Every finding on record at Highland House Nursing & Rehabilitation Center

Based on interview and record review, it was determined the facility failed to follow physician orders and provide necessary treatment related to bowel care for 2 of 3 sampled residents (#s 12 and 18) reviewed for change of condition. This placed residents at risk for dehydration, incontinence and weight loss. Findings include:A 7/1/25 Standing Orders signed by the physician on 7/3/25, indicated if a resident experienced new onset diarrhea, staff were to hold bowel care if loose stools occurred.1. Resident 12 admitted to the facility in 1/2026 with diagnoses including adult failure to thrive. A 1/31/26 admission MDS indicated Resident 12 was moderately cognitively impaired. A 3/2026 Documentation Survey Report (CNA tasks) documented Resident 12 had loose stools as follows:-3/1/26: Night shift -3/4/26: Evening shift -3/7/26: Evening and night shift-3/8/26: Day shift -3/9/26: Day shift -3/11/26: Day, evening, and night shift-3/12/26: Day and night shift -3/13/26: Day shift -3/14/26: Day shift -3/15/26: Day shift -3/16/26: Day shift -3/17/26: Day shift documented as two times -3/18/26: Day shift -3/19/26: Day shift -3/20/26: Day shift -3/23/26: Day shift -3/24/26: Day shift -3/25/26: Day, evening and night shift -3/26/26: Day shift -3/27/26: Day shift and evening shift -3/28/26: Day shift -3/29/26: Day shift A 3/2026 MAR documented Miralax (a medication used to relieve constipation by softening stools and increasing bowel movement frequency) one time a day for bowel care. Miralax was administered from 3/2/26 to 3/10/26. A 3/4/26 Follow up Note from the physician indicated Resident 12 had an episode of loose stools and was managed with loperamide (a medication used to treat diarrhea) and a temporary hold of bowel medications. Review of Resident 12's clinical record found no documented evidence she/he received loperamide or any other medication to assist with loose stools in 3/2026.On 4/1/26 the State Survey agency received a public complaint which indicated Resident 12 had loose stools for about a month and staff had not ordered the appropriate medication to treat the loose stools. On 4/21/26 at 9:58 AM, Resident 12 stated she/he had loose stools for over a month and received medication one time for the loose stools. On 4/22/26 at 11:09 AM, Staff 6 (CNA) stated she reported Resident 12's loose stools to the nurse, and the nurse informed her Resident 12 had received a stool softener. On 4/22/26 at 12:41 PM, Staff 4 (CNA) stated she kept reporting Resident 12's loose stools in 3/2026. Staff 4 stated not all the CMAs knew Resident 12 had PRN medication for her/his loose stools. Staff 4 stated at times she would have to change Resident 12 three to five times a shift but could only document one time. On 4/22/26 at 12:51 PM, Staff 2 (DNS) would have expected staff to use appropriate PRN medication as prescribed if Resident 12 complained of having loose stools.2. Resident 18 was admitted to the facility in 6/2024 with diagnoses including Alzheimer's disease. A 2/15/26 admission MDS indicated Resident 18 was severely impaired for cognition. A 3/2026 Documentation Survey Report (CNA tasks) documented Resident 18 had loose stools as follows:-3/1/26: Day shift -3/6/26: Night shift -3/7/26: Night shift-3/8/26: Night shift -3/12/26: Night shift -3/13/26: Day and night shift -3/16/26: Evening shift -3/18/26: Day and evening shift -3/19/26: Day shift -3/21/26: Night shift -3/25/26: Day shift -3/27/26: Evening and night shift -3/28/26: Night shift -3/30/26: Day, evening, and night shift -3/31/26: Day shift A 3/2026 MAR documented Miralax (a medication used to relieve constipation by softening stools and increasing bowel movement frequency) one time a day for constipation. Resident 18 was administered Miralax daily in 3/2026 except for 3/19/26 and 3/31/26. The MAR also indicated to administer Senna two tablets every evening for constipation. Resident 18 was administered Senna every evening in 3/2026 except on 3/16/26 which referred the reader to Administration notes. Loperamide (a medication used to treat diarrhea) was documented to be administered PRN every eight hours for loose stools. Resident 18 was administered Loperamide on 3/1/26 and 3/19/26. A 3/16/26 Administration Note documented senna was held because Resident 18 had loose stools. A 4/2026 Documentation Survey Report documented Resident 18 had loose stools as follows:-4/1/26: Day shift-4/2/26: Night shift-4/3/26: Day and night shift-4/6/26: Day shift-4/7/26: Night shift-4/8/26: Day shift-4/10/26: Evening shift -4/11/26: Night shift -4/13/26: Evening and night shift -4/14/26: Day shift-4/17/26: Evening and night shift A 4/2026 MAR documented Miralax one time a day for constipation. Resident 18 was administered Miralax daily from 4/1/26 through 4/14/26. The MAR also indicated to administer senna two tablets every evening for constipation. Resident 18 was administered Senna every evening from 4/1/26 through 4/13/26. Loperamide was documented to be administered PRN every eight hours for loose stools. Resident 18 was not administered Loperamide from 4/1/26 through 4/17/26. On 4/22/26 at 10:48 AM, Staff 15 (CNA) stated Resident 18 had loose stools frequently and she stated she reported it to the medication aide and the medication aide reported it to the nurse. On 4/22/26 at 10:42 AM, Staff 13 (CMA) stated she normally checked the residents' chart to see if they had a bowel movement and the consistency. Staff 13 stated she did not remember seeing Resident 18 having loose stools. On 4/22/26 at 12:57 PM, Staff 2 (DNS) would have expected staff to no longer administer Miralax and senna when a resident had loose stools.

Based on observation and interview it was determined the facility failed to keep air temperatures between 71 and 81 degrees Fahrenheit for 2 of 4 halls reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: On 9/30/25 at 9:34 AM, the thermostat in the 100 Hall displayed a temperature of 67 F. A second thermostat in the hall displayed a temperature of 68 F. On 9/30/2025 at 4:35 PM, Resident 106 stated her/his room was cold in the morning and she/he had to put on extra clothes. On 9/30/2025 at 4:42 PM, Resident 65 stated her/his room was very cold at times and stated her/his roommate, who could not be interviewed, frequently complained of being cold. On 12/2/25 at 9:00 AM, temperatures were taken in rooms 501, 505 and 506 by Staff 12 (Maintenance Director) and ranged from 66-68 F. Staff 12 stated hall thermostats being set too low was an ongoing problem in the facility. On 12/2/25 at 10:07 AM, Staff 24 (CNA) stated she received complaints from residents of rooms being too cold. On 12/2/25 at 10:09 AM, the thermostat in 500 Hall displayed a temperature of 68 F. On 12/2/25 at 10:15 AM, Resident 111 stated her/his room was always cold. On 12/2/25 at 10:24 AM, Staff 1 (Administrator) observed 500 Hall thermostats displaying temperatures below 71 F and stated he was very frustrated by the problem of low air temperatures in the facility and had to continually remind staff not to adjust thermostats.

Based on observation, interview, and record review it was determined the facility failed to ensure community use CBG monitors were cleaned with an Environmental Protection Agency approved disinfectant for 2 of 5 Halls (300 Hall and 400 Hall). This placed residents at risk for cross contamination. Findings include: 1. On 9/30/25 at 11:14 AM Staff 31 (CNA) was observed to clean a community use CBG monitor with an alcohol wipe. Staff 31 stated she always used the wipes to clean the monitors. Staff 31 stated Resident #s 5, 11, 61, 80, and 90 had CBGs checked. a. Resident 5 was admitted to the facility in 11/2025 with a diagnosis of diabetes. Resident 5's clinical record revealed she/he did not have a blood-borne pathogen diagnosis On 9/30/25 at 12:10 PM Staff 32 (Interim DNS) stated staff should not clean CBG monitors with alcohol wipes but with a disinfectant which killed blood-borne pathogens. b. Resident 11 was admitted to the facility in 9/2025 with a diagnosis of diabetes. Resident 11's clinical record revealed she/he did not have a diagnosis of a blood-borne pathogen. On 9/30/25 at 12:10 PM Staff 32 (Interim DNS) stated staff should not clean CBG monitors with alcohol wipes but with a disinfectant which killed blood-borne pathogens. c. Resident 61 was admitted to the facility in 8/2022 with a diagnosis of diabetes. Resident 61's clinical record revealed she/he did not have a diagnosis of a blood-borne pathogen. On 9/30/25 at 12:10 PM Staff 32 (Interim DNS) stated staff should not clean CBG monitors with alcohol wipes but with a disinfectant which killed blood-borne pathogens. d. Resident 80 was admitted to the facility in 8/2024 with a diagnosis of diabetes. Resident 80's clinical record revealed she/he did not have a diagnosis of a blood-borne pathogen. On 9/30/25 at 12:10 PM Staff 32 (Interim DNS) stated staff should not clean CBG monitors with alcohol wipes but with a disinfectant which killed bloodborne pathogens. e. Resident 90 was admitted to the facility in 11/2017 with a diagnosis of diabetes. Resident 90's clinical record revealed she/he did not have a diagnosis of a blood-borne pathogen. On 9/30/25 at 12:10 PM Staff 32 (Interim DNS) stated staff should not clean CBG monitors with alcohol wipes but with a disinfectant which killed bloodborne pathogens. 2. On 9/30/25 at 11:44 AM Staff 32 (CNA) stated she/he cleaned the community use CBG monitors with alcohol wipes. Residents who required diabetic monitoring were Resident 66 and 76. a. Resident 66 was admitted to the facility in 9/2025 with a diagnosis of diabetes. Resident 66's clinical record revealed she/he did not have a diagnosis of a blood-borne pathogen. On 9/30/25 at 12:10 PM Staff 32 (Interim DNS) stated staff should not clean CBG monitors with alcohol wipes but with a disinfectant which killed blood-borne pathogens. b. Resident 76 was admitted to the facility in 4/2019 with a diagnosis of diabetes. Resident 76's clinical record revealed she/he did not have a diagnosis of a blood-borne pathogen. On 9/30/25 at 12:10 PM Staff 32 (Interim DNS) stated staff should not clean CBG monitors with alcohol wipes but with a disinfectant which killed blood-borne pathogens.

Based on interview and record review it was determined the facility failed develop a comprehensive care plan for 1 of 1 sampled resident (#9) reviewed for dialysis. This placed residents at risk for unmet dialysis needs. Findings include: Resident 9 was admitted to the facility in 5/2025 with a diagnosis of kidney disease. A 5/20/25 admission MDS indicated Resident 9 received dialysis Resident 9's Pre and Post Dialysis Assessment form revealed she/he had a central line to the right chest for dialysis access. Resident 9's comprehensive Care Plan Report initiated on 5/13/25 revealed she/he required dialysis. The care plan did not indicate the location of the access site or what to do if the access site came apart or was accidently pulled out. On 12/3/25 at 8:33 AM Staff 14 (LPN Resident Care Manager) verified the care plan did not have the access site identified and the care plan did not include what to do if there was an emergency related to the central line. On 12/3/25 at 11:48 AM Staff 1 (Administrator) acknowledged not all staff may know what to do if the emergency care was not on the care plan.

Based on observation, interview, and record review it was determined the facility failed to ensure behavior health services were provided for 3 of 5 sampled residents (#s 9, 19, and 36) reviewed for behavioral-emotional health and hospice. This placed residents at risk for unresolved emotional needs. Findings include:1. Resident 9 was admitted to the facility in 4/2025 with a diagnosis of kidney disease. Resident 9's 8/13/25 Quarterly MDS revealed she/he was moderately cognitively impaired. Resident 9's 8/19/25 Initial Assessment by Witness 7 (Psychologist) revealed Resident 9 had anxiety, memory issues, fear of relocation, and had thoughts of embarrassment due to her/his current health and living situation. Resident 9 denied depression but alluded to the presence of depression. Witness 7 indicated Resident 9's behavioral health needs included emotional support and anxiety management. The plan included a referral to psychiatry to manage medication, low dose antianxiety medications, and regular therapy. Resident 9's clinical record did not reveal a referral to psychiatry or therapy notes. On 9/29/25 at 1:54 PM Resident 9 stated she/he was always depressed, was observed to be tearful during the interview, and stated she/he felt hopeless. Resident 9's 11/20/25 Significant Change MDS revealed Resident 9 was cognitively intact. On 12/2/25 at 11:46 AM Staff 18 (Social Service Director) stated Witness 7's contract was terminated in 9/2025 or 10/2025, and a new mental health provider did not start yet. Staff 18 stated Resident 9 was often tearful, sad, and was for a long time. On 12/3/25 at 10:29 AM Resident 9 stated it helped when she/he spoke to Witness 7. Resident 9 also stated she/he was able to address many issues but still had additional issues to resolve. Resident 9 stated it was really nice to have someone to talk with and to have someone listen. Resident 9 was observed to become tearful and stated, some things [she/] he can't get away from, and Witness 7 listened to her/him and helped her/him come to peace. On 12/3/25 at 1:48 PM Staff 1 (Administrator) stated a new mental health provider was to start in 10/2025, but the facility was notified they would not be available until 1/2026. Staff 1 stated there was no interim plan in place for behavioral health services. 2. Resident 19 was admitted to the facility and 12/2018 with diagnoses including depression, mood disturbances and suicidal ideations. The 12/11/18 Preadmission Screening and Resident Review (PASARR) Level 1 revealed Resident 19 exhibited indicators of severe mental illness. No documentation was found in Resident 19's clinical record to indicate the facility followed up with the mental health referral or requested a Preadmission Screening Review (PASRR) Level II evaluation. A 12/14/18 care plan indicated Resident 19 had psychosocial well-being concerns, a history of suicidal ideations and needed long term care. The facility was to provide counseling by mental health services. The 4/14/23 Suicidal Precautions Checklist revealed Resident 19 made suicidal statements and reported feeling depressed and worthless. Resident 19 was to continue mental health provider services as needed for ongoing assessment and treatment for depression. A 5/5/23 Psych Consultant note recommended Resident 19 continue mental health provider services for ongoing assessment and treatment for depression. No documentation was found in the clinical record to indicate the facility followed up with the above recommendations. A 4/1/25 Psych Consultant note revealed Resident 19 reported having a rough couple of months due to family and personal challenges. Resident 19 expressed feeling lonely, isolated, and had difficulty in maintaining social connections. Resident 19 disclosed feeling depressed and stated her/his current antidepressants don't' seem to be working. Resident 19 noted experiencing suicidal thoughts and described methods she/he had considered, such as using something sharp to self-harm. Resident 19 stated I wanna end it, but I'm not brave enough. The assessment revealed Resident 19 presented with significant depressive symptoms including feelings of hopelessness, sadness, lack of motivation, and passive suicidal ideation. Resident 19's suicidal ideation and depressive symptoms pose a significant risk and warrant close monitoring. Resident 19 reported disconnection from her/his care team and lack of involvement. Staff were to immediately conduct a risk assessment for suicidal ideations and develop a crisis plan. Staff were to refer Resident 19 for psychiatric care and continue to provide regular psychotherapy. Staff were to follow up within one week to assess progress with referrals, ongoing depressive symptoms, and safety concerns. No documentation was found and the clinical record to indicate the facility followed up with the above recommendations. The 7/1/25 Quarterly MDS indicated Resident 19 was cognitively intact. An 8/5/25 Psych Consultant note revealed Resident 19 reported worsening depression with significant hopelessness and passive suicidal ideations. Resident 19 expressed profound isolation and despair. Resident 19's symptoms had worsened compared to the prior session, with escalating despair and more intense thoughts of self-harm. Resident 19 denies active suicidal plans but does endorse ongoing passive ideations; suicide risk remained elevated. Staff were to discuss the resident's case and advocate for evaluation for alternate placement and options to address unmet needs. No documentation was found in the clinical record to indicate the facility followed up with the above recommendations. On 9/29/25 at 5:38 PM, Resident 19 talked about her/his life situation. Resident 19's mood fluctuated throughout the interview as she/he spoke about these concerns. Resident 19 admitted to having thoughts of self-harm, including wanting to cut her/his legs off. Resident 19 stated a while ago she/he was seen by a counselor but did not know why they had not returned. Resident 19 stated they would like to see a professional counselor. On 10/1/25 at 8:37 AM, Staff 38 (CNA) stated Resident 19 fixated on her/his past life, which caused her/his significant depression. Resident 19 had a history of self-sabotage and often punished herself/himself by intentionally urinating on herself/himself and refusing to eat. On 12/1/25 at 10:53 AM, Staff 39 (CNA) stated Resident 19 had been more depressed since August. Staff 39 stated at that time, the resident's antidepression medications was increased, and to her knowledge, this was the last time the resident received counseling. Staff 39 stated Resident 19 had a history of expressing suicidal ideations. Staff 39 stated Resident 19 recently talked about driving her/his motorized wheelchair over the overpass to jump off. Staff 39 stated when Resident 19's depression worsened she/he would stop caring for herself/himself. Staff 39 further stated Resident 19's moods frequently fluctuated, and she/he was difficult to redirect. On 12/2/25 at 9:23 AM, Staff 40 (Social Service Assistant) stated Resident 19's depression had recently increased. Staff 40 confirmed Resident 19's family recently voiced concerns about her/his worsening depression and behaviors but she did not follow up. Staff 40 reported the facility recently ended their contract with the previous behavioral health provider and confirmed, for the past several months, Resident 19 had not been receiving treatment for her/his behavioral health needs. On 12/2/25 at 11:23 AM, Staff 18 (Social Worker) stated Resident 19's behaviors fluctuated, and she/he had a history of suicidal ideations. Resident 19 was receiving behavioral health services until the facility ended their contract several months ago and she did not know when the facility was going get a new behavioral health provider. Staff 18 stated she was not aware of Resident 19's family concerns about her/his increased depression or request for behavioral health services. Additionally, Staff 18 stated about a year ago she completed a PASRR audit, but resident 19 was not included. Staff 18 confirmed Resident 19's PASRR Level I indicated SMI indicators, but no follow-up was initiated. On 12/2/25 at 3:15 PM, Staff 20 (Unit Manager/LPN) stated she was familiar with Resident 19's psychiatric history and behaviors. Staff 20 reported Resident 19's depression fluctuated but typically worsened during the holidays. Staff 20 stated the resident had been seen by behavioral health services a few months ago, but the facility did not have a behavioral health provider at this time. Staff 20 further stated she was not aware of Resident 19's family's concerns regarding the resident's increased depression or their request for behavioral health services. On 12/2/25 at 3:10 PM, Staff 1 (Administrator) confirmed the facility had not followed up on physician recommendations for behavioral health services and the facility would not have a behavioral health provider until 1/2026. On 12/3/25 at 10:15 PM, Witness 9 stated Resident 19's antidepressant medication had been increased, but it did not appear to be effective. Witness 9 expressed concerns about her/his self-harming behaviors. Witness 9 stated Resident 19's depression often worsened during the holidays, leaving her/him feeling hopeless and helpless. Witness 9 stated Resident 19 would benefit from counseling services to help her/him learn coping strategies. Witness 9 further stated she notified the facility of her concerns and requested behavioral health services, including counseling, but the facility had not responded. 3. Resident 36 admitted to the facility and 2/2025 with diagnosis including encephalopathy (disease of the brain that changes its function). The 3/4/25 care plan indicated Resident 36 had a history of trauma related to physical abuse. Resident 36 was to maintain optimal quality of life despite a history of trauma. Resident 36 was unaware of the specific situations that caused her/him stress or feelings of being overwhelmed and she/he relied on staff support. A 6/10/25 Provider Note revealed Resident 36 exhibited symptoms of anxiety and paranoia, hearing external threats regarding her/his finances and personal safety. Resident 36 showed signs of mild cognitive impairment. Staff to consider a psychiatric evaluation to assess the resident's paranoia and possible delusional thinking. Diagnoses include delusional disorder and generalized anxiety. On 9/30/25 at 1:00 PM, an interview was attempted with Resident 36, however the resident appeared frightened, avoided eye contact, and responded with nonsensical statements. A 10/19/25 Progress Note revealed staff notified Resident 36's physician regarding increased aggression during exit seeking behavior. The physician's response directed staff to have Psych follow up with Resident 36. On 12/2/25 at 1:30 PM, Staff 39 (CNA) and the surveyor approach resident 36 in her/his room. The resident appeared frightened and confused and began making statements staff were stealing her/his belongings. Staff 39 stated resident 36 often had difficult behaviors and was difficult to redirect. Staff 39 further stated she was not aware what type of behavioral health services the resident received. On 12/2/25 at 3:04 PM, Staff 20 (Unit Manager/LPN) stated she did not know what psych services the facility currently provided for Resident 36. On 12/2/25 at 3:10 PM, Staff 1 (Administrator) stated Resident 36 was a complex resident with a history of trauma. Staff 1 confirmed the facility had not followed up on the physician's recommendations for behavioral health services and the facility would not have a behavioral health provider until 1/2026.

Based on record review and interview it was determined the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified of a resident's discharge or hospitalization for 3 of 3 sampled residents (#s 11, 98, and 100) reviewed for discharge and hospitalization. This placed residents at risk for lack of knowledge regarding their rights, choices and potential financial responsibilities. Findings include:1. Resident 11 was admitted to the facility in 9/2025 with diagnoses including stroke and respiratory failure. A review of Resident 11's clinical record revealed she/he was discharged to the hospital on 8/30/25 and discharged from the facility on 10/15/25. No evidence was found in the clinical record to indicate the Long-Term Care Ombudsman was notified of the resident's discharges on 8/30/25 and 10/15/25. On 12/1/25 at 1:57 PM, Staff 1 (Administrator) acknowledged the Long-Term Care Ombudsman was to be notified of discharges and transfers, and it was not clear who was responsible to complete the task within the facility. On 12/3/25 at 10:40 AM, Staff 18 (Social Worker) confirmed she was not aware of the required notification to the Long-Term Care Ombudsman for transfers or discharges. 2. Resident 98 admitted to the facility in 7/2025 with diagnoses including Methicillin Susceptible Staphylococcus Aureus infection (severe infection) and diabetes. A 7/26/25 admission MDS indicated Resident 98 was cognitively intact. A review of Resident 98's health record revealed she/he was hospitalized on [DATE]. No evidence was found in Resident 98's health record indicating the Office of the State Long-Term Care Ombudsman was notified of the resident's hospitalization. On 12/3/25 at 13:59, Staff 1 (Administrator) stated he was aware the Office of the State Long-Term Care Ombudsman's office should be contacted with all discharges and transfers to the hospital and acknowledged the facility had not notified the Office of the State Long-Term Care Ombudsman's office about Resident 98's hospitalization. 3. Resident 100 admitted to the facility in 7/2025 with diagnoses including fractured ribs and fractured left arm. A 7/7/25 admission MDS indicated Resident 100 was cognitively intact. A review of Resident 100's health record revealed she/he was discharged on 7/17/25. No evidence was found in Resident 100's health record indicating the Office of the State Long-Term Care Ombudsman was notified of the resident's discharge. On 12/3/25 @ 13:59, Staff 1 (Administrator) stated he was aware the Office of the State Long-Term Care Ombudsman's office should be contacted with all discharges and transfers to the hospital and acknowledged the facility had not notified the Office of the State Long-Term Care Ombudsman's office about Resident 100's discharge.

Based on interview and record review it was determined the facility failed to ensure a resident's pressure ulcers were thoroughly investigated for 1 of 1 sampled resident (# 40) reviewed for hospice. This placed residents at risk for additional pressure ulcers. Findings include:Resident 40 was admitted to the facility in 6/2025 with a diagnosis of heart disease. Resident 40's Progress Notes revealed on 9/14/25 she/he was identified to have a pressure injury to the lower spine. The top of the wound had a small opening and treatment was provided. Resident 40's clinical record revealed she/he had two 9/15/25 Skin and Wound Evaluation forms. One revealed Resident 40 developed a facility acquired DTI (Deep Tissue Injury- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) located to the buttocks which was 7.5 cm long and 2.4 cm wide. The form indicated the skin was intact but discolored and new treatment orders were implemented. The second form revealed a facility acquired DTI to the spine which was 6.6 cm long and 2.6 cm wide. The form indicated the skin was intact but discolored and new treatment was implemented. Resident 40's 9/14/25 New Pressure Ulcer investigation indicated a new pressure injury was identified to her/his lower spine. the team review included Resident 40's diagnosis, immediate interventions. interventions to be added, and notifications. There was no root cause analysis to determine if this was an avoidable or unavoidable pressure ulcer, or if neglect of care was suspected. Resident 40's clinical record did not have an investigation for the DTI to the buttocks identified on 9/15/25. On 12/3/25 at 11:48 AM with Staff 1 (Administrator) and Staff 28 (Wound Nurse), Staff 1 stated the team worked together to complete the investigations to ensure the investigations were complete and the root cause analysis identified the cause of the problem to prevent re-occurrence. Staff 1 stated this was not done for Resident 40's 9/14/25 DTI investigation. Staff 28 stated the nurse who identified the 9/15/25 buttock DTI did not initiate an investigation; therefore, it was not completed.

Based on interview and record review it was determined that the facility failed to implement nutritional interventions to prevent weight loss for 1 of 4 sampled residents (#40) reviewed for nutrition. This placed residents at risk for continued weight loss. Findings include: Resident 40 was admitted to the facility in 6/2025 with a diagnosis of heart disease. a. Resident 40's 6/16/25 Nutritional Evaluation revealed the dietary manager was to evaluate Resident 40 for fortified food, if the resident would accept any of the typical offerings. Resident 40's clinical record revealed a diet order for fortified meals was initiated on 8/3/25. On 12/3/25 at 11:20 AM Staff 37 (District Dietary Manager) stated if a RD wrote orders for a fortified diet the dietary staff implemented the order. The RD would send an email to the dietary staff or would directly add the fortified meal into the resident's dietary orders. Staff 37 stated if a RD recommended a fortified diet but did not write an order, the dietary manager would not communicate with the resident, and the Resident Care Manager would need to obtain an order from a resident's physician. On 12/2/25 at 3:07 PM Staff 36 (LPN Resident Care Manager) stated he did not see communication to Resident 40's physician in 6/2025 related to a fortified diet and did not see a 6/2025 nutrition committee note related to adding fortified meals, and verified the fortified meals were not stared until 8/2025. b. Resident 40's 9/11/25 Nutrition Evaluation revealed she/he had weight loss and current interventions included two different supplemental drinks. Resident 40 was noted to refuse oral intake and there were concerns for depression. The recommendation was to consider starting mirtazapine (antidepressant which can also be an appetite stimulant). Resident 40's clinical record did not reveal staff communicated with Resident 40's medical provider if starting mirtazapine was an option to support weight gain. On 12/2/25 at 3:07 PM Staff 36 (LPN Resident Care Manager) stated when a recommendation by a RD was made to add a medication, staff communicated with a resident's physician. Staff 36 stated he did not see a note in Resident 40's record related to the RDs recommendation to add an antidepressant and did not see it in the nutrition committee notes. Staff 36 stated Resident 40 was depressed and losing weight. Staff 36 stated when Resident 40's medical provider met with her/him Resident 40 elected hospice services, but Staff 40 stated he did not see any notes related to weight loss or adding mirtazapine.

Based on interview and record review it was determined the facility failed to ensure a resident's advance directive was in her/his clinical record for 1 of 1 sampled resident (#3) reviewed for advance directives. This placed residents at risk for end-of-life decisions not being honored. Findings include: Resident 3 was admitted to the facility in 2/2025 with a diagnosis of diabetes. Resident 3's 8/14/24 Care Conference form indicated she/he had an advance directive at home. There was no evidence Resident 3's advance directive was present in her/his clinical record. On 12/2/25 at 11:45 AM Staff 18 (Social Service Director) stated Resident 3 reported she/he had an advance directive at home, but her/his spouse did not bring it to the facility. Staff 18 stated she would follow up with the spouse at the next quarterly care conference to ensure she/he brought it to the facility. On 12/3/25 at 11:48 AM Staff 1 (Administrator) stated if a resident had an advance directive, it was to be in the resident's clinical file as soon as possible.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident's antipsychotic medication was not increased when adverse side effects were present for 1 of 4 sampled residents (# 92) reviewed for nutrition. This placed residents at risk for irreversible involuntary movements. Findings include: Resident 92 was readmitted to the facility in 8/2025 with a diagnosis of dementia. Resident 92's AIMS (Abnormal Involuntary Movement Scale) evaluations revealed on 1/11/25 she/he scored 2, on 8/15/25 she/he scored 7. The scale ranges from zero to 28, the higher the number, the greater the impact of involuntary movements on the resident. Resident 92's Progress Notes from 8/14/25 to 9/9/25 revealed the following:-8/15/25 Alert, able to make needs known. Pleasant and cooperative. -8/16/25 Alert, able to make needs known, and adjusting to the facility. Resident had tremors per baseline. -8/17/25 Alert, independent to eat.-8/24/25 Resident pressed her/his call light every 20 to 30 minutes requesting staff to assist with all her/his ADLs.-8/26/25 Resident reported she/he was doing well and had no complaints. There were no notes from 8/31/25 through 9/10/25. Resident 92's 9/2025 ADL report revealed behavior symptoms from 9/1/25 to 9/9/25 included 12 shifts with yelling, one shift with wandering, and two shifts with abusive language. Resident 92's 9/2025 TAR revealed no documented behaviors from 9/1/25 through 9/9/25 including paranoia, distressing delusions, hallucinations or yelling. Resident 92's 9/9/25 communication form from Staff 14 (LPN Resident Care Manager) to Staff 26 (NP) revealed the night staff reported Resident 92 yells out most of the night shift after 10:00 PM. Staff 14 requested Staff 26 assess Resident 92. A handwritten response by Staff 26 indicated Resident 92's antipsychotic medication was increased. Resident 92's 9/2025 MAR revealed she/he was administered Risperdal (antipsychotic) two mg in the morning and four mg in the evening from 9/1/25 through 9/8/25. The evening dose was increased to four mg on 9/9/25. Resident 92's 9/13/25's AIMS score was 10. Resident 92's 9/10/25 Progress Note-Follow up (NP note) revealed I had previously attempted to wean down her[/his] Risperdal and nursing reported increased behaviors screaming, delusions so I increased her[/his] dose back to where it was at her[/his] re-admission, she[/he] is noted to have increased lip smacking, head tremors.' The note also indicated a referral was placed for a psychiatry evaluation and medication management. The note also indicated Staff 26 observed Resident 92 in the past to have extreme episodes of paranoid delusions while not on Risperdal. On 10/2/25 at 8:19 AM Resident 92 was observed to attempt to bring her/his straw to her/his mouth but was not able bring the straw to her/his lips to drink. Resident 92 stated she/he wanted to drink but she/he was shaking too much. Resident 92's hands and head were observed to have involuntary movement. On 10/2/25 at 8:25 AM Staff 25 (CMA) stated Resident 92 had bad shakes. In the past, Resident 92 was able to feed her/himself. On 10/2/25 at 10:57 AM Staff 27 (CNA) stated at times Resident 92 yelled, but she/he was easily redirected. Staff 27 stated Resident 92 was able to make her/his needs known. Staff 27 stated at times Resident 92 spoke to someone in the room who was not present, but she/he was not distressed while talking. Staff 27 stated Resident 92 had shakes, and it was different each day, some days were worse than others. On 10/2/25 at 11:26 AM Staff 14 stated when she notified Staff 26 about Resident 92's behaviors she did not indicate she/he was hallucinating, but staff reported Resident 92 yelled. On 10/2/25 at 2:08 PM Staff 26 stated she initially saw Resident 92 during her/his previous admission. Historically, Resident 92 had behaviors including paranoid delusions, hallucinations, and she/he screamed. Resident 92 was on a higher dose of Risperdal during her/her previous admission, and the facility staff were able to decrease the dose before she/he was discharged from the facility. When resident 92 was re-admitted to the facility in 8/2025 an outside provider increased her/his Risperdal dose. Staff 26 stated on 9/9/25 facility staff reported Resident 92 yelled out, and when she/he was stable, she/he usually did not yell. Staff 26 stated she believed staff also reported Resident 92 was hallucinating. Staff 26 stated if she would have known the resident was easily redirected, she would not have increased the Risperdal.

Based on observation, interview, and record review it was determined the facility failed to ensure residents did not have cigarettes and lighters in their rooms and a fall investigation was thoroughly completed for 3 of 10 sampled residents (#1, 11, and 110) reviewed for accidents. This placed residents at risk for accidents. Findings include: 1. Resident 1 was admitted to the facility in 7/2024 with diagnoses including chronic obstructive pulmonary (lung) disease and epilepsy (brain disorder characterized by seizures). The 2/2025 facility Resident Smoking Policy and Procedure revealed ignition sources were not permitted in resident rooms. Lighters belonging to independent smokers were required to be stored in an assigned smoking locker. The 4/9/25 Nursing Smoking Screen revealed Resident 1 smoked more than 10 times daily and was able to light her/his own cigarettes. The 7/25/25 Annual MDS revealed Resident 1 had a BIMS of 15 (cognitively intact), used her/his wheelchair independently, and was a smoker. An 8/11/25 revised care plan directed staff to educate Resident 1 on the facility smoking policy, designated smoking locations, and safety concerns. On 9/29/25 at 12:26 PM, Resident 1 was observed in her/his room with a lighter in a plastic bag attached to her/his wheelchair and cigarettes in a dresser drawer. Resident 1 stated she/he was an independent smoker. On 9/30/25 at 12:06 PM and 2:00 PM, Resident 1 was observed to enter her/his room after being outside. Staff 19 (LPN) stated she thought Resident 1 quit smoking because the resident no longer returned smoking supplies to the resident's lock box at the front desk. On 9/30/25 at 12:13 PM, Staff 37 (CNA) stated she provided care to Resident 1 and did not believe the resident kept smoking supplies in her/his room because she was often seen at the front desk with the nurse. On 9/30/25 at 3:15 PM, Staff 30 (CNA) stated CNAs were hands-off with residents who were independent smokers and Staff 30 was unsure if independent smokers were required to store smoking supplies in a locked box. On 10/1/25 at 8:50 AM, Staff 36 (LPN) confirmed Resident 1 was in bed and had no smoking supplies in her/his lock box. Staff 36 stated she was unsure about the smoking policy for Resident 1 and the resident was not flagged to ensure smoking items were returned to the lock box. On 10/1/25 at 8:55 AM, Staff 14 (Unit Manager-LPN) stated no smoking materials were expected in Resident 1's room and acknowledged the resident was non-compliant with smoking rules. On 10/1/25 at 9:09 AM, Staff 1 (Administrator) acknowledged the facility needed to find a new solution for the storage of Resident 1's lighter and smoking supplies. 2. Resident 11 was admitted to the facility in 4/2024 with diagnoses including stroke, respiratory infection, and respiratory failure. A 5/8/24 Nursing Restraint vs Enabler Screen identified Resident 11's bed canes were used for bed mobility. The 7/4/25 Quarterly MDS revealed Resident 11 had a BIMS assessment score of 14 (cognitively intact), the resident was on oxygen and had lower and upper impairment on one side. The 7/2025 TAR revealed Resident 11 required three liters of oxygen per minute via a nasal canula (plastic tubing in the nose), staff were to monitor the resident for shortness of breath and maintain oxygen saturation at or above 90%. A 7/15/25 revised care plan revealed Resident 11 required the assistance of two staff for transfers, she/he was at risk for falls, and interventions included bilateral bed canes, fall mats, and placement of her/his bed in the lowest position against the wall. An 8/30/25 Unwitnessed Fall investigation completed by Staff 13 (LPN) revealed, at approximately 2:45 PM, a CNA discovered Resident 11 on her/his knees with her/his face and upper body leaning on the bed. Resident 11 stated she/he attempted to get out of bed to assist a new roommate and appeared confused earlier in the day. No injuries were observed. Resident 11 was transported to the emergency room after unsuccessful attempts to return her/him to her/his wheelchair. The resident became difficult to rouse, and her/his oxygen saturation was at 59%. The report indicated predisposing factors of the fall included change in cognition, illness, and confusion about the new roommate. No additional information about the fall was found. On 9/30/25 at 5:15 PM, Staff 1 (Administrator) stated no issues were found based on the 8/30/25 fall investigation. Staff 1 expected staff to follow fall interventions according to the care plan. On 10/1/25 at 12:29 PM, Staff 13 stated staff did not know how Resident 11 fell and acknowledged a lack of documentation. Staff 13 confirmed she did not complete the required paperwork or request witness statements. On 10/1/25 at 1:42 PM, Staff 30 (CNA) stated Resident 11 was confused on 8/30/25 and was last observed in her/his room [ROOM NUMBER] minutes prior to the fall. Staff 30 did not recall the resident's bed being in the lowest position. On 10/1/25 at 3:44 PM, Staff 15 (CNA) stated she immediately assisted Resident 11 after the fall on 8/30/25. Staff 15 stated she found Resident 11 dangling from the bed with her/his head stuck between the bed and a bed cane. Staff 15 stated Resident 11's nasal canula was dislodged when the resident was found. Staff 15 confirmed her witness statement was not requested. On 12/2/25 at 4:34 PM, Staff 14 (Unit Manager-LPN) stated Resident 11 used her/his bed canes routinely for repositioning and a revised evaluation of the resident's bed canes was expected after her/his fall. Staff 14 acknowledged witness statements from all staff were not obtained as expected and the fall investigation was not thorough. 3. Resident 110 was admitted to the facility in 9/2025 with a diagnosis of heart disease. A 2/2025 facility Resident Smoking Policy and Procedure revealed ignition sources of any kind were not to be kept by residents. Lighters belonging to independent smokers must be stored in their assigned smoking locker. Resident 110's 9/25/25 admission MDS revealed she/he was cognitively intact. Resident 110's Care Plan initiated on 9/26/25 revealed she/he was a supervised smoker. Resident 110 was to follow all the facility smoking rules. Staff were to instruct the resident on the facility smoking policy. On 9/29/25 at 11:25 AM Resident 110 was observed in bed with oxygen on, and she/he had cigarettes and a lighter on her/his bedside table. Resident 110 stated she/he took her/his oxygen off when she/he went out to smoke. On 10/1/25 at 9:09 AM Staff 1 (Administrator) stated lighters were not to be kept in the resident's room. On 12/3/25 at 8:51 AM Staff 27 (CNA) stated all residents were to keep cigarettes and lighters in a locked box even if they were independent smokers. Staff 27 stated she recalled 9/29/25 when Resident 110 had cigarettes and a lighter in her/his room and she removed them and put them in the locked box.

Based on observation, interview and record review it was determined the facility failed to revise care plan interventions for 1 of 1 sampled resident (#22) reviewed for position and mobility. This placed residents at risk for unmet needs. Findings include:Resident 22 was admitted to the facility in 7/2024 with diagnoses including chronic curvature of the spine, dementia, and repeat falls. The 7/28/25 Annual MDS revealed Resident 22 required a wheelchair for transportation and was dependent on staff for walking and transfers. The 10/2025 Documentation Survey Report indicated Resident 22 did not walk ten feet and was dependent on staff to ambulate for all recorded shifts. A 11/10/25 revised care plan indicated Resident 22 required the extensive assistance of one staff with the use of a walker to ambulate, used a cane for mobility and a sit to stand lift for transfers. Resident 22's care plan had no reference to the use of a pillow for positioning comfort. On 10/1/25 at 8:39 AM, Resident 22 was observed in bed eating breakfast from a bedside table. The resident leaned to her/his right side and a pillow was in place for support. There was no walker in the resident's room. On 12/2/25 at 10:03 AM, Staff 21 (CNA) stated Resident 22 leaned to her/his right side automatically, had pain during repositioning, and a pillow was used for her/his comfort. Staff 21 stated a Hoyer (hydraulic mechanical lift) was needed to transfer Resident 22 to her/his wheelchair and the resident had not used a walker for almost a year because she/he was unable to stand. On 12/2/25 at 1:17 PM, Resident 22 was observed sleeping and leaned to her/his right side in bed with no support. On 12/2/25 at 1:24 PM, Staff 19 (LPN) confirmed Resident 22 was more active six months earlier and Unit Managers were to update care plans for residents. On 12/3/25 at 9:57 AM, Staff 22 (CNA) stated she worked multiple halls and shifts and concluded Resident 22's care plan was inaccurate based on verbal information from other CNAs. Staff 22 stated she attempted to sit Resident 22 upright with no support to eat and confirmed the information about Resident 22's pain during repositioning and use of a pillow was needed in the care plan. Staff 22 stated it was an accident waiting to happen without accurate information regarding Resident 22's use of a Hoyer for transfers and need for a wheelchair to ambulate. On 12/3/25 at 11:56 AM, Staff 14 (Unit Manager-LPN) expected Staff 23 (MDS-RN) to compare MDS information and update the care plan each quarter. Staff were to compare the care that was provided to the resident to revise the care plan. Staff 14 acknowledged a review of Resident 22's care plan required a team approach and the resident's care plan was not accurate or revised in many areas. Staff 14 expected staff to notify her when a resident's care plan was not safe to ensure timely revisions. On 12/3/25 at 2:09 PM, Staff 2 (DNS) expected Staff 23 to interview staff and assess residents each quarter. Staff 2 expected care plans to address the specific care needs of each resident.

Based on interview and record review it was determined the facility failed to ensure a resident received thickened liquids as ordered for 1 of 4 sampled residents (#40) reviewed for nutrition. This placed residents at risk for aspiration. Findings include: Resident 40 was admitted to the facility in 6/2025 with a diagnosis of heart disease. Resident 40's 9/16/21 Dietary Order Details revealed she/he was to receive mildly thickened liquids. Resident 40's 9/21/25 Progress Notes revealed Staff 29 (LPN) notified Residents 40's medical provider that she/he aspirated during a meal. Resident 40's provider ordered a chest x-ray. Resident 40's 9/21/25 communication form to Resident 40's medical provider revealed she/he aspirated at lunch while drinking Ensure which was not thickened. The form included a handwritten note by Resident 40's medical provider dated 9/23/25 which revealed Resident 40's chest x-ray was negative. On 10/1/25 at 7:19 AM Staff 29 verified a CNA provided Resident 40 a supplemental drink which was not thickened, Resident 40 aspirated, and she notified her/his physician. On 12/2/25 at 7:09 PM Staff 14 (LPN Resident Care Manager) stated the supplemental drinks such as Ensure were to be thickened by a nurse, CMA, or dietary staff if a resident was on a thickened liquid diet.

Based on interview and record review, it was determined the facility failed to ensure a resident did not develop a pressure ulcer, failed to identify a pressure ulcer, and provide physician ordered treatments for 2 of 3 sampled residents (#s 3 and 76) reviewed for pressure ulcers. This placed residents at risk for delayed care and worsening pressure ulcers. Findings include: 1. Resident 3 was admitted to the facility in 2/2025 with diagnoses including diabetes, peripheral vascular disease (impaired circulation), and right hemiparesis (weakness) due to a stroke. Resident 3's 2/26/25 Admission/readmission Evaluation form revealed she/he was admitted to the facility without a pressure ulcer. Resident 3's Care Plan initiated on 2/26/25 revealed she/he required limited assisted with bed mobility, had peripheral vascular disease and her/his legs were to be elevated when sitting or sleeping (initiated 3/6/25). The care plan also directed staff to report new skin issues. Resident 3's 2/27/25 Nurse Practitioner Encounter Note revealed Resident 3 reported she/he had weakness to the right knee and leg. The resident was assessed to have generalized weakness due to deconditioning and had right sided weakness which was her/his baseline. Resident 3 was also assessed to have swelling in the legs and staff were to keep her/his legs elevated above the heart. Resident 3's 3/4/25 admission MDS revealed she/he was cognitively intact, had chronic pain, and a contracture to the right leg. Resident 3 was at risk for developing pressure ulcers due to diagnoses and medical conditions including diabetes, heart disease, kidney disease, peripheral vascular disease, and hemiparesis. Resident 3' 3/2025 Documentation Survey Report (CNA documentation) revealed on 3/20/25, 3/21/25, and 3/22/25 CNAs identified a red and discolored area, and the area was not new. The report indicated on day shift Resident 3 was independent to roll left to right on day shift 21 shifts and otherwise required moderate to substantial assistance, on evening shift 17 shifts she/he was independent, otherwise required contact assistance or more, and refused assistance on one shift. On night shift Resident 3 required contact assistance or more on 17 shifts, the activity was documented as not applicable on seven shifts, and she/he was independent on one shift. Resident 3's Progress Notes from 3/1/25 to 3/31/25 indicated she/he was independent with bed mobility but did not indicate her/his heels were elevated off the bed. There were no notes related to 3/20/25, 3/21/25, and 3/22/25 when a CNA identified skin issues on the Documentation Survey Report. Resident 3's 4/2025 Documentation Survey Report revealed Resident 3 required substantial to moderate assistance to roll in bed on most shifts. On evening shift there were 12 shifts when Resident 3 was independent, or the activity was not applicable. On night shift there were six shifts when the resident was independent, or the activity was not applicable. Resident 3's 5/7/25 Skin and Wound-Total Body Skin Assessment completed by Staff 28 (Wound Nurse) at 7:52 AM. The assessment indicated Resident 3 did not have any skin issues. Resident 3's 5/7/25 at 3:25 PM Progress Notes revealed a CNA found wounds on Resident 3's heels. Resident 3's 5/8/25 Skin and Wound Evaluation form revealed she/he had a facility acquired DTI (Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. A DTI occurs in the tissue that has been subjected to pressures that exceed the tolerance level of muscle tissue. The muscle cell is deformed and irreversibly injured from the pressure) to the right heel. The DTI was 4.2 cm long and 1.8 cm wide, 100% covered with eschar (layer of dead tissue), had a moderate amount of drainage, and the edges were macerated (softened by drainage). Resident 3' 5/8/25 Skin and Wound evaluation form revealed Resident 3 had a facility acquired DTI to the left heel. The left heel DTI was 4.9 cm long and 2.5 cm wide, 100% covered with eschar, had a moderate amount of drainage and the edges were macerated. On 9/29/25 at 9:21 AM Staff 35 (CNA) stated when Resident 3 was initially admitted to the facility she/he was able to reposition in bed, but she/he could not put a pillow under her/his legs because she/he had leg weakness. Staff 35 stated Resident 3 did not refuse care, wore two different shoes, and the shoes were not tight. On 9/29/25 at 9:23 AM Staff 9 (LPN) stated when Resident 3 was first admitted to the facility she/he was able to move, but it was hard for her/him to move her/his legs. Resident 3 initially did not use pillows under her/his legs until after she/he developed pressure ulcers. Staff 9 stated Resident 3 did not refuse care, usually wore a black orthotic shoe and the shoe did not fit tight. If a CNA identified a skin issue, the CNA was to notify the nurse, the nurse was to assess the skin, make a progress note, notify the resident's medical provider, and provide care as needed. A skin sheet was initiated if it was a skin issue that needed to be monitored weekly, such as a pressure ulcer. On 9/29/25 at 3:28 PM Resident 3 stated she/he had bad circulation to her/his legs. Resident 3 stated she/he was not able to turn in bed independently and the staff did not provide pillows under her/his legs until she/he developed pressure ulcers. Resident 3 denied refusing to elevate her/his heels off the bed. On 9/29/25 at 4:13 PM Witness 8 (Spouse) stated Resident 3 had severe neuropathy (nerve damage which causes weakness, numbness, and pain usually in the hands and feet) and impaired circulation to her/his feet. The staff did not assist Resident 3 to turn, and she/he would not request assistance. On 9/30/25 at 10:32 Staff 34 (CNA) stated Resident 3 did not refuse care and she/he accepted a pillow under her/his leg to elevate heels off the bed. Staff 34 stated she recalled in 3/2025 Resident 3 had an area to the back of both heels and ankles which was red and purple and the skin was very flaky. Staff 34 also stated she notified a nurse. On 9/30/25 at 9;30 am Staff 7 (CNA) stated Resident 3 was assisted with repositioning and required extensive assistance. Resident 3 had pillows, but the pillows were not used very often until after the heel wounds developed. On 10/1/25 at 3:52 PM Staff 28 (Wound Nurse) stated she completed all the residents' weekly Total Body Skin Assessments. Staff 28 stated she reviewed the shower sheets to see if the CNAs reported any skin issues and also did a physical skin assessment on each resident. Staff 28 stated she completed Resident 3's 5/7/28 assessment in the morning of 5/7/25 and documented no skin issues and acknowledged the CNAs found the Resident 3's DTIs the same evening when they provided her/his shower. Staff 38 stated it was hard to say how long the DTI was there. On 10/1/25 at 4:10 PM Staff 33 (Interim DNS) acknowledged Resident 3's Total Boday Assessment sheet completed the morning of 5/7/25 indicated she/he did not have any skin issues and approximately eight hours later had two DTIs with eschar. Staff 33 stated DTIs could develop very fast, but it was likely the DTIs were not identified in the am. Staff 33 also indicated there was no skin assessment in Resident 3's clinical record after the CNA identified skin issues on the 3/2025 Documentation Survey Report. 2. Resident 76 was admitted to the facility in 3/2025 with diagnoses including diabetes and stroke. A New Pressure Ulcer investigation dated 8/4/25 indicated Resident 76 was found with soiled dressing on the right heel. Upon removal, a 2 cm by 2 cm unstageable pressure ulcer (a wound with full-thickness tissue loss where the base is covered, making it impossible to determine the stage) was observed. No physician orders for the right heel wound were present in the medical record prior to 8/4/25. On 10/2/25 at 9:18 AM Staff 7 (CNA) stated during the end of 7/2025, she provided Resident 76 a shower and observed a skin tear on the right heel. Staff 7 reported the wound to the nurse. On 10/2/25 at 12:07 PM, Staff 1 (Administrator) confirmed there were no physician orders for Resident 76's right heel wound before 8/4/25.

Based on interview and record review it was determined the facility failed to provide sufficient respiratory services for 1 of 3 sampled residents (#11) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs. Findings include:Resident 11 was admitted to the facility in 4/2024 with diagnoses including stroke and respiratory failure. The 5/24/23 facility Transportation Agreement revealed all vehicles were to be staffed and equipped in accordance with the minimum requirements of federal, state, and local laws and regulations. The 7/4/25 Quarterly MDS revealed Resident 11 required oxygen therapy. The 7/2025 TAR indicated Resident 11 required three liters of oxygen per minute via a nasal canula (a plastic tubing in the nose), staff were to monitor the resident for shortness of breath and maintain oxygen saturation (the amount of oxygen traveling through the blood) at or above 90%. A 7/2/25 signed Transportation Request Form indicated Resident 11 had appointments for labs and imaging on 7/7/25, she/he required a companion, and yes was marked for oxygen. On 9/29/25 at 3:24 PM, Witness 5 (Family Member) stated Resident 11 went to appointments without sufficient oxygen on 7/7/25 and emergency oxygen was needed. On 12/1/25 at 12:57 PM, Staff 16 (CNA) stated she accompanied Resident 11 to appointments on 7/7/25 and only one tank of oxygen was available. Staff 16 stated a new appointment was added during the trip and the transportation company did not have additional oxygen in the vehicle. Staff 16 stated Resident 11 was at an imagining appointment when her/his oxygen tank was nearly depleted. Staff 16 stated she felt unprepared for Resident 11's trip and contacted multiple facility staff to obtain emergency oxygen. On 12/1/25 at 1:32 PM, Staff 17 (Receptionist) stated nurses were responsible to assess oxygen needs prior to resident transport. Staff 17 stated she assumed all nurses were aware the transportation company did not carry emergency oxygen for appointments. On 12/1/25 at 1:47 PM, Staff 9 (LPN) stated he recalled the situation with Resident 11's oxygen and acknowledged he did not calculate a contingency for additional oxygen supply for residents who were transported to appointments. On 12/2/25 at 4:30 PM, Staff 13 (LPN) indicated she completed the form for Resident 11's appointment on 7/2/25 but was not present when Resident 11 left for the appointment on 7/7/25. Staff 13 was unaware the transportation company did not carry additional oxygen, and the Transportation Request Forms requirements were unclear. On 12/2/25 at 4:34 PM, Staff 14 (Unit Manager-LPN) expected nurses to calculate oxygen needs of residents during trips to the best of their ability. Staff 14 acknowledged she was unaware the transportation company did not carry additional oxygen and options for supplemental oxygen during trips were needed. On 12/3/25 at 9:03 AM, Witness 4 (Transportation Contract Manager) stated the facility was contacted due to concerns about residents' lack of oxygen during transport and acknowledged the contract required clarification regarding oxygen availability. On 12/3/25 at 1:56 PM, Staff 2 (DNS) acknowledged clearer expectations were needed regarding resident needs during appointments, including oxygen.

Based on interview and record review it was determined the facility failed to ensure residents were treated with respect and dignity for 1 of 6 sampled residents (#12) reviewed for abuse. This placed residents at risk for being treated with a lack of respect and dignity. Findings include: Resident 12 admitted to the facility in 11/2024, with diagnoses including Parkinson's Disease. Resident 12 was on Hospice Services and passed away on 3/9/25. The 2/17/25 facility investigation revealed several staff attempted to assist Resident 12 to sit down in her/his wheelchair. Resident 12 displayed agitation, which included spitting on the ground and toward staff members. Staff 6 (CNA) flicked the resident on the back of her/his hand and stated, If you're going to be mean to me, I'm going to be mean to you. The resident experienced no negative outcome as a result of the interaction. The 2/18/25 Progress Note indicated Resident 11 was combative with staff and Hospice was notified of her/his behavioral changes. The 2/19/25 Progress Note indicated Resident 12 had possible psychosocial distress and increased agitation. Hospice was notified and new medication orders were received. On 4/2/25 at 2:30 PM, Staff 6 stated he flicked Resident 12 on the back of the hand and made the statement in attempt to be playful and calm the resident down. Staff 6 stated the resident was combative and he attempted to light the mood because they had a history of working together. Staff stated he was trying to be playful so Resident 12 would know staff were there to help her/him. On 4/2/25 at 10:45 AM, Staff 1 (Administrator) verified Resident 12 was not treated with respect or dignity by Staff 6.

Based on interview and record review it was determined the facility failed to accurately assess facility acquired pressure ulcers for 1 of 3 sampled residents (#11) reviewed for skin conditions. This placed residents at risk for unassessed and worsening pressure ulcers. Findings include: The National Pressure Injury Advisory Panel defined shearing as a pressure injury when tissue layers moved over the top of each other, and a Stage 3 pressure ulcer as a full thickness tissue loss where subcutaneous fat may be visible but bone, tendon or muscle are not exposed and some slough (dead tissue often appearing as a yellow, tan, or white fibrous material) may be present but does not obscure the depth of tissue loss. Resident 11 was admitted to the facility in 1/2025, with diagnoses including intestinal bypass and failure to thrive. The resident discharged on [DATE]. The 1/9/25 Nursing Admission Evaluation revealed Resident 11 had a red coccyx upon admission. The 1/11/2025 Admission MDS indicated Resident 11 was at risk for pressure ulcers and had no pressure ulcers. The 2/5/25 Wound Evaluation indicated Resident 11 had coccyx shearing. The evaluation indicated the wound had 90% granulation tissue, 10% slough, and light serosanguineous drainage. No wound measurements or staging were completed and the evaluation incorrectly indicated the wound was present on admission. The description of the wound described a Stage 3 pressure ulcer. On 4/2/25 at 3:20 PM, Staff 3 (LPN Unit Manager) acknowledged the skin wound evaluation incorrectly identified the coccyx wound as present on admission, the description of the wound defined a Stage 3 pressure ulcer and the assessment was not fully comprehensive.

Based on interview and record review it was determined the facility failed to evaluate a potential unavoidable accident of a feeding tube being dislodged to prevent recurrence for 1 of 3 sampled residents (#11) reviewed for safety. This placed residents at risk for dislodged feeding tubes. Findings include: Resident 11 admitted to the facility in 1/2025, with diagnoses including failure to thrive and malnutrition. Resident 11's 1/9/25 Hospital Records revealed a J-tube (feeding tube inserted into stomach or small intestine) was surgically placed. The 1/11/25 Admission MDS revealed Resident 11 had a J-tube for enteral feedings (nutritional support). The 2/10/25 Progress Note indicated Staff 7 (CNA) transported Resident 11 to the shower room and when she removed the blanket, the J-tube dislodged and fell out. Staff 7 indicated the J-tube was intact when she placed a bath blanket over her/him in preparation to go to the shower room. The note further revealed an order was received to transfer the resident to the hospital for the J-tube replacement. Review of Resident 11's medical record revealed no documented evidence the resident's accident of her/his J-tube (feeding tube inserted into stomach or small intestine) dislodging was evaluated or investigated to determine how the resident's J-tube had dislodged and how to prevent recurrence. Staff 7 was not interviewed due to no contact information. On 4/2/25 at 2:00 PM, Staff 2 (DNS) stated she did not know how the J-tube dislodged and an incident report or facility investigation was not completed because the facility did not complete them for tubes that fell out. On 4/3/25 at 9:40 AM, Witness 12 (Family) stated staff reported when they pulled the blanket off Resident 11 they also pulled the J-tube out.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 4 sampled residents (#13) reviewed for medications. This placed residents at risk for respiratory distress. Findings include: Resident 13 admitted to the facility in 3/2025, with diagnoses including failure to thrive. Resident 13 was on hospice services. Resident 13's 3/20/25 Progress Note indicated she/he was seen by a hospice nurse and the resident's methadone order was increased to 7.5 mg twice daily. Resident 13's 3/20/25 Hospice Order instructed staff to discontinue the previous order for methadone liquid 5 mg twice daily and to increase the methadone liquid 10 mg/ml to 7.5 ml to equal 7.5 mg by mouth every 12 hours for pain management (7.5 ml equaled 75 mg). The 3/2025 MAR indicated Resident 13 was administered 7.5 ml (75 mg) of Methadone on 3/20/25 at 8:00 PM by Staff 10 (CMA). Resident 13's 3/21/25 Hospice Orders included orders for Naloxone HCL nasal spray 4 mg one dose now (medication to reverse narcotic medication effects) and oxygen at 2 liters per minute prn for O2 sats less than or equal to 88%. The order also clarified the previous methadone order to specify 7.5 mg was 0.75 ml. Resident 13's 3/21/25 Progress Note indicated Naloxone HCL and oxygen were administered to the resident and the hospice nurse remained in the room for approximately one hour after medication administration. On 4/1/25 at 3:18 PM, Staff 10 (CMA) verified she gave Resident 13 7.5 ml of methadone instead of 0.75 ml. Staff 10 further stated when she saw the revised dose in the MAR she consulted with Staff 11 (Charge Nurse LPN) because she thought the new dose should be 0.75 ml. Staff 10 stated Staff 11 reviewed the original order and instructed Staff 10 to administer the medication as 7.5 ml to the resident. Staff 11 was contacted three times by telephone on 4/2/25 at 7:38 AM and 2:00 PM and 4/3/25 at 9:18 AM. Staff 11 did not respond to the voicemail requests for an interview.

Based on interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 2 of 3 sampled residents (#s 2 and 3) reviewed for abuse. This placed residents at risk for unwanted sexual abuse. Findings include: Resident 1 was admitted to the facility in 11/2023 with diagnoses including altered mental status. Resident 2 was admitted to the facility in 10/2023 with diagnoses including dementia. Resident 3 was admitted to the facility in 1/2024 with diagnoses including dementia. Review of a progress note dated 7/22/24 at 8:50 PM revealed Resident 1 was observed with her/his hand down the front of Resident 2's pants. The residents were separated and the administrator was notified. Review of a physician note dated 7/25/24 at 1:26 PM revealed Resident 1 was caught with her/his hands down the pants of a female resident and in bed with her/his roommate. Resident 1 was placed in a private room and had 1:1 supervision by facility staff. Resident 1 was alert and oriented to place only during the physician visit. Review of a facility investigation dated 7/29/24 revealed on 7/22/24 at 7:45 AM Staff 3 (LPN) observed Resident 1 and Resident 2 sitting in wheelchairs, in the hallway, next to each other. When Staff 3 exited a room she observed Resident 1 with their hand in the pants of Resident 2. Staff 3 separated the residents and notified Staff 1 (Administrator). The investigation indicated Resident 2 was not harmed and had no recollection of the incident. Resident 1 was immediately moved to a different hallway with Resident 3. On 7/24/24 at 4:25 AM Staff 2 (CNA) entered the room with Resident 1 and Resident 3 and found Resident 1 in bed with Resident 3. Staff 2 observed Resident 1's hand on Resident 3's penis. Staff 2 notified the charge nurse and Resident 1 and Resident 3 were separated and Resident 1 was moved to a private room with 1:1 supervision by facility staff. Resident 3 was interviewed and had no recollection of the incident. The facility investigation acknowledged both events occurred and no psychosocial harm occurred. In an interview on 8/2/24 at 9:51 AM Resident 3, who was alert, not oriented to place and able to answer questions, said she/he never had a roommate. Resident 3 also stated facility staff treat her/him well and had never been abused by another resident. In an interview on 8/2/24 at 10:01 AM Resident 1, who was alert, not fully oriented and able to answer questions, indicated she/he did not remember touching Resident 2 or Resident 3 and never had a roommate. Resident 1 did not know where she/he lived or how long she/he had been at the facility. In an interview on 8/2/24 at 10:25 AM Resident 2 said she/he had no concerns with care and did not remember the incident with Resident 1. Resident 2 was alert but not oriented to placed and time. In an interview on 8/2/24 at 2:58 PM Staff 2 said on 7/24/24 at 4:25 PM she observed Resident 1 in bed with Resident 3 and Resident 1 had her/his hand on Resident 3's penis. In an interview on 8/7/24 at 8:26 AM Staff 3 said on the evening of 7/22/24 Resident 1 was observed with his/her hand down the front of Resident 2's pants. Staff 3 said the residents were immediately separated and Resident 1 was moved to a different room in a different hallway. In an interview on 8/7/24 at 9:21 AM Staff 1 acknowledged Resident 1 had inappropriate sexual contact with Resident 2 and sexually abused Resident 3. It was determined this citation met the criteria for Past Non-compliance based on the following: The facility was found in non-compliance with the regulatory requirement at F600 at the time of Resident 2's 7/22/24 and Resident 3's 7/24/24 sexual abuse. The facility reported the incident to the State Agency on 7/22/24 and 7/24/24. The abuse of Resident 2 and 3 occurred after the most recent complaint survey of 7/16/24 and before this current survey of 8/7/24. The facility corrected the non-compliance by completion of an incident investigation, identified the regulatory non-compliance and in-serviced all staff on the following resident care plans and abuse policies and procedures. The facility conducted weekly audits to keep residents safe from further abuse and no additional incidents occurred since 7/24/24.

Based on interview and record review it was determined a facility employee sexually abused 6 of 10 sampled residents (#s 6, 7, 8, 9, 10 and 11) who were reviewed for sexual abuse. As a result of the pattern of sexual abuse, it was determined to be an immediate jeopardy situation and residents experienced psychosocial harm. Findings include: 1. Resident 6 was admitted to the facility in April 2024, with diagnoses including a stroke. Review of a progress note dated 6/16/24 at 9:45 AM revealed Resident 6 reported to staff that a night shift male CNA came into her/his room every hour to provide incontinence care and played with her/his clit. Resident 6 requested Staff 2 to not provide care for her/him anymore. Review of a facility's investigation completed on 6/21/24 revealed on 6/16/24 Resident 6 reported to facility staff an allegation of sexual abuse by Staff 2 (CNA). Resident 6 indicated Staff 2 would enter the resident's room every hour to provide incontinence care even though the resident did not require incontinence care and was playing with my clit. The resident also indicated on one occasion Staff 2 stood by the resident's closet with his hand in his pants. Resident 6 thought Staff 2 was masturbating. The investigation indicated Staff 2 acknowledged inappropriately touching Resident 6 three times on 6/16/24 on her/his vagina and clitoris while providing incontinence care during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement). The investigation concluded Resident 6 was sexually abused by Staff 2. In an interview on 6/25/24 at 11:55 AM, Resident 6, who was alert and oriented and able to answer questions, said Staff 2 had inappropriately touched the resident's vagina and clitoris on three occasions. Resident 6 stated she/he had increased anxiety and difficulty sleeping, but was glad Staff 2 did not work at the facility anymore. In an interview on 6/25/24 at 12:00 PM, Staff 1 (CNA) said Resident 6 reported to her the night shift CNA (Staff 2) sexually abused Resident 6 and did not want Staff 2 to provide care for her/him anymore. Staff 1 said Resident 6 had problems sleeping for the next three to four days after the abuse. 2. Resident 7 was admitted to the facility in May 2024, with diagnoses including Post-Traumatic Stress Disorder (PTSD) and depression. Review of a facility's investigation completed on 6/21/24 revealed on 6/18/24 Resident 7 reported to staff she/he was molested and was waiting for police. Resident 7 indicated she/he had been molested multiple times by a male CNA (Staff 2) who was tall with red hair. The resident indicated Staff 2 had touched and spoke to her/him inappropriately. The investigation included an interview with Resident 7 who reported Staff 2 touched her/his breasts and vagina and Staff 2 would touch himself during these occurrences. Resident 7 was visibly upset and distressed when talking to staff about the incident. The investigation indicated Staff 2 acknowledged inappropriately touching Resident 7 on two occasions during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement). In an interview on 6/26/24 at 7:47 AM, Resident 7 stated she/he was sexually abused by Staff 2 (CNA) on the night shift. Resident 7 stated Staff 2 touched her/his breasts and vagina and was afraid and experienced anxiety because of the abuse. Resident 7 said she/he would not be returning to the facility. During the interview, this surveyor observed the resident lying in bed visibly shaking. 3. Resident 8 was admitted to the facility in March 2024, with diagnoses including diabetes. Resident 8 was discharged from the facility and was unable to be interviewed. Based on the reasonable person concept, the surveyor concludes Resident 8 suffered psychosocial harm as a result of being sexually abused. Review of a facility's investigation dated completed on 6/21/24 indicated Staff 2 acknowledged he inappropriately touched Resident 8 two times on the vagina and penetrated her/his vagina with his fingers during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement). 4. Resident 9 was admitted to the facility in March 2024, with diagnoses including kidney failure. Based on the reasonable person concept, the surveyor concludes Resident 9 suffered psychosocial harm as a result of being sexually abused. Review of a facility's investigation completed on 6/21/24 indicated Staff 2 (CNA) acknowledged he inappropriately touched Resident 9 on one occasion on the vaginal area while the resident was sleeping during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement). Staff 2 also indicated Resident 9 woke up and told him to leave her/his room. In an interview on 6/25/24 at 10:22 AM, Resident 9, who was alert and oriented and able to answer questions, stated on one occasion Staff 2 tried to touch her/him inappropriately and she/he told him to go away. 5. Resident 10 was admitted to the facility in June 2024, with diagnoses including a cervical fracture. Resident 10 was discharged from the facility and was unable to be interviewed. Based on the reasonable person concept, the surveyor concludes Resident 10 suffered psychosocial harm as a result of being sexually abused. Review of a facility investigation completed on 6/21/24 indicated Staff 2 (CNA) acknowledged he inappropriately touched Resident 10 on one occasion on the vaginal area while the resident was sleeping during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement). 6. Resident 11 was admitted to the facility in April 2024, with diagnoses including diabetes. Resident 11 was not interviewable. Based on the reasonable person concept, the surveyor concludes Resident 11 suffered psychosocial harm as a result of being sexually abused. Review of a facility's investigation completed on 6/21/24 indicated Staff 2 (CNA) acknowledged he inappropriately touched Resident 11 on one occasion where he penetrated the resident's anus during incontinence care during an interview with Staff 3 (Administrator), Staff 4 (DNS) and Witness 11 (Law Enforcement). In an interview on 6/26/24 at 11:22 AM, Staff 3 (Administrator) acknowledged Resident 6, 7, 8, 9, 10 and 11 were sexually abused by Staff 2 and was present when Staff 2 admitted to sexually abusing multiple residents at the facility. In an interview on 6/26/24 at 12:15 PM, Staff 4 (DNS) acknowledged Resident 6, 7, 8, 9, 10 and 11 were sexually abused by Staff 2 and was present when Staff 2 admitted to sexually abusing multiple residents at the facility. In an interview on 6/27/24 at 12:17 PM, Witness 11 (Law Enforcement) confirmed Staff 2 admitted to the inappropriate sexual contact with multiple residents at the facility. Witness 11 indicated Staff 2 was arrested, taken to jail and faced multiple criminal charges. On 7/16/24 at 10:16 AM, Staff 3 (Administrator) was notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related to the sexual abuse of six resident by Staff 2. It was determined this citation met the criteria for Past Non-Compliance based on the following: The facility was in non-compliance with the regulatory requirement of F600 at the time of the reported 6/16/24 sexual abuse allegation. The facility reported the incident to the State Survey Agency (SSA) on 6/16/24. The abuse of Resident 6, 7, 8, 9, 10, and 11 occurred after the most recent annual recertification survey of 6/14/24 and before the current survey of 7/16/24. On 6/18/24, the Past Noncompliance was corrected when the facility completed a thorough investigation and determined sexual abuse had occurred. The facility's Plan of Correction included: -Alleged perpetrator immediately suspended; -All cognitively intact residents interviewed to ensure no additional residents were sexually abused; -Staff interviewed from various shifts and departments to ensure there were no observations or complaints of abuse in the past 3 months with cognitively intact or cognitively impaired residents; -Provider and residents' families notified; -Care plans for the residents involved in the allegation were updated to include female-only caregivers; -Residents involved in the allegation placed on alert charting and referred to the facility's psychologist; -Skin assessments focused on identifying sexual trauma conducted; -Local law enforcement notified; -Audits conducted weekly until substantial compliance reached, then monthly for two months with verification of sustained compliance; -Audit trends will be reported to facility QAPI for three months for review and further recommendations.

Based on observation, interview, and record review it was determined the facility failed to appropriately assess and evaluate smokers who required supervision for 2 of 10 sampled residents (#s 17 and 24) and 7 out of 10 sampled residents (#s 2, 18, 19, 20, 21, 22 and 23) not appropriately assessed or reassessed timely for smoking. Resident 17 and Resident 24 were observed independently in possession of smoking materials and were not assessed or reassessed for smoking safety. Resident 17 was care planned to require assistance with smoking. Resident 24 was found by the facility smoking independently in her/his room. An immediate jeopardy was called. Findings include: 1. Resident 17 admitted to the facility 1/2020 with diagnoses including diabetes and depression. A revised care plan dated 3/23/21 indicated Resident 17 was a smoker and the smoking rules were reviewed with the resident. Resident 17 required supervision when smoking and she/he was to store all smoking materials (including cigarettes and lighter) at the nurses station. Staff were directed to notify the charge nurse immediately if it was suspected Resident 17 was not following the smoking policy. A review of Resident 17's electronic medical record revealed no smoking evaluation was completed. Random observations made from 4/26/21 through 4/28/21 revealed Resident 17 outside of the facility, on the West (approximately 2000 feet) end of the building sitting in her/his wheelchair with two or three other residents smoking cigarettes on the sidewalk. No staff were present. An observation on 4/29/21 at 1:46 PM revealed Resident 17 sitting in her/his wheelchair in her/his room eating lunch with her/his cigarettes and lighter in a cup holder attached to her/his wheelchair. Resident 17 stated she/he always had her/his cigarettes and lighter with her/him and left the building to smoke. On 4/29/21 at 2:00 PM Staff 1 (CNA) stated Resident 17 was alert, oriented and able to state her/his needs. Staff 1 stated she/he was an independent smoker and left the building to smoke. Staff 1 was not sure if Resident 17 picked up her/his cigarettes and lighter at the nurses station or if she/he always had them with her/him. On 4/29/21 at 2:26 PM Staff 8 (Unit Manager/LPN) stated typically residents were assessed upon admission to ensure they could smoke safely and if they were deemed independent or should be supervised when smoking. Staff 8 stated Resident 17 was a supervised smoker and she had concerns regarding her/his non-compliance. Staff 8 stated she brought concerns to management regarding smoking safety on multiple occasion however nothing was addressed. Staff 8 stated this was an ongoing issue and she was concerned about residents smoking safely. Staff 8 was not sure how often residents were to be re-assessed for smoking. On 4/29/21 at 3:05 PM Staff 24 (LPN) was not sure if Resident 17 smoked and indicated residents who smoked were supposed to pick up their smoking materials at the nurse's station and turn them in after smoking. Staff 24 stated she was unsure who was [NAME] residents' smoking materials. Staff 24 stated she did not know when or how often residents were assessed or reassessed for smoking. On 4/29/21 at 3:18 PM Staff 12 (CNA) stated Resident 17 was an independent smoker and left the building to smoke her/his cigarettes. Staff 12 stated Resident 17 always had her/his cigarettes and lighter with her/him and was not sure if they needed to be checked in and out. On 4/29/21 at 4:15 PM Staff 4 (Administrator) stated a smoking evaluation was never completed for Resident 17. On 4/29/21 at 8:35 PM Staff 4 and Staff 14 (Regional Nurse Consultant) acknowledged some residents' smoking evaluations were not completed on admission or quarterly and care plans were not initiated or reflective of residents who smoked. On 5/20/21 at 10:17 AM Staff 4, Staff 5 (DNS), Staff 14 and Staff 15 (Infection Control Preventionist) were present for an interview. Staff 4 stated she was unaware smokers were not turning in their smoking materials, and she indicated she was unaware residents were not being assessed or reassessed for smoking safety/safely. 2. Resident 24 admitted to the facility 10/2020 with diagnoses including chronic heart failure, [CONDITION(S)] and depression. A care plan initiated on 11/12/20 (37 days after admission) indicated Resident 24 was a smoker and could smoke unsupervised. Resident 24 was instructed about the facility policy on smoking, locations, times, and safety concerns. A smoking evaluation dated 11/12/20 indicated Resident 24 was able to hold, light and put out a cigarette safely. Resident 24 was compliant with the smoking policies and could smoke unsupervised. An encounter note dated 11/18/20 indicated the resident smoked marijuana and possibly using other illicit substances out in the smoking section (outdoors) and Resident 24 required close monitoring, a referral for drug and alcohol (ETOH) treatment was suggested in the past but was declined. A nursing note dated 4/13/21 revealed Resident 24 was discovered in her/his room smoking and in the outside garden area, which was prohibited. On 4/29/21 at 4:30 PM Resident 24 was asked where she/he kept her/his cigarettes and lighter. Resident 24 replied the cigarettes were in her/his drawer and lighter was in her/his pocket. Resident 24 got up out of bed and opened the dresser drawer and showed the surveyor two packs of cigarettes and showed her/his lighter in her/his pocket. A review of Resident 24's electronic record revealed no reassessments were completed for smoking since 11/12/20. On 4/29/21 at 8:35 PM Staff 4 (Administrator) and Staff 14 (Regional Nurse Consultant) acknowledged some residents' smoking evaluations were not completed on admission or quarterly and care plans were not initiated or reflective of residents who smoked. On 5/20/21 at 10:17 AM Staff 4, Staff 5 (DNS), Staff 14 and Staff 15 (Infection Control Preventionist) were present for an interview. Staff 4 stated she was unaware smokers were not turning in their smoking materials, and she indicated she was unaware residents were not being assessed or reassessed for smoking safety/safely. 3a. Resident 2 was admitted to the facility in 10/2020 with diagnoses including chronic heart failure and [CONDITION(S)] (abnormal thought processes and an unstable mood) disorder. A review of Resident 2's electronic record revealed no smoking evaluation was completed and no care plan was initiated regarding Resident 2 being a smoker. On 4/28/21 at 10:15 AM Staff 1 (CNA) stated Resident 2 was an independent smoker. Staff 1 stated Resident 2 was to pick her/his cigarettes and lighter up at the nurses station to go outside and smoke. Staff 1 was not sure if Resident 2 kept her/his cigarettes on her/his or turned them in each time she/he went out for a smoke break. On 4/29/21 at 1:12 PM Staff 3 (CNA) and at 1:31 PM Staff 2 (CNA) stated Resident 2 was able to state her/his needs and did not need much assistance with her/his ADL care needs. Staff 2 and Staff 3 stated they were not sure what Resident 2's smoking status was, but observed her/him go out to smoke on her/his own. On 5/3/21 at 2:39 PM Staff 25 (CNA) stated Resident 2 was independent for all her/his ADL care needs and able to state her/his needs. Staff 25 stated she thought Resident 2 was supposed to be supervised to smoke at designated times into the smoking area. On 5/3/21 at 7:14 PM Staff 11 (CMA/CNA) stated she assisted taking a variety of supervised residents out to smoke on different occasions, however she had concerns regarding smoking safety. Staff 11 stated on her shift on 5/3/21 she took a vape pen from Resident 24 because she/he had it between her/his legs; no one is monitoring residents for smoking safely and adequately, and management just turns a blind eye to the situation. On 5/5/21 at 9:13 AM Staff 26 (CNA) stated Resident 2 was independent with her/his cares and able to state her/his needs. Staff 26 was not sure about Resident 2's smoking status and indicated she did not receive training regarding the facility's smoking policy and procedures. b. A record review of Residents 18, 19, 20, 21, 22 and 23 revealed the following information: -Resident 18 had no smoking evaluation and her/his care plan was not reflective of her/his smoking status. -Resident 19 had no smoking evaluation completed and her/his care plan was not reflective of her/his smoking status. -Resident 20 was not reassessed on a regular basis regarding smoking safety and status. -Resident 22's smoking evaluations was not completed timely. -Resident 23's smoking evaluation was not completed timely. On 5/3/21 at 2:39 PM Staff 25 (CNA) stated she had concerns with residents' smoking safety and was not sure of the policy and procedures to follow because of the poor communication with management. She stated even if you report a concern about smoking nothing happens. On 5/3/21 at 7:14 PM Staff 11 (CMA/CNA) stated she assisted taking a variety of supervised residents out to smoke on different occasions, however she had concerns regarding smoking safety. Staff 11 stated Resident 22 was not safe to smoke on her/his own, had poor vision in one eye and was smoking independently when she/he should be supervised. Staff 11 stated Resident 22 was caught smoking in her/his room about one year ago and had cigarette burn holes in her/his flannel shirt. Staff 11 stated no one is monitoring residents for smoking safely and adequately, and management just turns a blind eye to the situation. On 4/29/21 at 8:35 PM Staff 4 (Administrator) and Staff 14 (Regional Nurse Consultant) acknowledged some residents smoking evaluations were not completed on admission or quarterly and care plans were not initiated or reflective of residents who smoked. On 4/29/21 at 10:30 PM Staff 4 and Staff 14 provided additional information to the survey team which revealed an additional eight residents who resided in the building that were not assessed or reassessed timely and had care plans that were not reflective of the residents' smoking status. On 5/20/21 at 10:17 AM Staff 4 (Administrator), Staff 5 (DNS), Staff 14 (Regional Nurse Consultant) and Staff 15 (Infection Control Preventionist) were present for an interview. Staff 4 stated she was unaware smokers were not turning in there smoking materials, and she indicated she was unaware residents were not being assessed or reassessed for smoking safety/safely. On 4/29/21 at 8:12 PM Staff 4, Staff 5 (DNS), Staff 14 (Regional Nurse Consultant) and Staff 15 (Infection Control Preventionist) were informed of the failure to appropriately evaluate, assess or reassessed residents on a regular basis regarding smoking safety. The failure constituted a situation of immediate jeopardy to the health and welfare of residents. A plan of correction was requested to immediately ensure residents were appropriately evaluated assessed and reassessed for smoking safety. On 4/29/21 at 9:48 PM a final immediate plan of correction was received from the facility. The facility's abatement plan of correction included: -All smoking materials would be confiscated placed in a secure area at the nurses station. -All residents would be evaluated to determine smoking status, assessments completed or updated to reflect residents smoking status. -Care plans would be initiated or revised to reflect appropriate smoking status of all residents who smoke in the facility. -Inservices to be completed with all nursing staff on the requirement to re-assess smoking safety quarterly, annually and with a change of condition. -Inservices to all staff which included re-education on the smoking policy; following plan of care regarding safe storage of smoking materials and to report non-compliant residents to the Charge Nurse/Administrator.

Based on observation, interview and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for 1 of 3 sampled residents (#6) reviewed for nutrition. Resident 6 had severe weight loss of 14 pounds (greater than 10% of her/his body weight) in a three-month period. Findings include: Resident 6 was admitted to the facility in 10/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's weights revealed the following: -3/22/20: 129.4 pounds. -No weights were obtained during the month of 4/2020. -5/22/20: 117 pounds -6/28/20: 115.2 pounds A total weight loss of 14.2 pounds. This resulted in a severe weight loss of 10.9%. On 6/3/20 lab results revealed Resident 6 had low sodium levels and protein levels. A 9/24/20 Nutritional Evaluation indicated Resident 6 was independent with meals and able to make her/his diet needs known. The resident was on a regular diet, regular texture and thin liquids. Resident 6 was a vegetarian but ate fish and turkey if it was unprocessed. Resident 6 did not eat cheese or dairy and did not like snacks between meals. On 4/27/21 at 10:25 AM Resident 6 stated, she/he was a vegetarian and had lost roughly 14 to 15 pounds in 6/2020. Resident 6 stated she/he had multiple conversations with management, kitchen staff and dieticians but continued to receive inappropriate meals. Resident 6 stated staff worked closely on her/his food preferences however, they continued to serve her/him small portion sizes of vegetables, salads, and meat products (such as beef, meatloaf and ham). Resident 6 stated the food continued to be an issue in the building and she/he was very frustrated with the facility regarding her/his dietary needs. Resident 6 stated she/he did not expect the facility to accommodate everything, but they should make sure she/he got adequate portions and ensure her/his meals were served correctly. On 4/27/21 at 12:27 PM lunch was served to Resident 6 in her/his room. Resident 6 removed the lid and there was no steam coming from the plate. Resident 6 took her/his fork and attempted to cut her/his crab patty and indicated the patty was hard, over cooked and not palatable. Resident 6 also had a small portion (approximately a quarter of a cup) of mixed vegetables and she/he stated, these are cold, not palatable and I always ask for double portion of veggies and never receive that amount. Resident 6 also had on her/his plate approximately half a cup of mashed potatoes. On 4/28/21 at 10:27 AM Staff 1 (CNA) stated he worked for the facility for roughly eight months and on the 200 hall. Staff 1 stated Resident 6 was a vegetarian and reported food concerns to him. Staff 1 stated Resident 6 often did not get the correct food items, received meat with her/his meals and received pretty small portions of vegetables. On 4/28/21 at 2:17 PM Staff 16 (Certified Dietary Manager) stated she worked with Resident 6 regarding her/his food preferences and knew she/he was a vegetarian. Staff 16 acknowledged this was an ongoing issue as far back as 2020 and she had a hard time honoring her/his food preferences at times. When asked how she ensured Resident 6 received the appropriate vegetarian diet she indicated her kitchen staff should be reviewing her/his meal ticket and providing the appropriate items and double portion of vegetables. Staff 16 acknowledged Resident 6 did not always get the right portions of food and incorrect items put on her/his meal trays and she needed to monitor kitchen staff more closely. Staff 16 did not recall if Resident 6 lost weight. On 4/29/21 at 1:23 PM Staff 3 (CNA) stated Resident 6 was a vegetarian and complained about her/his meals. Staff 3 stated recently Resident 6 was delivered two small salads (in two cup of soup bowls) and all that was in the salad was romaine lettuce and tomatoes. Staff 3 further stated the previous week she/he was served meatloaf when Resident 6 was to be provided a meat substitute. On 4/29/21 at 1:31 PM Staff 2 (CNA) stated she provided care for Resident 6 since 2020 and knew she/he was a vegetarian. Staff 2 stated meals were an ongoing issue and Resident 6 often got the wrong meals delivered, small portion sizes and not what she/he ordered. On 4/29/21 at 3:21 PM Staff 12 (CNA) stated Resident 6 was a vegetarian and her/his meals were often incorrect and her/his portion sizes were too small of portions of veggies. Staff 12 stated she went to the kitchen and requested larger portions for Resident 6. On 5/3/21 at 2:29 PM Staff 9 (CMA) stated Resident 6 was a vegetarian and he remembered her/him having difficulty getting the correct meals in 2020. The kitchen kept sending her/his meals with meat on it and small portion sizes of veggies. Staff 9 stated the kitchen still struggled with getting her/his meals correct. In an interview on 5/3/21 at 1:50 PM Staff 20 (Registered Dietitian) stated she did not work with Resident 6 but reviewed her/his Nutritional Evaluation on 9/24/20. Staff 20 stated Resident 6's overall weight loss for 180 days (from 3/22/20 through 9/20/20) appeared to stabilize however, the time period of 3/22/20 to 6/28/20 weight loss of 14 pounds was a significant loss for Resident 6. In an interview on 5/5/21 at 10:14 AM Staff 13 (Nurse Practitioner) stated he worked with Resident 6 on a regular basis and a common topic of concern was her/his food intake. Staff 13 stated Resident's 6 nutritional needs were not being met. Staff 13 stated he recalled during the time period of roughly four months (2/2020 through 6/2020) she/he lost a significant amount of weight and was fragile. Staff 13 stated additionally Resident 6's labs during that time frame revealed she/he was low in sodium and protein. Staff 13 stated there were still issues around Resident 6 being provided with adequate and correct meals from the kitchen. On 5/5/21 at 4:13 PM Staff 5 (DNS), Staff 15 (Infection Control Preventionist) and Staff 14 (Regional Nurse Consultant) were present for an interview. Staff 5 stated if residents had significant weight loss they were seen by a registered dietician and followed by NAR (Nutrition at Risk). Staff 5 stated all long-term care residents should be weighed at least once a month to ensure weights were appropriate.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 1 of 2 sampled residents (#100) reviewed for abuse. As a result of this deficient practice Resident 100 experienced sexual abuse by Resident 101. Findings include: Resident 101 admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A 9/19/19 Quarterly MDS revealed Resident 101 had a BIMS of 5 indicating a severe cognitive impact. Resident 100 admitted to the facility in 4/2019 with [DIAGNOSES REDACTED]. A 5/7/19 Admission MDS revealed Resident 100 was rarely understood had short and long term memory problems and was severely impaired. On 10/11/19 at 1:45 PM a Facility Reported Incident was received by the State Survey Agency which reported sexual abuse between two residents. Resident 101 was found by Witness 2 (Caregiver) to be sucking on Resident 100's breast and had her/his hands down Resident 100's pants. Witness 2 obtained help and the residents were separated. Resident 101 was placed on one on one staff observation. A review of Resident 101's medical record revealed no documented history of inappropriate sexual behaviors. A 10/11/19 Social Service Note revealed Staff 4 (Social Services) contacted Witness 3 (family member) and reported to Witness 3 the sexual abuse to Resident 100. Witness 3 reported Resident 100 was sexually assaulted in the past and was diagnosed with [REDACTED]. On 10/15/19 at 10:11 AM Staff 1 (DNS) stated the investigation was due that day and she was unsure if it would be substantiated for abuse due to the cognitive level of both residents. The 10/15/19 signed DNS Investigation revealed Resident 101 was found by Witness 2 sucking Resident 1's left breast. Resident 101 also had her/his hand down Resident 100's pants. Witness 2 alerted staff and the two residents were separated. One on one supervision was initiated for Resident 100. The summary of the investigation revealed both residents were severely impaired and unable to be interviewed, Resident 101 did not have a history of inappropriate sexual contact with staff or residents. It was determined abuse or neglect with intent did not occur. The act of sexual contact remains. It was inconclusive either resident was upset by the interaction. On 10/15/19 at 10:29 AM Witness 2 stated when she went into the lounge room Resident 100's arms were up in the air and she/he was looking down at Resident 101. Witness 2 stated Resident 100 had a concerned and confused look on her/his face. Witness 2 thought Resident 101 was sleeping because her/his head was down so she walked up quietly and asked Resident 101 what she/he was doing. Resident 101 pulled Resident 100's shirt down and stated nothing. Witness 2 reported no staff were around so she went to another hall in the facility and found a staff member to assist. Witness 2 stated she spent the rest of her shift with Resident 100 and she/he was not her/his usual self. Resident 100 was quiet and had a worried look on her/his face and would not let go of Witness 2's hand. Witness 2 stated she saw Resident 100 on 10/14/19 and she/he was back to her/his baseline. On 10/15/19 at 11:14 AM Witness 3 (Family Member) stated Resident 100 suffered [MEDICAL CONDITION] from a sexual assault in the past and believed if she was cognitively intact this would have triggered Resident 100's [MEDICAL CONDITION]. Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not be immediately apparent. Other residents may not be able to speak due to a medical condition and/or cognitive impairment, cannot recall what had occurred or may not express outward signs of physical harm, pain or mental anguish. Utilizing the reasonable person concept, it was reasonable to assume with Resident 100's [DIAGNOSES REDACTED].

Based on observation, interview and record review it was determined the facility failed to provide care to prevent the development of pressure ulcers and failed to follow the plan of care for the use of heel protection boots and floating of heels for 1 of 2 sampled residents (#44) reviewed for pressure ulcers. This resulted in the development of one deep tissue injury and two unstageable pressure ulcers on Resident 44's right lower posterior extremity. Findings include: The National Pressure Ulcer Advisory Panel provides the following definitions: - Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (thin, stringy dead tissue) or eschar (thick, hard, dark dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. - Deep Tissue Pressure Injury (DTPI): Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. - For all practical purposes, evolving deep tissue injury should be provided the same level of pressure redistribution as a Category/Stage III or IV pressure ulcer. Offloading and pressure redistribution may allow reperfusion of ischemic and injured tissue, limiting the extent of infarcted or dead tissue. Once the ulcer has fully evolved, support surface needs can be re-evaluated. Resident 44 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. Resident 44's Care Plan initiated 5/6/17 stated Resident 44 had limited physical mobility related to a right leg fracture and non-weight bearing status on the right lower extremity (RLE). She/he used an immobilizer (a device with velcro closures used to prevent movement of the leg) for support of the fractured leg. A Care Plan intervention initiated on 5/6/17 stated the resident would remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown and fall related injuries through the next review date. The Care Plan also indicated skin concerns would heal and the resident would remain free from skin breakdown, heel protector boots were to be worn and resident was to be turned in bed at least every two hours as she/he allowed. A revision dated 6/1/17 directed staff to float Resident 44's heels at all times. The Kardex (care directive for CNA staff) dated 5/19/17 indicated the immobilizer was adjusted by taking the metal rod out to prevent pressure. The resident was extensive assist of one staff to provide bath/showers but there were no instructions for immobilizer care during shower listed. Under the heading Dressing/Splint Care there were no directions for care related to the immobilizer splint. An MDS CAA for Pressure Ulcers dated 5/25/17 indicated Resident 44 was at very high risk for skin issues related to immobility and moisture exposure due to incontinence. The resident's RLE was supported via the use of an immobilizer; a potential source of pressure. Resident 44's Care Plan included turning and repositioning strategies, barrier cream to protect from moisture, weekly skin checks and other preventative measures. The Pressure Ulcer CAA was triggered by immobility, incontinence and assessed risk for pressure sores. The resident had no pressure ulcers at the time of the assessment. Weekly Skin Observation reports and Skilled Nursing Observation reports dated 6/4/17 through 6/8/17 noted Resident 44's skin color as pink, dry, warm and intact with skin turgor from good to sluggish. A Skilled Nursing Observation report dated 6/9/17 at 11:45 am noted skin color as pink and skin turgor as sluggish. A Nursing Progress Note dated 6/9/17 at 3:02 pm stated a CNA requested the LPN to look at Resident 44's ankle. It appeared the immobilizer had been rubbing on her/his lower leg for a time. There was a wound seen that was dry and scabbed over. It was not causing the resident much pain at the time and the LPN got an order for [REDACTED].>A Nursing Weekly Wound Evaluation dated 6/9/17 at 3:30 pm stated initial evaluation indicated the presence of a wound from rubbing on the immobilizer. The place of wound development was in-house. The wound was located on the right ankle (outer) and was a very dry scabbed area 6.5 cm x 0.8 cm. A Long Term Care Monthly assessment dated [DATE] indicated Resident 44 had a deep tissue injury (DTI) to the right lateral lower leg and ankle on 6/9/17 and would be followed via Wound Rounds. The right lower extremity had two suspected DTIs and one sloughy unstageable wound. On 6/26/17 at 3:08 pm Staff 2 (Unit RN Care Manager) reported Resident 44 had three facility acquired wounds. Wound #1 was located on the right posterior ankle and was unstageable. Wound #2 was located on the right lower posterior leg and was unstageable. Wound #3 was located on the right lower leg and appeared to be a DTI. Staff 2 reported the wounds appeared to be related to the use of the leg immobilizer and they were going to request to discontinue use of the device. On 6/28/17 at 1:56 pm Staff 2 stated Resident 44's wounds were acquired in the facility and appeared to be related to the use of the leg immobilizer. Staff 2 reported staff had been doing skin checks but staff must not have removed the immobilizer to check the skin underneath or they would have seen the pressure areas developing sooner. On 6/30/17 at 8:19 am Staff 3 (LPN) described Nursing Observations as a head to toe assessment of each resident. Staff tried to do the assessments on shower days so they could do a complete check of the skin. Staff 3 reported she would look at the resident's skin herself and the CNA's would also report if they saw anything. If there was a device in place that was removable it should be removed for a skin check. Staff would document if a device was not removable. On 6/30/17 at 12:35 pm Staff 2 verified there were no specific orders for the use of the leg immobilizer and nursing staff had not signed off on any orders for it's use. Removing the immobilizer for skin checks should have been on the TAR as an intervention. There should have been clarification regarding opening and looking under the immobilizer to check skin on the Care Plan. The Skin Assessments should have caught the skin issue sooner. 2. Resident 44's Care Plan initiated 5/6/17 stated resident had a limited physical mobility related to a right leg fracture and non-weight bearing status on the right lower extremity (RLE). She/he used an immobilizer (a device with velcro closures used to prevent movement of the leg) for support of the fractured leg. Interventions included heel protector boots and a revision dated 6/1/17 directed staff to float Resident 44's heels at all times. The Kardex (a care directive for CNA staff) dated 5/19/17 directed staff to use heel protector boots for Resident 44. On 6/26/17 at 9:49 am Resident 44 was observed asleep in her/his room without heel protector boots, immobilizer, or heels floated. On 6/27/17 at 1:50 pm and 6/28/17 at 10:15 am Resident 44 was observed in her/his room resting and her/his heels were not floated and the heel protector boots were not on. On 6/28/17 at 11:41 am Resident 44 was observed in the dining room for the noon meal. There were pillows under her/his legs but there was no immobilizer on the right leg. Staff 2 (Unit RN Care Manager) verified the immobilizer was not on the resident's leg. On 6/28/17 at 3:16 pm the Resident was observed in bed without heel protector boots and her/his heels were not floated. On 6/28/17 at 3:17 pm Staff 5 (LPN) acknowledged that Resident 44's heels were not floated and no heel protector boots were on. On 6/29/17 at 9:45 am the Resident was observed lying in bed without heel protector boots and her/his heels were not floated. On 6/29/17 at 9:48 am Staff 3 (LPN) verified Resident 44's heels were not floated and no heel protector boots were on. On 6/29/17 at 9:53 am Staff 6 (CNA) stated she was not aware that the resident needed the heel protector boots or that Resident 44 heels needed to be floated at all times. Staff 6 (CNA) looked at the Kardex and saw the instructions for the heel protector boots and stated it was the first time she had seen the order for the boots. Staff 6 indicated she would have to get some boots from central supply as there were no boots in Resident 44's room. Staff 6 also acknowledged that there was a pillow between the residents knees but nothing to float her/his heels.

Based on interview and record review it was determined the facility failed to provide the necessary care and services related to a urinary catheter for 1 of 3 sampled residents (#1) reviewed for urinary catheter. As a result Resident 1 experienced weakness, pain, obtained a urinary tract infection and was hospitalized for [REDACTED]. The facilities Foley Catheter Protocol dated 7/31/15 (revised) revealed the following: 1. If a resident is admitted with an indwelling catheter, an assessment will be completed within 72 hours to identify if there is a medical necessity for usage. 2. This will be documented on the Foley catheter justification record. 3. Ensure a physician order [REDACTED]. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Resident 1's October 2016 TAR revealed no documentation for care, catheter usage, size or frequency of change. Resident 1's Care Plan dated 10/27/16 revealed the resident had a Foley catheter and an intervention included Foley care every shift using soap and water, secure tubing, encourage fluids, keep urinary tract flushed, monitor urine amount, color, clarity and odor. Change Foley catheter each month or per physician orders. No documentation was found to indicated care was provided or a physician order. Resident 1's November 2016 TAR revealed no documentation for catheter care, usage, size or frequency of change. The TAR also revealed no documentation the catheter was changed in November. A progress note dated 12/5/16 revealed Resident 1 had tea colored urine, cloudy, and odorous. Resident 1's December 2016 TAR revealed on 12/7/16 a urinalysis was collected for possible UTI culture and sensitivity if indicated will need to change catheter for sample and discontinue order when collected. Change Foley catheter on the 7th monthly. No documentation could be found for care, size or catheter usage. physician's orders [REDACTED]. Resident 1's December 2016 MAR indicated [REDACTED]. Therapy Note dated 12/14/16 at 3:32 pm revealed Resident 1 refusing therapy due to not feeling well. Therapy Note dated 12/15/16 at 2:57 pm revealed Resident 1 asleep upon entry to room, therapist woke resident and Resident 1 stated I want to sleep Went back to room two more times resident was unable to be woken. Therapy Note dated 12/16/16 at 4:23 pm revealed Resident 1 appears to be exhibiting a declining state as evidence by decreased activity tolerance and alertness, per nursing resident food intake has declined as well. Therapy Note dated 12/19/16 at 2:10 pm revealed Resident 1 complaining of pain around catheter area and felt like throwing up. Resident 1 returned to room and the nurse was notified. Nursing Note dated 12/20/16 at 9:33 pm revealed Resident 1 complained of nausea all shift, had medication to help with nausea then vomited after three bites of dinner. Son came in and he asked for Resident 1 to be sent to the Emergency Department. Discharge Summary from hospital dated 12/25/16 revealed Resident 1 was admitted with weakness from UTI associated from Foley catheter. The Foley catheter was discontinued and Resident 1 improved with antibiotics. On 2/28/17 at 1:27 pm Witness 1 (family member) stated Resident 1 did not have a history of UTIs. Resident 1 kept getting sick and the facility kept stating they did not know what to do. On 3/2/17 at 11:06 am Witness 2 (Director of Emergency Department) stated general guidelines for Foley is to remove at earliest possible time frame and should be some form of physician ordered care. A Facsimile Cover Sheet dated 3/6/17 at 10:45 from Staff 1 (DNS) revealed the Foley catheter justification and 72 hour Foley assessment was not located in medical documentation for discharged Resident 1. On 3/16/17 at 10:10 am Staff 1 (DNS) confirmed Foley catheter protocols were not followed and no documentation of care for Foley catheter was documented for October 2016 and November 2016. Staff 1 also confirmed the care plan was not followed for Foley care and Resident 1 obtained a UTI.

Based on interview and record review the facility failed to provide an environment that was free from accident for 1 of 6 sampled residents (# 1) who sustained a fall with injury. The facility failed to use an assistive device that was care planned to prevent an avoidable accident. Resident 1 sustained a significant fall with injury. Findings include: Resident 1 admitted to the facility in December 2010. [DIAGNOSES REDACTED]. On 6/25/12 at 11:10 am, Witness 1 (Complainant) stated Resident 1 lived independently with help prior to admission to the nursing facility. Witness 1 stated Resident 1 had her/his legs amputated about [AGE] years ago due to complications from [DIAGNOSES REDACTED]. Resident 1 used siderails daily on the bed at home and at the facility. Witness 1 stated the resident's siderails were used at the facility but on 1/4/11 "one siderail was not up and (she/he) fell " at 11:45 pm. On 6/26/12 at 2:40 pm, Witness 2 (Family Member) stated he thought the siderail had been removed from the bed and Resident 1 required 2 siderails for mobility and safety purposes. Witness 2 stated the resident's bed was angled into the room and not against the wall "that's how (she/he) liked it positioned." Witness 2 confirmed Resident 1 fell out of bed on the night of 1/4/11, went to the ER for evaluation and s/he returned to the facility with the resident at 5:30 am. The interdisciplinary care plan dated 4/12/10 included a problem area for ADL deficit due to [DIAGNOSES REDACTED]. Resident 1 was care planned for two half siderails while in bed for self positioning/mobility when in bed. Resident 1 used an air mattress on her/his bed due to a coccyx wound. The 6/10/10 Restraint Risk Assessment indicated siderails to both sides of the bed were used daily for reasons of feeling safe and for mobility. The rails were used at the resident's request. The resident was paralyzed from the waist down and had bilateral above the knee amputations. The resident was explained the benefits and risk for the siderail use. The re-admission MDS dated [DATE] indicated the resident was alert and oriented. Resident 1 required extensive assistance for bed mobility and transfers, hygiene and bathing, was dependent for toileting due to colostomy and urostomy and was non-ambulatory due to amputations and [DIAGNOSES REDACTED]. The MDS indicated bedrails were used daily. According to the Resident Incident Report dated 1/4/11 at 11:45 pm, Resident 1 was found on the floor of her/his room with injuries to the face and a painful left wrist. Resident 1 had been in bed asleep prior to the unwitnessed fall. The half siderail on the outside of the resident's bed was down, the other half siderail was up. The physician and family were notified. Orders were received to send the resident to the hospital for evaluation. A staff member was in the hallway and heard the resident yell for help; the resident was found face down on the floor. The narrative description indicated Resident 1 was bleeding from the nose and her/his left arm was underneath her/him. The resident was conscious and calling for help. The RNCM follow-up indicated the resident "may have had a seizure and fell from bed." The Interdisciplinary Progress Notes dated 1/4/11 at 11:45 pm, indicated the nurse "found resident on the floor calling out for help, nose bleeding, resident complained of pain in the left wrist." No report of pain to head/neck/back, 911 called and resident transported to the ER for evaluation via ambulance. At 2:30 am, the hospital called the facility and stated the resident would be returning to the facility. The resident had "golf ball sized swelling on right forehead, CT scan and xrays showed no fractures to nose or left wrist." The hospitals history and physical examination [REDACTED]. The report indicated the resident had fallen out of bed, may have been due to a seizure, and was noted to have been bleeding from the nose. The resident's workup was negative for any evidence of skull fracture, intracranial bleed or disruption of the ventricular shunt (due to [DIAGNOSES REDACTED]). The monthly Physician order [REDACTED]. Each month contained signed physician orders [REDACTED]." On 6/25/12 at 4:30 pm, Staff 2 (RNCM) stated she was Resident 1's care manager part of her/his time at the facility. Staff 2 confirmed she had updated the most current care plan and the resident was to have two siderails used on her/his bed at all times. Staff 2 stated the resident used the rails for maneuvering in bed and for feelings of safety due to her/his history of seizures. On 6/27/12 at 11:30 am, Witness 3 (former staff RN) stated Resident 1 used siderails and felt she/he needed them due to mobility issues and safety. Witness 3 stated she started her shift at 10:00 pm, a CNA (she was unable to remember which CNA) noticed there was not a siderail and as the CNA went to tell her they heard the resident fall and yell for help. Resident 1 stated she/he was not sure if she/he rolled out of bed or had a seizure. Witness 3 stated the resident was alert and bleeding from the face and was laying on the left wrist. Witness 3 stated the resident's bed was at an angle into the room and did not have one side against the wall. Witness 3 stated she was sure the siderail wasn't down, she thought it was missing/removed from the bed. On 6/27/12 11:45 am, Staff 3 (CNA) stated he worked the night of Resident 1's fall. Staff 3 stated the CMA was passing medications and heard the resident call for help. Staff 3 entered the resident's room with the nurse and the CMA. Staff 3 stated the resident had fallen out of bed, landed on her/his face and was bleeding. The resident had previously been asleep. On 6/27/12 at 12:20 pm, Staff 4 (CMA) stated she remembered the resident always used her/his siderails for turning. On 6/27/12 at 12:50 pm, Staff 5 (CMA) stated she was the person who found the resident on the floor. Staff 5 confirmed the resident used both siderails on her/his bed for turning and bed mobility. Staff 5 stated the resident would raise the bed to a high position to better see the television that was mounted on the wall and out the window. Staff 5 stated the resident used an air mattress and prior to the fall the resident had been sleeping. Staff 5 stated she had been in Resident 1's room about 15 minutes before the fall, "I went in to see if (she/he) wanted a pain pill and (she/he) was asleep, I turned down the TV." On the night of the resident's fall there was only one siderail up on the far side of the bed, she did not know if the rail was down or if it was missing from the bed. Staff 5 stated the resident was alert after the fall but could not remember what happened. Staff 5 stated the resident benefited from the half rails due to mobility and she/he would pull her/himself over to assist with care.

Based on observations, staff and witness interviews; and hospital and facility record review it was determined the facility failed to appropriately implement the care-planned wanderguard alarm for 2 of 2 sampled residents (#s 1 and 2) who had a wanderguard. Resident 1 sustained a head trauma, a scalp laceration and the wound required sutures on 10/23/10. Findings include: 1. Resident 1 was admitted in June, 2010 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan updated on 7/29/10 included the use of a wanderguard (a monitoring device that sounds with an attempt to exit the facility) on Resident 1's wheelchair armrest and on her wrist. The resident's care plan also included a low bed placed against a wall and a fall mat next to her bed. Resident 1's care plan indicated the CNAs were to visually check the resident every hour. The care plan directed the CNAs to toilet the resident every two to three hours, while she was awake. The Elopement Risk assessment dated [DATE] indicated Resident 1 exited the facility frequently. The resident was assessed to need both a wheelchair and a wrist wanderguard for her safety. The resident's Fall Risk assessment dated [DATE] assessed her need for a personal alarm, a fall mat and her bed placed against the wall. Resident 1 was assessed as needing an alarm on her self-releasing seat belt (SRSB, a device that alarms when the seat belt is opened). The October, 2010 Physician order [REDACTED]. Resident 1's Pocket Care Plan (a care plan used by the CNAs) dated 10/18/10 included the need for the resident's wheelchair to have a SRSB and an alarm. The care plan indicated the resident was to have a "wanderguard" with no other details provided. The resident's October, 2010 MAR required the CMAs to check the placement and function of Resident 1's wrist and wheelchair wanderguard every evening. Documentation of the CMAs initials on the resident's October, 2010 MAR indicated both wanderguards were checked. The facility's Resident Incident Report dated 10/23/10 recorded the occurrence of Resident 1's fall on the facility grounds on 10/23/10 at 11:50 am. According to the report, a facility staff member saw the resident lying on the ground outside and observed bleeding on the back of the resident's head. Documentation revealed the resident's wheelchair was found inside the facility at the time of her outside fall. The incident report included the action taken after the fall was to place a wanderguard on the resident. The hospital records dated 10/23/10 documented Resident 1's emergency room visit. The resident's head CT scan revealed an acute head trauma and a scalp contusion (swelling). The resident's scalp laceration was sutured and she was then transported back to the facility. Staff 1's (RNCM) fall incident investigation dated 10/25/10 documented the resident's inability to undo her SRSB, when given verbal cueing. The investigation showed the RNCM interviewed Staff 2 (Nursing Assistant, NA), assigned to Resident 1's care on 10/23/10. The investigative report revealed Staff 2 was unsure if the resident's SRSB alarm was turned on. The RNCM's investigative report also included an interview with Staff 3 (CMA), who gave medications during the evening of 10/22/10. According to the report Staff 3 indicated Resident 1's wheelchair wanderguard was checked for placement and function. Staff 3 stated she neglected to see the October, 2010 MAR's instruction to check Resident 1's arm wanderguard. On 10/28/10 at 12:00 pm a low bed positioned against the wall and a fall mat were observed in the resident's room. Resident 1 was not present. On 10/28/10 at 12:10 pm Resident 1 was in the dining room with her SRSB latched and the alarm switched on. Wanderguards were observed on the resident's right wrist and on the arm of her wheel chair. Witness 2 (family member) was present in the dining room and stated she was not sure why the resident's wrist wanderguard was not on during the fall on 10/23/10. On 10/28/10 at 1:15 pm Staff 4 (DNS) provided a written witness account of Resident 1's fall on 10/23/10. Witness 1 (a facility resident) wrote he saw Resident 1 had difficulty walking on the grounds outside the facility and he looked for help. Witness 1 asked the activity staff member who walked by him to check Resident 1. According to Witness 1's account, the staff member checked the resident who was then lying on the ground. She asked him to call for help and a nurse went outside to Resident 1. On 10/28/10 at 1:30 pm Staff 5 (Activity Assistant) stated Witness 1 requested she check on a resident who was outside. Staff 5 stated she saw Resident 1 lying on the ground and the resident's head was bleeding. She stated a request for help resulted in Resident 1's assessment by a nurse. On 10/28/10 at 1:50 pm Staff 6 (Charge Nurse) stated Resident 1 had been seen in the past with a stuffed animal exiting the facility. She stated the resident seemed to think the stuffed animal needed to use the restroom and took it outside. She stated the staff often observed the resident's location. On 10/28/10 at 2:25 pm Staff 3 (CMA) agreed she did not see the October, 2010 MAR instruction to check the placement and function of Resident 1's wanderguard on her arm. On 10/28/10 at 3:05 pm Staff 2 (NA) stated it was not known for certain if the resident's SRSB alarm was on prior to Resident 1's fall on 10/23/10. On 10/28/10 at 3:15 pm Staff 7 (LPN) stated at the time of Resident 1's recent fall outside, she observed the resident's wheelchair inside the facility. Staff 7 related the resident's SRSB alarm was not sounding at that time and the alarm was then checked by her, revealing proper function. On 11/1/10 at 10:30 am and 11:30 am, Resident 1 was observed with her eyes closed lying in her low bed. Her bed was against the wall, a fall mat was in place and her wanderguard was present on her right wrist. On 11/1/10 at 12:30 pm Staff 2 (NA) stated she was assigned to Resident 1's care on the day shift of 10/23/10. Staff 2 stated the wanderguard alarms on the wheelchair and the resident's arm were not checked that day. On 11/1/10 at 1:40 pm Resident 1 was observed sitting in a wheelchair in the dining room, with her SRSB alarm switched to the "on" position. The resident had her wheelchair and wrist wanderguards in place. 2. Resident 2 was a long-term facility resident with [DIAGNOSES REDACTED]. She had a history of [REDACTED]. The Fall Summary Record, indicated Resident 2's last fall was on 5/12/10, when the resident attempted to self-transfer. The new fall prevention measures put in place were a sensor alarm and a low bed. The facility's Informed Consent for Restraint Use dated 6/10/10 revealed permission for the use of a self releasing seat belt (SRSB) for Resident 2. A fax sent to the physician on 10/22/10 related Resident 2 exhibiting a significant unintentional wander risk. The physician signed an order for [REDACTED]. Resident 2's Comprehensive Care Plan dated 10/22/10 identified several interventions that could be used when the resident demonstrated her need to wander, such as a family member could accompany the resident outdoors. One approach on the resident's care plan was the placement of a wanderguard. There was no information on the care plan as to where to place the resident's wanderguard. Resident 2's Pocket Care Plan (used by CNAs) dated 10/25/10 directed the use of a self-releasing seat belt (SRSB) on the resident's wheelchair, a low bed and a bed sensor alarm (sounds if the bed is vacated). The care plan listed "wanderguard" with no details provided as to whether a wrist and/or a wheelchair wanderguard was needed for Resident 2. According to the resident's November, 2010 MAR a wanderguard was to be checked for placement and function every evening. There was no information on the MAR to know whether the resident had a wrist and/or wheelchair wanderguard. On 11/1/10 at 10:30 am Resident 2 was observed in her room with a low bed against the wall. She was sitting in her wheelchair with her SRSB on and a wanderguard on her right wrist. She self-propelled her wheelchair. On 11/1/10 at 11:00 am Staff 1 (RNCM) stated she received a physician's orders [REDACTED]. On 11/1/10 at 11:15 am Staff 8 (CNA) stated the resident usually propels herself around the facility in her wheelchair. Staff 8 was aware of the presence of a wanderguard alarm on Resident 2's wrist. On 11/1/10 at 12:30 pm the resident was observed in the front lobby sitting in her wheelchair with both her SRSB and wrist wanderguard on.