10/16/2025 identified Resident #17 had a communication problem and expressive aphasia. Interventions included anticipating and meeting needs, allowing adequate time for responses, not rushing the resident, and asking yes/no questions when appropriate. The RCP failed to include the resident's diagnosis of immunodeficiency. Interview and observation with LPN #4 on 1/5/2026 at 12:22 PM identified Resident #17 had a hard, wet cough. LPN #4 stated she was unaware Resident #17 had a cough prior to observation with the surveyor. Observation on 1/6/2026 at 9:58 AM identified Resident #17 continued to have a hard wet cough. Review of the clinical record from 1/05/2026 at 12:00 PM through 1/07/2026 at 9:30 AM failed to identify any documentation of Resident #17's new cough, an RN assessment, provider notification, or monitoring of vital signs, including temperature, pulse, respirations, blood pressure, or oxygen saturation. Interview and observation with LPN #4 on 1/7/2026 at 10:00 AM identified on 1/5/2026 she did not document Resident #17's new cough and did not report the change in his/her respiratory status to the RN or APRN. LPN #4 stated on 1/5/2026 she auscultated Resident #17's lungs and she found them clear and did not observe further coughing at that time. Observation with LPN #4 identified she asked Resident #17 if he/she was still coughing the resident responded, yes. LPN #4 then auscultated Resident #17's lungs and identified the presence of rhonchi and rales. Interview with RN #3 (supervisor) on 1/7/2026 at 10:40 AM identified she was not notified on 1/5/2026 by LPN #4 that Resident #17 developed a new cough. RN #3 identified she would have expected to be notified. RN #3 stated had she been notified she would have conducted an RN assessment and notified the APRN. The facility Change of Conditions Notification policy identified in part that the facility will inform the resident, resident's healthcare provider, and the resident's family/legal representative when there is a change in condition. Staff will identify the change in condition and notify the licensed nurse. The licensed nurse per state regulations will conduct a complete physical/mental evaluation and document the findings in the medical record.

Based on review of clinical record, observations, facility policy, and interviews for 1 of 2 residents (Resident #17) reviewed for positioning/mobility, the facility failed to apply a right upper extremity splint per the physician's order, for a resident with contractures. The findings include: Resident #17 diagnoses included hemiplegia and hemiparesis of the right side, contracture of the right hand and right wrist, and vascular dementia.A physician's order dated 8/27/2021 directed to apply a right palm guard between 6 AM and 8 AM up to 8 hours for prevention of contractures to the right hand and check skin prior to and following application. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 had a Brief Interview of Mental Status (BIMS) score of two (2) indicative of severe cognitive impairment, did not display behaviors of rejection of care, and required maximal assistance with personal hygiene, upper and lower body dressing.The Resident Care Plan (RCP) dated 10/16/2025 identified Resident #17 had an Activities of Daily Living (ADL) self-care performance deficit with right sided weakness. Interventions included placing a right wrist, hand, finger orthotic (WHFO) on at 8:00 AM and take off at bedtime.Observation on 1/6/2026 at 10:00 AM identified Resident #17 was in bed with both hands visible and resting on top of the bedcovers without a splint, palm guard, or hand guard on his/her right hand. Observation and interview on 1/7/2026 at 10:00 AM with Licensed Practical Nurse (LPN) # 4 identified Resident #17 did not have a splint or hand guard applied to his/her right hand. LPN #4 stated Resident #17 should have had a palm guard applied at 8:00 AM and the Nurse Aide (NA) was responsible for placing the palm guard on him/her.Observation and interview on 1/7/2026 at 10:18 AM with NA #6 identified Resident #17 did not have a splint or hand guard applied to his/her right hand although the Kardex directed to apply Resident #17's right palm guard at 8:00 AM. NA #6 identified she was not aware she was responsible for applying Resident #17's right palm guard. NA #6 stated she never placed Resident #17's palm guard on him/her at any time. LPN #4 and NA #6 were unable to locate Resident #17's palm guard within his/her room. LPN #4 indicated she would contact Occupational Therapy (OT) for a replacement palm guard.Interview with OT #1 on 1/7/2026 at 11:03 AM identified that Resident #17 required a right palm guard to maintain his/her skin integrity, prevent skin breakdown, reduce the risk of infection, and prevent his/her fingernails from growing into his/her right palm. OT #1 identified staff were responsible for applying and removing Resident #17's right palm guard. OT #1 stated he had not been notified Resident #17 was missing his/her palm guard. OT #1 stated he should have been notified due to the urgency of the situation.Subsequent to surveyor inquiry OT #1 obtained a replacement palm guard and placed it on Resident #17's right hand.Review of facility ADL policy identified; in part, that staff will provide assistance to complete ADL activities per the patient centered evaluation and care plan. The care includes personal device care utilizing essential personal care items such as hearing aids, contact lenses, glasses, orthotics, and walker, etc.

Based on observations, clinical record review, review of facility policy and staff interviews for 1 of 2 residents reviewed for elopement risk (Resident #10), the facility failed to replace a resident's expired Wander Guard per facility policy for a resident at risk for elopement. The findings include: Resident #10 was admitted on [DATE] with diagnoses that included dementia and stroke.A nursing admission assessment dated [DATE] identified Resident #10 had cognitive and hearing impairment.An elopement risk evaluation dated [DATE] identified Resident #10 was at risk for elopement related to a history of wandering/elopement, being cognitively impaired, and having the physical ability to leave the building. Interventions included applying a wander device.A physician's order dated [DATE] directed to check the placement of the Wander Guard device. The order also indicated the specific serial number of the device assigned to Resident #10 and noted an expiration date of 10/2025. The physician's order did not indicate a location on the resident's body.A physician's order dated [DATE] directed to check the location of the Wander Guard on Resident #10's left wrist every shift.A physician's order dated [DATE] directed to check the expiration date of the Wander Guard every 7 days on the day shift. Additionally, the order indicated the specific serial number of the device and noted an expiration date of 9/2027. The order further indicated the device was located on the resident's right lower extremity.A review of the Treatment Administration Record (TAR) identified from [DATE] through [DATE], nursing staff had documented checking the placement of the Wander Guard device that had an expiration date of 10/2025 and the device that expired on 9/2027. The TAR also indicated that nursing staff had documented checking the expiration date of the Wander Guard device with an expiration date of 9/2027.On [DATE] at 12:00 PM, Resident #10 was observed in his/her room eating lunch. A Wander Guard device was observed on Resident #10's left wrist with an expiration date of 10/2025 written in blue. The resident denied having any other devices, and when the resident raised her/his pant legs, no devices were noted on the left or right ankles.On [DATE] at 12:11 PM, an observation and interview with LPN#7 identified that Resident #10's Wander Guard device had a written expiration date of 10/2025. LPN#7 indicated that she had seen the date on the Wander Guard device on [DATE] but had not informed the manager because it had been a Saturday. LPN#5 further indicated that the unit managers usually changed the Wander Guard devices.On [DATE] at 12:31 PM, an interview with the unit manager (RN#5) identified when there was a physician's order for checking a Wander Guard device, it usually meant that a device had been applied. RN#5 indicated the unit managers change the Wander Guard device but was not able to identify why Resident #10 had a device that expired 10/2025 (3 months ago).On [DATE] at 12:48 PM, an interview with the nursing supervisor (RN#3) indicated that she put the order dated [DATE] to check the expiration date of a Wander Guard device that expired 9/2027, but could not recall why. RN#3 indicated that what may have happened was that an LPN may have come to her for a new Wander Guard device for Resident #10, and after giving the LPN the new device, placed a new order with the new device's expiration date and serial number. RN#3 indicated that Wander Guard devices were kept in an administration office that nursing supervisors and managers had access to and that either the supervisor or the managers would provide the devices to the LPN's who would then place them on the resident. An observation with RN#3 of Resident #10's Wander Guard device identified that the device was functioning but had an expiration date of 10/2025 and had a serial number matching the serial number of the device placed on [DATE].A review of the facility policy for Wander Guard/Secure Care Alarm indicated that the expiration dates and/or battery life of the Wander Guard devices would be checked weekly and documented in TAR. The policy further indicated that any device that has expired would be discarded and replaced.

Based on, clinical record reviews, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #1) who had a changed in meal consumption and was at risk for a weight loss, the facility failed to ensure a reweight was done timely and/or physician and/or Advanced Practice Registered Nurse had been a significant weight loss. The findings include: Resident #1's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was without cognitive impairment and required supervision after set-up with eating. The Resident Care Plan dated 2/4/19 identified resident had gastric reflux. Interventions included no concentrated sweets diet, dietary consult for nutritional regimen and ongoing monitoring, medications as ordered, monitor/document/report signs and symptoms of gastric reflux including choking when lying down, heartburn, dyspepsia, nausea/vomiting, swallowing problems. An admission physician's orders [REDACTED]. Review of the resident's weight record identified Resident #1 weighed 195 pounds (lb) on 3/25/19, 177 lb on 4/5/19, 177 lb on 4/8/19, 179 lb on 4/12/19 indicating a weight loss of eighteen pounds in two (2) weeks. The Dietician's progress note dated 4/12/19 at 1:44 PM identified Resident #1 with a significant weight loss of 17.6 lb weight loss in two (2) weeks, the resident currently on low concentrated sweets diet, regular consistency, and thin liquids with good PO intake, meal intakes range between 50-100%, spoke with resident who report a decent appetite but does not enjoy the food provided. The note indicated Resident #1 refused supplements at this time but would like ice cream provided at meals instead and meal ticket updated with the resident's preferences. Review of the nurse's notes from 4/5/19 through 4/12/19 failed to reflect documentation that the physician and/or Advanced Practice Registered Nurse (APRN) were notified of the weight loss. The nurse's note dated 4/30/19 at 6:15 PM identified the AAPRN was notified of Resident #1's 20lb weight loss and no new orders were given. Interview and review of the clinical record with the Director of Nursing (DON) on 6/12/19 the record failed to documentation the physician and/or APRN was notified prior to 4/30/19 and the dietitian was notified on 4/12/19 of the significant weight loss. The DON identified the facility policy was to do a reweight within forty-eight (48) hours if a significant weight loss was suspected and to notify the physician and dietitian when the weight loss was confirmed. Interview with LPN #1 on 6/13/19 at 11:00 AM identified she reported the weight loss to the Unit Manager, Registered Nurse (RN) #1. LPN #1 stated it is the facility practice to notify the unit manager of any significant weight loss and then the unit manager will notify the physician/APRN, the dietitian, and the family. Interview with a Unit Manager, RN #2, on 6/13/19 at 11:30 AM identified when she took over the unit at the end of April, she became aware of Resident #1's weight loss and reported it to the APRN and family. Although attempted, RN #1 was not available for interview. The facility weight policy identified if a weight loss or gain is noted of 3 lbs in one week or 5% or more in a month a re-weight will be taken within 48 hours to validate the weight loss or gain. If the weight is accurate the charge nurse will notify the nursing supervisor, physician, dietitian, and responsible party.

Based on clinical record reviews, review of facility documentation, facility policy review, and interviews for one of six sampled residents (Resident #5) who had a behavior of inappropriate sexual contact, the facility failed to prevent an incident of sexual abuse between two residents. The findings include: Resident #5's [DIAGNOSES REDACTED]. The Conservator of Person (COP) record dated 12/8/2016 identified that Resident #5 had a psychological, emotional, and/or physical condition that resulted in Resident #5 being unable to receive and evaluate information and make decisions due to dementia with memory loss and agitation, and a Conservator was appointed by the Probate Court. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had some confusion, was unable to state the correct day, month and/or year, required cueing for word recall, and required supervision for ambulation and transfers. The Resident Care Plan (RCP) dated 4/23/19 identified a sexual behavior problem, as evidenced by lifting his/her blouse, asking others to put their hand under his/her shirt, trying to kiss residents of the opposite sex, and dementia with impaired thought process. Interventions directed to monitor the resident's behavior closely when around residents of the opposite sex, seat away from those residents of the opposite sex, administer medications as ordered, and supervise as needed. Review of the (MONTH) 2019 Documentation Record identified Resident #5 was checked hourly. The nurse's note dated 5/18/19 at 8:25 PM identified Resident #5 was found naked in bed with Resident #6, the residents were separated, Resident #5 was initially upset and aggressive towards the staff, had eventually calmed with a dose of Trazadone 50 milligrams and Resident #5 was placed on one to one (1:1) supervision until Resident #6 was transferred to another unit (on 6/6/19). Resident #6's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified Resident #6 had some confusion, was unable to state the correct month and/or year, required cueing for word recall, required one (1) person supervision when ambulating. The resident care plan dated 3/5/19 identified the resident had a potential in alteration of mood related to the dementia. Interventions directed to monitor, document and report changes in feelings, interests, appetite, ability to concentrate, sleep patterns and behavioral health consults as needed. The nurse's note dated 5/18/19 at 8:25 PM identified Resident #6 was observed naked in bed with another resident on top. The note indicated Resident #6 was very agitated and yelling at the staff because of being interrupted. The note identified Residents #6 was placed on one to one (1:1) supervision and the resident eventually calmed down with snacks and fluids. The social service note dated 5/19/19 at 9:36 AM identified Resident #6 could not recall the incident. The nurse's note dated 6/6/19 identified Resident #6 was transferred to another unit subsequent to the 5/18/19 incident. The Reportable Event Form dated 5/18/19 at 8:20 PM identified Resident #5 was observed undressed in bed with another resident. The report identified a nurse aide, Nurse Aide (NA) #3, observed both residents naked in the bed with Resident #6 on top of Resident #5, NA #3 told the residents to stop and called the nurse. The report indicated the Nursing Supervisor, Registered Nurse (RN) #2, identified she completed an assessment on Resident #5 and no trauma and/or bleeding was observed. RN #2 identified that when leaving Resident #5's room, Resident #5 asked why she was there and RN #2 explained what happened, and Resident #5 stated he/she only takes his/her clothes off for his/her spouse. The social service note dated 5/19/19 identified Resident #5 was seen in follow-up to the 5/18/19 incident. The note indicated Resident #5 reported nothing happened between the two (2) residents, they are good friends, he/she would never do anything like that and Resident #5 reported feeling good. The Advanced Practice Registered Nurse (APRN) progress note dated 5/20/19 identified Resident #5's Conservator of Person did not condone a sexual relationship for Resident #5. The nurse's note dated 5/24/19 at 1:45 PM identified a discussion was had with Resident #5's COP and the COP wanted Resident #5 to have no personal contact with Resident #6. Interview, clinical record review, and facility documentation review with RN #2 on 6/18/19 at 12:36 PM identified Resident #5 was conserved and not able to give consent to sexual activity due to confusion. Interview, clinical record review, and facility documentation review with NA #3 on 6/18/19 at 1:06 PM identified Resident #5 and Resident #6's rooms were next to each other, both residents were able to ambulate independently, and he had seen them being flirtatious prior to the incident. NA #3 stated when he entered the room, he saw both residents naked in the bed, with Resident #6 on top of Resident #5, and both residents were upset to be interrupted when he told Resident #6 to get off Resident #5. NA #3 stated the nurse had asked him to check on Resident #6 because the resident was on hourly checks and Resident #5 and Resident #6 were flirtatious towards each other. Interview, clinical record review, and facility documentation review with the Director of Nursing (DON) identified prior to the 5/18/19 incident, Resident #5 had behaviors of exposing him/herself to others. The DON stated staff were aware that Resident #5 thought Resident #6 was his/her spouse and Resident #5 paid a lot of attention to Resident #6. The DON indicated Resident #5's conservator had told her that Resident #6 looked like Resident #5's spouse and Resident #5 thought Resident #6 was his/her spouse. The DON stated after the incident, Resident #5 was put on one to one (1:1) monitoring until Resident #6 was transferred to another unit. The DON stated Resident #5 and Resident #6 were both confused, and conserved, and unable to make a decision regarding intimate contact.

Based on clinical record reviews, review of facility documentation, facility policy review, and interviews for one of six sampled residents (Resident #5) who had a behavior of inappropriate sexual contact, the facility failed to implement a new intervention and/or provide appropriate supervision to prevent an episode of intimate contact between the residents. The findings include: Resident #5's [DIAGNOSES REDACTED]. The Conservator of Person (COP) record dated 12/8/2016 identified that Resident #5 had a psychological, emotional, and/or physical condition that resulted in Resident #5 being unable to receive and evaluate information and make decisions due to dementia with memory loss and agitation, and a Conservator was appointed by the Probate Court. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had some confusion, was unable to state the correct day, month and/or year, required cueing for word recall, and required supervision for ambulation and transfers. The Resident Care Plan (RCP) dated 4/23/19 identified a sexual behavior problem, as evidenced by lifting his/her blouse, asking others to put their hand under his/her shirt, trying to kiss residents of the opposite sex, and dementia with impaired thought process. Interventions directed to monitor the resident's behavior closely when around residents of the opposite sex, seat away from those residents of the opposite sex, administer medications as ordered, and supervise as needed. Review of the (MONTH) 2019 Documentation Record identified Resident #5 was checked hourly. The nurse's note dated 5/18/19 at 8:25 PM identified Resident #5 was found naked in bed with Resident #6, the residents were separated, Resident #5 was initially upset and aggressive towards the staff, had eventually calmed with a dose of Trazadone 50 milligrams and Resident #5 was placed on one to one (1:1) supervision until Resident #6 was transferred to another unit (on 6/6/19). Resident #6's [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] identified Resident #6 had some confusion, was unable to state the correct month and/or year, required cueing for word recall, required one (1) person supervision when ambulating. The resident care plan dated 3/5/19 identified the resident had a potential in alteration of mood related to the dementia. Interventions directed to monitor, document and report changes in feelings, interests, appetite, ability to concentrate, sleep patterns and behavioral health consults as needed. The nurse's note dated 5/18/19 at 8:25 PM identified Resident #6 was observed naked in bed with another resident on top. The note indicated Resident #6 was very agitated and yelling at the staff because of being interrupted. The note identified Residents #6 was placed on one to one (1:1) supervision and the resident eventually calmed down with snacks and fluids. The social service note dated 5/19/19 at 9:36 AM identified Resident #6 could not recall the incident. The nurse's note dated 6/6/19 identified Resident #6 was transferred to another unit subsequent to the 5/18/19 incident. The Reportable Event Form dated 5/18/19 at 8:20 PM identified Resident #5 was observed undressed in bed with another resident. The report identified a nurse aide, Nurse Aide (NA) #3, observed both residents naked in the bed with Resident #6 on top of Resident #5, NA #3 told the residents to stop and called the nurse. The report indicated the Nursing Supervisor, Registered Nurse (RN) #2, identified she completed an assessment on Resident #5 and no trauma and/or bleeding was observed. RN #2 identified that when leaving Resident #5's room, Resident #5 asked why she was there and RN #2 explained what happened, and Resident #5 stated he/she only takes his/her clothes off for his/her spouse. The social service note dated 5/19/19 identified Resident #5 was seen in follow-up to the 5/18/19 incident. The note indicated Resident #5 reported nothing happened between the two (2) residents, they are good friends, he/she would never do anything like that and Resident #5 reported feeling good. The Advanced Practice Registered Nurse (APRN) progress note dated 5/20/19 identified Resident #5's Conservator of Person did not condone a sexual relationship for Resident #5. The nurse's note dated 5/24/19 at 1:45 PM identified a discussion was had with Resident #5's COP and the COP wanted Resident #5 to have no personal contact with Resident #6. Interview, clinical record review, and facility documentation review with RN #2 on 6/18/19 at 12:36 PM identified Resident #5 was conserved and not able to give consent to sexual activity due to confusion. Interview, clinical record review, and facility documentation review with NA #3 on 6/18/19 at 1:06 PM identified Resident #5 and Resident #6's rooms were next to each other, both residents were able to ambulate independently, and he had seen them being flirtatious prior to the incident. NA #3 stated when he entered the room, he saw both residents naked in the bed, with Resident #6 on top of Resident #5, and both residents were upset to be interrupted when he told Resident #6 to get off Resident #5. NA #3 stated the nurse had asked him to check on Resident #6 because the resident was on hourly checks and Resident #5 and Resident #6 were flirtatious towards each other. Interview, clinical record review, and facility documentation review with the Director of Nursing (DON) identified prior to the 5/18/19 incident, Resident #5 had behaviors of exposing him/herself to others. The DON stated staff were aware that Resident #5 thought Resident #6 was his/her spouse and Resident #5 paid a lot of attention to Resident #6. The DON indicated Resident #5's conservator had told her that Resident #6 looked like Resident #5's spouse and Resident #5 thought Resident #6 was his/her spouse. The DON stated after the incident, Resident #5 was put on one to one (1:1) monitoring until Resident #6 was transferred to another unit. The DON stated Resident #5 and Resident #6 were both confused, and conserved, and unable to make a decision regarding intimate contact.

Based on review of the clinical records, facility investigations, interviews and review of facility policies, for one resident of two sampled residents utilizing a wanderguard (R#1), the facility failed to ensure adequate supervision of the resident and/or failed to provide a safe environment for a resident with elopement risk and/or for two of four residents with falls (R#2, and R#5), the facility failed to ensure a safe transfer during the utilization of a mechanical lift and/or provide the necessary supervision to prevent falls. The findings include: 1. i. Review of the clinical record for Resident #1 identified a past medical history of [REDACTED]. Review of the Minimum Data assessment dated [DATE], identified that the resident was moderately impaired for daily decision making. The assessment identified that the resident could ambulate independently while in the room or hallway and would self-propel a wheelchair. Review of the Resident Care Plan (RCP) dated 7/24/14, identified that the resident had a wanderguard placed on his/her wheelchair on 2/4/14 secondary to the potential for elopement, wandering and attempts to open locked doors. The care plan identified that the wanderguard was placed on the resident ' s wheelchair rather than his/her person secondary to the resident's fragile skin and vanity. According to facility policy for the wandering resident, the guard will be placed on the resident's body. Review of physician orders dated 8/6/14 identified that at 16:41, the resident's every 15 minute checks were terminated since they were no longer indicated. The checks had been initiated earlier that day secondary to the resident's behavior witnessed by a social worker. On 8/7/14, Resident #1 was found outside the building leaning against a car. The resident ' s wheelchair was found at the employee entrance located in the basement/ground level of the building. This was the second time the resident was found outside the building, (the first on 6/17/14) according to the resident care plan. During interview on 1/28/15 at approximately 1:30 PM, Clinical Manager #1 stated that the resident's family was involved in the decision not to place the wanderguard on the resident, but rather on the wheelchair. Upon return to the resident ' s unit on 8/7/14, the resident was placed initially on a one to one for several hours, then progressing to every fifteen minute checks. ii. A tour of the facility with the acting ADNS and Facility Manager on 1/26/15 at 1:20 PM, identified that entrances/exits contained wanderguard alarms on the first floor. Travel by elevator to the ground (basement) floor identified a new wanderguard alarm system (installed 8/27/14) just off the elevator prohibiting wanderguard wearers from traveling down the hallway to the employee entrance and shipping /loading dock. Observation of the door the resident exited through (where the resident's wheelchair was found) identified that the door opened onto a flight of approximately eight stairs. Upon exiting the building an inclining walkway lead to the parking lot where the resident was found. During interview on 1/26/14 at 1:20 PM, the Facility Manager stated that it was not usual to see residents in the basement as there were vending machines and a place to sit to visit. During interview on 1/28/14 at 1:30 PM, Clinical Manager #1 stated that he never really thought about the fact that although residents wore wanderguards and were allowed to roam throughout the building, there never was a wanderguard alarm system on the basement floor. Post resident elopement, the facility installed a wanderguard alarm in the basement hallway on 8/27/14. 2. Resident #2 sustained a deep laceration to the left lower extremity on 10/3/14 during a mechanical lift from chair to bed. While being placed on the bed, the resident was noted to hit his/her right shoulder against the bedrail that had been put in place prior to transfer. The resident complained of pain and was transferred to the Emergency Department (ED) for repair of the laceration and an x-ray of the right shoulder. The ED x-ray identified an oblique fracture of the mid distal clavicle without displacement. During interview on 2/5/15 at 9:25 PM, MD #2 stated that this type of fracture is always associated with trauma. The resident returned to the facility with a sling in place and instructions to follow-up with the orthopedic clinic associated with the hospital. Review of the facility policy for utilizing the mechanical lift identified that the procedure requires two people to complete the procedure, during which time the resident is gently lifted and comfortably lowered to the desired surface. According to the facility investigation, secondary to the resident's actively bleeding laceration, the nurse assistants completing the transfer were trying to transfer the resident expeditiously, causing the resident to hit the right shoulder on the bed rail. 3. R#5 was admitted to the facility with [DIAGNOSES REDACTED]. cellulitis with septic shock, chronic kidney disease (CKD) on hemodialysis (HD), end stage liver disease, [DIAGNOSES REDACTED] atrial fibrillation not on Coumadin, [DIAGNOSES REDACTED], and anemia secondary to acute blood loss and anemia of chronic disease, and history of falls. An admission Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 9 (moderately impaired range 8-12), extensive assistance of 2 staff for bed mobility, transfer, dressing, toilet use, and personal hygiene; extensive assistance of 1 staff for locomotion; not steady moving from seated to standing position, moving on and off the toilet, and surface to surface transfer; supervision of 1 staff for walking, functional limitation in range of motion to both upper extremities; use of wheelchair as an assistive device; on scheduled pain medications; and had a fall in the last month; height 73 inches, weight 254 pounds (lbs); antibiotic; and dialysis A Resident Care Plan (RCP)s initiated 08/24/14 identified problems of impaired mobility; alteration in thought, mood and behavior; and potential for injury due to falls. Interventions included ambulate with walker and assistance of 1 with Physical Therapy (PT), work on self propelling wheelchair on unit (09/05/14); patient caregiver education; cue resident with activities of daily living (ADL's), monitor for safety with ADL's and ambulation; assistive devices: walker, monitor for compliance with safety precautions. A Physical Therapy weekly note documented by Physical Therapist (PT) #1 on 09/04/14 identified that R #5 required bilateral upper extremity support for dynamic activity. The level of assistance required for sit to stand transfers fluctuated with the level of fatigue and attention to task. Ambulation required contact guard assistance with a rolling walker. Review of a facility conducted investigation coordinated by Registered Nurse (RN) #6 identified that, on 09/06/14, R #5 was assisted to the bathroom by Nurse Aide (NA) #1 and another, unidentified NA (NA #6) via Sara lift (sit to stand). NA #6 left the resident room and NA #1 remained in the bathroom with R #5. NA # 1 left the bathroom and entered the resident room to get the wheelchair. When returning to the bathroom, NA #1 observed R #5 stand up from the toilet and walk towards the sink, grabbing the towel bar. NA #1 observed the resident lose his/her balance and fall backwards towards the door as the towel bar pulled off the wall. The resident was assessed and pain was managed until 09/08/14 when the location and intensity of the pain changed. R #5 was transferred to Acute Care Hospital #1 for an evaluation where a comminuted mildly impacted fracture of the left proximal humerus through the surgical neck was identified. A Safety assessment dated [DATE] identified that R #5 was at risk for injury with fall risk factors of confusion/disorientation, decreased lower extremity mobility, incontinence/frequency and generalized weakness and poor nutrition. Medications affecting balance and safety included antihypertensive and antibiotics. Predisposing diseases affecting balance and safety include severe edema of the bilateral extremities. A facility policy entitled Fall Prevention Program identified, in part, if a resident is seen falling, an initial assessment that included range of motion, full body assessment, and vital signs should be conducted. According to Lippincott Manual of Nursing Practice ninth edition/ copyright 2010 byWolters Kluwer Health/Lippincott Williams&Wilkins--Range of Motion pages 176-180 to perform passive range of motions move the joint smoothly through it's full range and do not push beyond the point of pain. To perform active range of motion (ROM) support the distal part and encourage the patient to take the joint actively through its ROM.

Based on clinical record review, review of facility documentation and interviews for two of three sampled residents (Resident #127 and #286) who required bilateral hand splinting, the facility failed to implement interventions to prevent the development of and/or the decline of a pressure ulcer. The findings include: 1. Resident #127's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #127 had memory deficits, severe cognitive impairment, exhibited a behavior of rejection of care, required total one person assistance with all activities of daily living and had no pressure ulcers. The resident care plan dated 11/14/13 identified bilateral upper extremity contractures. Interventions directed for bilateral hand splints to be worn at all times and skin check every shift by the licensed nurse, and bilateral elbow splints to be applied at bedtime and removed during morning care. The nurse's note dated 12/22/13 at 11:00 PM identified that the charge nurse was informed that Resident #127's left hand pinky finger was swollen and an open area was noted on the fifth digit. A physician's orders [REDACTED]. Review of the wound data collection tool dated 12/23/13 identified a stage four pressure ulcer on the left inner fifth digit that measured 2.0 centimeters (cm) by 1.50 cm by 0.25 cm, the wound bed was pink and no odor or drainage was noted. The wound data collection tool identified a stage two pressure ulcer on the left thumb that measured 1.0 cm by 1.50 cm by 0.125 cm and no odor or drainage was noted. The Advanced Practice Registered Nurse's progress note dated 12/31/13 identified the pressure ulcers. The left thumb medial inner surface wound bed measured 1 cm by 1.5 cm by 0.125 cm with approximately 40% eschar, rest of the bed red granulation tissue no surrounding [DIAGNOSES REDACTED] or maceration. The left exposed flexor tendon, ventral first phalange of the fifth finger measured 0.2 by 1.4 by 0.25 cm, bed was clean showing tendon, surrounding tissue with mild [DIAGNOSES REDACTED] and slight maceration. The 1/1/14 wound data collection tool identified that the left fifth digit had possible deep tissue damage, measured 1.0 cm by 0.7 cm by 0.25 cm, the appearance of the wound bed was pink, and red, the tendon was visible and serosanguineous drainage was present. The stage two left thumb measured 1.0 cm by 0.5 cm by 0.125 cm, the appearance of the wound was red and pink, slough and serosanguineous drainage was present. Review of the weekly wound collection tool identified that the left thumb and fifth digit pressure ulcers were healed by 2/17/14. Interview with the charge nurse, Registered Nurse (RN) #4, on 3/25/14 at 11:00 AM she identified that the licensed nurses were responsible for checking the skin when the hand splints were removed during care. RN #4 indicated that she did not retract the fingers and had only checked the palm. 2. Resident #286's [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment dated [DATE] identified that Resident #286 had memory deficits, severe cognitive impairments, required total one person assistance with activities of daily living, and a stage two pressure ulcer. The resident care plan dated 9/10/13 identified an alteration in skin integrity related to the left thumb re-opened on 9/7/13. Interventions directed palm protector to right hand at all times remove during morning and evening care, left hand orthotic to be applied at all times, removed for hand hygiene care and skin checks before and after application. The nurse's note dated 9/26/13 at 3:30 PM identified that the open area to Resident #286's left thumb had improved, now measured 1 cm by 0.5 cm by 0.25 cm, seen by wound nurse and to continue with current treatment. The nurse's note dated 10/2/13 at 2:52 PM identified that during the dressing change the size of the left thumb wound appeared larger than the previous day, 10/1/13, the wound measured 1.8 cm by 2 cm by 0.5 cm. Although the splint was in place, the index finger was noted to be pressing against the left thumb area, the occupational therapist was notified and assessed the splint. The insert device of the splint was noted to have failed and was replaced by the therapist. The wound nurse's note dated 10/4/13 identified that the left thumb had worsened to a stage four pressure ulcer with an open area of 1.8 cm by 2 cm by 0.5 cm, the wound bed had partial granulation and ligament and tendon were exposed. The note indicated the nurse reported that although the splint was in place it had partially deflated. The splint was replaced and a non-inflatable carrot was to be kept at the bedside in the event the air splint deflated. Review of facility documentation dated 10/3/13 identified that review of the event, the failure of the air splint appeared to be the cause of the decline. Interview with the Director of Rehab on 3/25/14 at 1:41 PM identified that the air bladder of the splint had been removed and was replaced with gauze. There was a question to if enough gauze was used.

Based on clinical record reviews, observations, and review of the manufacturer's instruction manual, facility investigation, and interviews for one of four sampled residents (Resident #129) who were reviewed for accidents, the facility failed to maintain equipment to prevent an injury and/or failed to ensure that kitchen equipment was utilized in accordance with the manufacturer's instructions to avoid an accident. The findings include: 1. Resident #129's [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] identified that Resident #129 had short and long term memory loss and required extensive assist of one person for transfers. The resident care plan directed the utilization of a Sara lift for transfers, ambulate with wheeled walker and contact guard assist and high risk for bleeding related to anticoagulant therapy. The nurse's note dated 7/6/13 identified that at approximately 10:00 PM the charge nurse was called by the nurse aide because Resident #129 had sustained an injury. Resident #129 was noted to have two lacerations and the resident's left hand was covered with blood. Subsequent to physician notification the resident was transferred to the hospital for an evaluation and treatment. Review of the Reportable Event Form dated 7/6/13 identified that in the process of being transported in a recliner, Resident #129 called out in discomfort. Upon examination, Resident #129 was found to have a laceration on the middle finger measuring 3 centimeters (cm) x 0.8 cm x 1.2 and 0.4 cm x 0.125 cm below the fingertip. Due to excessive bleeding Resident #129 was transferred to the hospital for an evaluation and treatment. The hospital discharge summary dated 7/6/13 identified the presence of a laceration on Resident #129's third digit. The summary indicated that the x-ray was negative and the laceration required seven sutures. Interview with NA #4 on 3/25/14 at 11:45 AM identified that she was pushing the resident in the recliner chair back to his/her room when Resident #129 called out in discomfort. The recliner chair was a recliner with openings for a tray but a tray was not attached. Interview with RN #3 on 3/25/14 at 2:00 PM identified that on 7/9/13 she assessed the recliner chair with the Unit Manager and at that time dried blood was observed in the opening where the recliner tray would slide into. The recliner chairs no longer utilize the trays and the opening had been left uncovered. Subsequent to the injury, the ends of the recliner chair were wrapped with kling. Observations of the chair with RN #3 on 3/25/14 at 2:30 PM identified a recliner chair with the ends wrapped with kling. The kling was removed and the edges were noted to be hard and not cushioned. Interview with the Assistant Operations Officer on 4/2/14 at 3:30 PM identified that subsequent to surveyor inquiry the kling was removed and the ends of the wheelchair arms were plugged. Although, the wrapped kling was probably effective the holes should be plugged when the recliner tray was not being utilized. 2. Interview with the Director of Nutritional Services on 3/25/14 at 2:00 PM identified that soup and hot breakfast cereals were cooked in large kettles in the kitchen, transferred to stainless steel cylinders, transported to each resident unit and placed in Countertop Soup Kettle warmers (similar to crock pots). The temperature of the warmers were to be set at 8 (range of 0-12), and the warmers were monitored by the nurses and nurse aides on each unit and/or the dietary aide assigned to the unit. The nurse aides served and delivered the hot cereal or soup to the residents. Additionally, the Director identified that following an incident that occurred on 3/5/14 in which Resident #190 sustained a burn after spilling the soup while eating dinner in bed, stickers were applied to each warmer that directed to set the temperature dial at 8. Observation of the Countertop Soup Kettle warmers in the dining areas of two resident units, 3 North and 3 South and 1 service area on the fourth floor with the Director of Nutritional Services, on 3/26/14 at 8:00 AM identified the following: at 8:10 AM on 3 North, warmer #1 was set at 9 and warmer #2 was set at 8. Interview with the NA present identified that he/she had turned down warmer #2 as it was steaming. At 8:20 AM on 3 South, warmer #1 was set at 8 and warmer #2 was set at 8.5 and the warmers were plugged into a surge protector. At 8:25 AM on the Dementia Special Care Unit, warmer #1 and #2 were set at 8.5. All warmers observed in use were covered with foil rather than with the appropriate lid. Interview with the Facilities Operation Manager on 3/26/14 at 10:30 AM identified that surge protectors were not routinely utilized by the facility and subsequently removed the device. Interview and review of the Countertop Soup Kettle Warmer instruction manual with the Director of Nutritional Services on 3/26/14 at 11:00 AM identified that facility staff who utilized the warmer did not receive documented, specialized training in safe operation of the equipment. The instruction manual identified that unless the operator is adequately trained and supervised there is a possibility of serious injury and owners of this equipment bear the responsibility to make certain that this equipment is used properly and safely and to strictly follow all of the instructions contained in this manual. Instructions included, in part, the outlet to which this plug is connected must be properly grounded; never use/heat the warmer with foil covering the inner warming pot; temperature should be set between 1 and 8 and at the lowest acceptable temperature to keep food at a constant temperature.

Based on clinical record review, review of facility documentation, review of facility policies, and interviews for one of three residents with abnormal laboratory results, Resident #1, the facility failed to ensure that the physician was notified of a critical laboratory result in a timely manner. The findings include: 1a. Resident #1's (R #1) had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] identified that R #1 had short and long term memory problems with severely impaired cognition, and was dependent on staff for transfers, mobility and eating. The care plan dated 8/30/12 identified that R #1 had the potential for fluid volume deficit and altered nutrition related to therapeutic (diabetic) diet and variable intake with interventions that included to monitor intake and pertinent lab values, monitor for signs or symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION], and to monitor change in mentation. Review of the clinical record dated 11/2/12 identified that R #1 had a temperature of 101.1 degrees (Normal 98.6 degrees) at 6:40 PM, was lethargic, had a poor appetite (consumed 25 % of supper meal). The documentation identified that Tylenol six hundred and fifty milligrams (650 mg.) was administered, that the physician was notified, and the resident's responsible party was informed. The physician directed staff to monitor the resident's status. Review of nurses notes dated 11/3/12 for the period of 12:00 AM to 2:00 PM identified that R #1 was monitored and remained lethargic, was medicated at 12:00 AM, 4:00 AM and 2:00 PM with Tylenol 650 mg for temperatures of 101.3 to 101.5 degrees. R #1 continued with poor appetite and was taking fluids with encouragement. The physician was notified and directed that a chest x-ray and stat (immediate) Basic Metabolic Panel (BMP) and a Complete Blood Count (CBC) be obtained. Review of a laboratory report dated 11/3/12 identified that R#1's blood glucose was reported as five hundred and eight five (585) (Normal 70-199 MG/DL) and that the critical value was called in by the laboratory service and read back to RN #1 at 5:20 PM on 11/3/12. Further review of the 11/3/12 laboratory report identified that R #1's White Blood Count (WBC) was 12.7 K/UL, (Normal 4.0-10.5K/UL), Blood Urea Nitrogen (BUN) was 36 MG/DL (Normal 7-17MG/DL), and that the resident's sodium level was157 mmol/l (Normal 135 - 145 mmol/l). Interview with RN #1 on 11/21/12 at 4:40 PM identified that on 11/3/12, she received a phone call from the laboratory on 11/3/12 at 5:20 PM and was informed that R #1's blood glucose was elevated. RN #1 stated that she informed the supervisor, RN #2. Review of the clinical record and facility documentation lacked documentation to reflect that the supervisor or the physician on duty, MD #3, was informed of R #1's critically elevated blood glucose level. The clinical record lacked documentation to reflect that any additional interventions were considered and/or implemented in response to R #1's critical blood glucose level. b. Interview with the supervisor, RN #2, on 11/23/12 at 10:20 AM identified that RN #2 was the nursing supervisor on 11/3/12 from 7:00 AM to 9:30 PM. RN #2 denied that she was informed of R#1's elevated blood glucose level. RN #2 stated that although she was aware that R #1 had a stat BMP and CBC obtained earlier on 11/3/12, she was not aware of the results. RN #2 stated that before the end of her shift, she noticed that there were laboratory reports on the printer and reminded MD #1 to check printer to review R #1's stat laboratory results. RN #2 stated that did not read the reports before she left the faciity on [DATE] at 9:30 PM. RN #2 stated that she reported this information to the oncoming supervisor, RN #3, for follow up. Review of R #1's clinical record and facility documentation lacked documentation to reflect that the oncoming supervisor, RN #3, was informed of R #1's critical elevated blood glucose level by RN #2 and/or that the physician, MD #1, was notified that R #1's laboratory reports may possibly be on the printer for the physician's review. b. Interview with supervisor, RN #3, on 11/23/12 at 2:00 PM identified that she was the nursing supervisor on 11/3/12 from 9:00 PM to 11/4/12 at 7:30 AM. RN #3 stated that she received report from RN #2 on 11/3/12 at 9:00 PM. RN #3 stated that RN #2 reported that R #1 remained lethargic, had a temperature of 100.5 at 2:00 PM on 11/3/12, and that a chest x-ray and stat laboratory work had been obtained. RN #3 stated that RN #2 reported that R #1's chest x-ray was reported as negative, that the resident's White Blood Count (WBC), Blood Urea Nitrogen (BUN), and Sodium levels were elevated, and that the physician was aware. RN #3 stated that she was not aware of R #1's critical blood glucose level. RN #3 stated that although she spoke with the physician on duty from 8:00 PM on 11/3/12 through 8:00 AM on 11/4/12, MD #1, throughout the shift and updated him on R #1's status, they did not discuss R #1's laboratory results. Review of R #1's clinical record and review of facility documentation lacked documentation to reflect that any additional interventions were considered and/or implemented in response to R #1's elevated WBC, BUN, and/or Sodium levels. c. Interview with MD #2 on 11/26/12 at 10:00 AM identified that on the morning of 11/4/12 when she began her shift, she obtained R #1's laboratory reports from the fax printer. MD #2 stated that while she was reviewing R #1's laboratory results from 11/3/12, RN #2 arrived on duty and informed MD #2 that R #1 had been febrile and lethargic over the past thirty six hours and that stat blood work had been ordered on [DATE]. MD #2 stated she reviewed the laboratory work from 11/3/12, found that R #1's BUN, Sodium and WBC were elevated, and directed that the resident be evaluated at the Emergency Department (ED) for antibiotics, hydration, and further work up. MD #2 stated that she was not the covering physician over the weekend and was not informed that R #1 had any changes in condition prior to the morning (approximately 9:00 AM) on 11/4/12. Multiple attempts to contact MD #1, who was the covering physician on 11/3/12, were unsuccessful. Review of R #1's clinical record dated 11/3/12 through 11/4/12, lacked documentation to reflect that the physician was notified of the resident's critical blood glucose level sent to the facility on [DATE] at 5:25 PM and/or failed to identify that the resident's remaining stat laboratory results were reviewed and/or responded to until 11/4/12 at 9:10 AM. Review of the facility's Laboratory and Diagnostic Tests Policy identified, in part, that critical test results/values are communicated to the physician within one hour upon receipt. Review of R #1's acute care record identified that R #1 arrived at the ED at 10:09 AM on 11/4/12. The ED record identified that R #1's laboratory values had increased and included the following: the resident's WBC rose to 15.7, BUN rose to 63, Sodium level rose to 164 and blood glucose rose to 691. R #1 was diagnosed with [REDACTED]. R #1 was admitted to the acute care hospital and treated with an insulin drip, intravenous fluids (IV) fluid, and antibiotic therapy.

Based on clinical record review, interviews and review of facility policy for one of three residents with a change in condition (Resident #1), the facility failed to ensure that critical laboratory results were reported to the physician and/or responded to upon receipt. The findings include: 1a. Resident #1's (R #1) [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] identified that R #1 had short and long term memory problems with severely impaired cognition, and was dependent on staff for transfers, mobility and eating. The care plan dated 8/30/12 identified that R #1 had the potential for fluid volume deficit and altered nutrition related to therapeutic (diabetic) diet and variable intake with interventions that included to monitor intake and pertinent lab values, monitor for signs or symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION], and to monitor change in mentation. Review of the clinical record dated 11/2/12 identified that R #1 had a temperature of 101.1 degrees (Normal 98.6 degrees) at 6:40 PM, was lethargic, had a poor appetite (consumed 25 % of supper meal). The documentation identified that Tylenol six hundred and fifty milligrams (650 mg.) was administered, that the physician was notified, and the resident's responsible party was informed. The physician directed staff to monitor the resident's status. Review of nurses notes dated 11/3/12 for the period of 12:00 AM to 2:00 PM identified that R #1 was monitored and remained lethargic, was medicated at 12:00 AM, 4:00 AM and 2:00 PM with Tylenol 650 mg for temperatures of 101.3 to 101.5 degrees. R #1 continued with poor appetite and was taking fluids with encouragement. The physician on duty, MD #3, was notified and physician orders [REDACTED]. Review of a laboratory report dated 11/3/12 identified that R#1's blood glucose was reported as five hundred and eight five (585) (Normal 70-199 MG/DL) and that the critical value was called in by the laboratory service and read back to RN #1 at 5:20 PM on 11/3/12. Further review of the 11/3/12 laboratory report identified that R #1's White Blood Count (WBC) was 12.7 K/UL, (Normal 4.0-10.5K/UL), Blood Urea Nitrogen (BUN) was 36 MG/DL (Normal 7-17 MG/DL), and that the resident's sodium level was157 mmol/l (Normal 135 - 145 mmol/l). Interview with RN #1 on 11/21/12 at 4:40 PM identified that on 11/3/12, she received a phone call from the laboratory on 11/3/12 at 5:20 PM and was informed that R #1's blood glucose was elevated. RN #1 stated that she informed the supervisor, RN #2. Review of the clinical record and facility documentation lacked documentation to reflect that the supervisor or the physician on duty, MD #3, was informed of R #1's critically elevated blood glucose level. The clinical record further lacked documentation to reflect that any additional interventions were considered and/or implemented in response to R #1's critical blood glucose level. b. Interview with supervisor, RN #3, on 11/23/12 at 2:00 PM identified that she was the nursing supervisor on 11/3/12 from 9:00 PM to 11/4/12 at 7:30 AM. RN #3 stated that she received report from RN #2 on 11/3/12 at 9:00 PM. RN #3 stated that RN #2 reported that R #1 remained lethargic, had a temperature of 100.5 at 2:00 PM on 11/3/12, and that a chest x-ray and stat laboratory work had been obtained. RN #3 stated that RN #2 reported that R #1's chest x-ray was reported as negative, that the resident's White Blood Count (WBC), Blood Urea Nitrogen (BUN), and Sodium levels were elevated, and that the physician was aware. RN #3 stated that she was not aware of R #1's critical blood glucose level. RN #3 stated that although she spoke with the physician on duty from 8:00 PM on 11/3/12 through 8:00 AM on 11/4/12, MD #1, throughout the shift and updated him on R #1's status, they did not discuss R #1's laboratory results. Review of R #1's clinical record and review of facility documentation lacked documentation to reflect that any additional interventions were considered and/or implemented in response to R #1's elevated WBC, BUN, and/or Sodium levels. Interview with MD #2 on 11/26/12 at 10:00 AM identified that on the morning of 11/4/12 when she began her shift at approximately 8:00 AM, she obtained R #1's laboratory reports from the fax printer. MD #2 stated that while she was reviewing R #1's laboratory results from 11/3/12, RN #2 arrived on duty and informed MD #2 that R #1 had been febrile and lethargic over the past 36 hours and that stat blood work had been ordered on [DATE]. MD #2 stated she reviewed the laboratory work from 11/3/12, found that R #1's BUN, Sodium and WBC were elevated, and directed that the resident be evaluated at the Emergency Department (ED) for antibiotics, hydration, and further work up. MD #2 stated that she was not the covering physician over the weekend and was not informed that R #1 had any changes in condition prior to the morning (approximately 9:00 AM) on 11/4/12. Multiple attempts to contact MD #1, who was the covering physician on 11/3/12, were unsuccessful. Review of R #1's clinical record dated 11/3/12 through 11/4/12, lacked documentation to reflect that the physician was notified of the resident's critical blood glucose level sent to the facility on [DATE] at 5:25 PM and/or failed to identify that the resident's remaining stat laboratory results were reviewed and/or responded to until 11/4/12 at 9:10 AM. Review of R #1's acute care record identified that R #1 arrived at the ED at 10:09 AM on 11/4/12. The ED record identified that R #1's laboratory values had increased and included the following: R #1's WBC rose to 15.7, BUN rose to 63, Sodium level rose to 164 and blood glucose rose to 691. R #1 was diagnosed with [REDACTED]. R #1 was admitted to the acute care hospital and treated with an insulin drip, intravenous fluids (IV) fluid, and antibiotic therapy. Review of the facility's Laboratory and Diagnostics Test Policy directed that critical test results/values are communicated to the physician/ Advance Practice Registered Nurse (APRN) within one hour of receipt. The policy further directed that the results are communicated to the physician to ensure that safe, accurate care and treatment decisions are made.

Based on clinical record review, review of facility documentation, and interviews for one of three sampled residents (Resident #114) who had a history of [REDACTED]. The findings include: Resident #114's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified that Resident #114 had moderate cognitive impairments, no behavioral symptoms, required extensive assistance of two person assistance with transfers in and out of the bed/chair, was non-ambulatory, no falls within the past six months prior to admission and was only able to stabilize unsteadiness with human assistance when moving from a seated to standing position, moving on and off the toilet, and/or surface to surface transfers. The Resident Care Plan dated 9/19/11 identified a potential for falls. Interventions directed evaluate fall patterns, remove clutter, call bell within reach, assure proper footwear, wheelchair and walker within reach at all times and bed and chair alarm. The nurse's note dated 10/5/11 identified that at 4:45 PM Resident #114 was transferred to the emergency department status [REDACTED].#114's and observed the resident lying prone on the floor. The assessment indicated that Resident #114 complained of right hip and elbow pain, was medicated for the pain, and was transferred to the hospital. The hospital's x-ray report identified that Resident #114 had sustained a distal femoral fracture. The facility's investigation dated 10/10/11 identified that the 7-3 PM nurse aide (NA #2) had put Resident #114 back to bed prior to 3:00 PM and failed to check the placement of the bed alarm. The oncoming nurse aide (NA #3) failed to check the placement and function of the bed alarm. Both nurse aides failed to follow the plan of care. Interview with the charge nurse Registered Nurse (RN) #1 on 2/29/12 at 9:15 AM identified that she and RN #2 were called to the room by the nurse aide. Resident #114 was found lying on the floor in front of the closet and the bed alarm was not sounding because there was no pad type alarm on the bed. Interview with the Vice President of Nursing (RN #4) and the 7-3 PM Unit Manager (RN #3) on 2/29/12 at 9:30 AM identified that the nurse aides are to check the alarms at the beginning and at the end of their shift and NA #2 and NA #3 failed to complete the checks at 3:00 PM on 10/5/11. Subsequent to the facility's investigation NA #2 and NA #3 were terminated.

Based on clinical record reviews, observation and interview for one of four residents reviewed for falls (R#1), the facility failed to transport a resident in a safe manner to prevent a fall. The findings include: R#1's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified an inability to administer the Brief Interview for Mental Status, long and short term memory deficits, extensive assistance required for transfers, ambulation did not occur and balance during transitions was not steady, only able to stabilize with human assistance. The Resident Care Plan (RCP)dated 5/4/11 identified a potential for falls with interventions to evaluate fall patterns and assistive devices and monitor for compliance with safety precautions. Review of nurse's notes dated 6/26/11 identified while the nurse aide was transporting the resident to the dining room, in a recliner chair, R#1 tumbled to the floor and sustained a laceration to the right eyebrow. R#1 was transferred to an acute care facility where he/she received four sutures on the right brow. Interview with NA#1 on 9/6/11 at 12:00 PM identified that R#1 has a history of moving around and kicking his/her legs. He/she was transporting R#1 into the dining room with the recliner chair in an upright position when the resident suddenly fell forward. He/she could't see the resident because of the height of the chair. Interview and review of the clinical record with the Physical Therapist (PT#1) on 9/7/11 at 1:20 PM identified that R#1 had demonstrated impaired positioning and an inability to maintain an upright position as early as 5/7/09 when a pummel cushion was provided. On 10/13/10 a foam cushion and dycem were provided to prevent the resident from sliding leaning forward. A custom molded wheelchair was provided 1/21/11 after a short trial of a geriatric chair. Occupational Therapy notes dated 2/22/11 identified that the process to obtain a custom wheelchair was initiated to meet seating and postitioning needs and R#1 was placed in a recliner chair at the family's request on 4/12/11. Interview with the Director of Nursing and RN#1 on 9/6/11 at 1:00 PM identified that R#1 does have a history of sudden movements and further stated that the recliner chair is not provided by therapy and it is not customary for the safety of the chair be assessed by therapy. PT#1 further stated that in a recliner chair positioned upright a resident is not as safe for a resident who slides forward. Although a custom chair was ordered to address positioning needs, the facility failed to provide direction to staff to provide interventions to prevent the resident from sliding out of the chair when the recliner is an upright position.