Every finding on record at Johns Island Post Acute

Based on observation, facility policy review, record review, and interview, the facility failed to ensure proper infection control measures were followed for Resident (R)4, for 1 of 1 resident reviewed on Contact Precautions.Findings include:Review of the facility policy, Isolation - Categories of Transmission-Based Precautions with a revision date of 09/2022, revealed, Contract Precautions . 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room. b. Gloves are removed and hand hygiene performed before leaving the room. 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room.Review of Resident (R)4's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to, osteomyelitis of vertebra (infection in the bones of the spine), osteomyelitis of the left ankle and foot, extended spectrum beta-lactamase (ESBL) resistance (multi-drug resistant organism), and senile degeneration of the brain. Review of R4's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/15/26, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated she had moderate cognitive impairment. According to the MDS R4 did not show any physical or verbal behaviors directed towards others. She was dependent on others for all Activities of Daily Living (ADL) except eating. She was non-ambulatory. Review of R4's Care Plan revealed a focus related to, Isolation Precautions: Resident requires contact, single room isolation precautions due to ESBL Infection, VRE Infection (multi-drug-resistant organisms). Her goal included, Isolation using contact, single room precautions will be maintained while medically necessary. Interventions included maintaining isolation using contact, single room precautions, performing hand washing after completing care and leaving room, and using personal protective equipment as recommended for the type of infection R4 had. Review of R4's Order Recap revealed an order for, Strict Single room isolation with: contact precautions related to Extended-Spectrum Beta-Lactamases (ESBL) and Vancomycin-Resistant Enterococci (VRE) every shift. This order started on 06/25/26. During a random observation on 07/01/26 at 3:00 PM, revealed a Contact Precautions sign on R4's door indicating that all staff must put on gloves and a gown prior to entering the room. Gloves and gown supplies were noted to be hanging on R4's door. Further observation revealed Certified Nursing Assistant (CNA)1 entering the room of R4 with no gloves or gown on. Additionally, CNA1 did not sanitize her hands prior to going into room. While in the room, CNA1 spoke with R4. CNA1 was observed placing her hands on the side of R4's bed sheet. CNA1 was not observed sanitizing hands after leaving the room.During an interview on 07/01/26 at 3:00 PM, CNA1 revealed all staff are supposed to put on gloves and a gown prior to entering the room due to Contact Precautions. CNA1 stated she was also supposed to sanitize her hands prior to entering R4's room and when leaving the room. CNA1 revealed she had just gone in R4's room to check if the resident needed anything. She stated she was not in the room to provide care and had not realized she touched R4's bed sheet. She revealed she works part time at the facility and just recently started.During an interview on 07/01/26 at approximately 3:45 PM, the Director of Nursing (DON) revealed when a resident is on Contact Precautions, the staff must put on gloves and a gown prior to providing care. She stated if they are just going in the room to ask a question, they don't need to put on gloves and a gown as long as they do not touch anything or provide care. The DON stated CNA1 should not have touched R4's bed sheet when in the room without gloves and a gown on.

Based on facility policy review, record review, and interview, the facility failed to check vital signs (VS) for Resident (R)1 and R2, according to the physician's order, for 2 of 3 residents reviewed. Findings include:Review of the facility policy, Medication and Treatment Orders with a revision date of 06/2016, revealed, Order for medications and treatments will be consistent with principles of safe and effective order writing. 1. Review of Resident (R)1's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to, metabolic encephalopathy (brain dysfunction due to chemical imbalances in the body), urinary tract infection, diabetes, hemiplegia and hemiparesis (paralysis and weakness on one side of the body), dementia, and acute kidney failure. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/26, revealed he had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated he had moderate cognitive impairment. Review of R1's Care Plan revealed he exhibited cognitive loss due to dementia. His goal stated avoiding complications, such as falls, injury, impaired nutrition/hydration, and decline in Activities of Daily Living (ADL). Another focus was for R1's urinary tract infection (UTI). His goal stated the UTI would resolve without complications. Another focus stated R1 was at risk for impaired cardiac function and complications. His goal was to have no signs of cardiac distress.Review of R1's Orders revealed an order for R1's vital signs to be checked every shift. Review of R1's Oxygen Saturation (O2 Sat) Summary revealed no O2 Sat entries for 05/27/26, 06/02/26, 06/28/26. Only one entry per day was found for 05/28/26, 05/29/26, 05/30/26, 05/31/26, 06/01/26, 06/03/26, 06/04/26, 06/09/26, and 06/11/26. Review of R1's Pulse Summary revealed no pulse entries for 05/21/26, 05/23/26, and 05/27/26. Only one entry per day was found for 05/14/26, 05/17/26, 05/24/26, 05/26/26, 05/30/26, 05/31/26, 06/01/26, 06/02/26, 06/03/26, 06/04/26, 06/08/26, 06/09/26, and 06/11/26. Review of R1's Respirations Summary revealed no respiration entries for 05/23/26, 05/27/26, 06/02/26, 06/08/26. Only one entry per day was found for 05/14/26, 05/17/26, 05/21/26, 05/24/26, 05/25/26, 05/26/26, 05/30/26, 05/31/26, 06/01/26, 06/03/26, 06/04/26, 06/07/26, 06/09/26, and 06/11/26. Review of R1's Temperature Summary revealed no temperature entries for 05/21/26, 05/23/26, 05/27/26, 06/08/26. Only one entry per day was found for 05/14/26, 05/15/26, 05/17/26, 05/18/26, 05/24/26, 05/26/26, 05/29/26, 05/30/26, 05/31/26, 06/01/26, 06/02/26, 06/03/26, 06/04/26, 06/09/26, and 06/11/26.Review of R1's Blood Pressure (BP) Summary revealed no BP entries for 05/21/26, 05/23/26, and 05/27/26. Only one entry per day was found for 05/14/26, 05/17/26, 05/18/26, 05/24/26, 05/26/26, 05/30/26, 05/31/26, 06/01/26, 06/02/26, 06/03/26, 06/04/26, 06/08/26, 06/09/26, and 06/11/26. 2. Review of R2's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including but not limited to, hemiplegia and hemiparesis, transient ischemic attack ( mini-stroke), hypertension (high blood pressure), chronic kidney disease, heart failure, and acute cystitis (bladder infection). Review of R2's admission MDS with an ARD of 06/18/26, revealed she had a BIMS score of 12 out of 15, which indicated she had moderate cognitive impairment. Review of R2's Care Plan revealed a focus on ADL and mobility decline requiring R2 to need assistance related to hemiplegia and heart failure. Her goal included to have needs anticipated and met by staff. Another focus stated R2 had a risk of impaired cognitive function. Her goal was to communicate basic needs on a daily basis. Another focus revealed R2 was at risk for impaired cardiac function and complications. Her goal stated R2 will have no signs of cardiac distress. Review of R2's Orders revealed an order for R2's vital signs to be taken every shift. Review of R2's O2 Sat Summary revealed no O2 Sat entries for 06/13/26, 06/14/26, and 06/27/26. Only one entry per day was found for 06/19/26, 06/20/26, 06/22/26, 06/23/26, 06/24/26, 06/28/26, 06/29/26, and 06/30/26. Review of R2's Pulse Summary revealed no pulse entries for 06/27/26. Only one entry per day was found for 06/13/26, 06/14/26, 06/19/26, 06/20/26, 06/22/26, 06/24/26, 06/28/26, 06/29/26, and 06/30/26.Review of R2's Respirations Summary revealed no respiration entries for 06/13/26, 06/14/26, 06/20/26, 06/24/26, and 06/27/26. Only one entry per day was found for 06/19/26, 06/22/26, 06/29/26, and 06/30/26. Review of R2's Temperature Summary revealed no temperature entries for 06/13/26 and 06/27/26. Only one entry per day was found for 06/14/26, 06/15/26, 06/16/26, 06/17/26, 06/18/26, 06/19/26, 06/20/26, 06/21/26, 06/22/26, 06/23/26, and 06/29/26. Review of R2's BP Summary revealed no entries for 06/27/26. Only one entry per day was found for 06/13/26, 06/14/26, 06/15/26, 06/16/26, 06/19/26, 06/20/26, 06/21/26, 06/22/26, 06/28/26, and 06/29/26. During an interview on 07/01/26 at 10:50 AM, R1's family member revealed R1 was discharged from the hospital yesterday after being taken directly there, when R1 was discharged from the facility on 07/12/26. She stated he was in the hospital for 2 weeks. She revealed the hospital doctors indicated he was severely dehydrated, his sodium level was very high, and he had a UTI. The family member stated she spoke with the Director of Nursing (DON) and let her know that she was dissatisfied with the care her husband received. She again stated the hospital doctor said he was severely dehydrated, and she is very upset because R1 was a feeder. She revealed he relied on staff members to give him fluids throughout the day because he was not able to do it himself. She revealed she had been a Certified Nursing Assistant (CNA) for 20 years, and she knew her job. She stated she was an old-school CNA and knew what is supposed to be done for residents. During an interview on 07/01/26 at 2:45 PM, Licensed Practical Nurse (LPN)1 revealed R1 needed total assistance with his care, and he needed to be fed. She stated vital signs are usually the CNA's responsibility. However, if the resident is brittle, the nurse may take them instead. She stated the nurse is not supposed to use the previous shift's VS readings if the order is for VS to be taken every shift. She revealed she always knew to get the VS on her shift, and if the VS were taken on the previous shift just before shift change, she would wait to get the VS until later in her shift.During an interview on 07/01/26 at approximately 3:45 PM, the DON revealed when the nurses document in Point Click Care (electronic medical system), the system will prepopulate the vital signs from the last set taken. If the last set taken was on a previous shift, PCC will populate those results. She stated some Agency staff may be unaware of this when they are writing their notes. She revealed her expectation is if VS are ordered to be taken every shift, then VS need to be documented every shift.

Based on review of facility policy, record review, interviews, and review of video footage, the facility failed to provide appropriate care for Resident (R)5, who had a respiratory care plan and physician orders, after the resident was choked by another resident on [DATE]. Additionally, the facility failed to provide wound care according to professional standards of practice for R8.On [DATE] at 5:30 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25 - Quality of Care.On [DATE], the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F684 at a lower scope and severity of D.An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F684, constituting substandard quality of care.Findings include: Review of the facility policy titled Abuse and Neglect Protocol with a revised date of [DATE], documented, . Monitoring and Follow-Up 1. Staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood, and function. Review of R5's Face Sheet, revealed R5 was admitted to the facility on [DATE], with diagnoses including but not limited to, age-related osteoporosis with current pathological fracture, chronic obstructive pulmonary disease, atherosclerotic heart disease, presence of xenogenic heart valve, dementia, epilepsy, spondylosis and need for assistance with personal care. Review of R5's 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed R5 had a Brief Interview of Mental Status (BIMS) score of 5 out 15, which indicated R5 suffered from severe cognitive impairment. Further review of R5's MDS revealed active diagnoses under the section heart/circulation, to include anemia, coronary artery disease, hypertension. Additionally, active diagnoses under the section pulmonary included, asthma, chronic obstructive pulmonary disease, or chronic lung disease. Further review of the MDS under the section Health Conditions indicated shortness of breath or trouble breathing when lying flat. The MDS also indicated R5 was receiving Respiratory Therapy. Review of R5's Physician Orders revealed the following orders: incruse ellipta inhalation aerosol powder activated 62.5 MCG/ACT, albuterol sulfate HFA inhalation aerosol solution 108 (90 base) MCG/ACT - 2 puff inhale orally every 4 hours as needed for wheezing or SOB, symbicort inhalation aerosol 80-4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for COPD, monitor for shortness of breath every shift, and keep HOB (head of bed) elevated due to SOB when lying flat. Review of R5's Medication Administration Record (MAR) for the month of [DATE], revealed, Keep HOB elevated due to SOB when lying flat every day and night shift with a start date of [DATE]. Review of the MAR revealed that this order was checked off as administered on [DATE] from 7P - 7A. However, interview with CNA5, who stated she entered the room at 7:15 AM on [DATE] and the HOB was not elevated. On [DATE] from 7A - 7P revealed this order was coded as 10 which indicated the resident was unavailable. Further review of the MAR revealed, Albuterol Sulfate HFA Inhalation Aerosol Solution 708 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for wheezing or SOB with a start date of [DATE]. According to the MAR, this order was left blank from [DATE] - [DATE]. Review of R5's Care Plan revealed a focus area Cognitive Impairment: Resident exhibits cognitive loss related to Dementia with a date initiated of [DATE], directed staff to, Anticipate needs and meet promptly. Observe for indicators of clinical changes: fever, n/v, cough, . Further review of the Care Plan revealed a focus area Respiratory: Resident is at risk for complications with the respiratory system due to Chronic Obstructive Pulmonary Disease (COPD) with an date initiated of [DATE], directed staff to, 4/13-Position with HOB elevated to prevent episodes of shortness of breath while lying flat. Administer medications as ordered. Monitor for side effects/adverse reactions and effectiveness. Monitor for shortness of breath, irregular respiration, wheezing, crackles, rhonchi, excessive secretions, coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, tightness of neck or chest muscles, malaise or fatigue and inform physician promptly. Monitor vital signs, skin color, oxygen saturation, and airway function. Further review revealed a care plan with a focus on Neurological Disease: Resident has a neurological disorder and is at risk for complications related to diagnosis of Epilepsy with an initiated date of [DATE], directed staff to, Administer medication as ordered. Monitor length of acute neurological symptoms . Monitor vital signs as ordered and PRN. Observe for signs and symptoms of neurological changes . Further review of R5's Care Plan revealed a care plan with a focus on Cardiac: At risk for impaired cardiac function and complications related to Atherosclerotic Heart Disease, Hyperlipidemia, Hypertension (HTN), and Xogenic Heart Valve with a date initiated of [DATE], directed staff to, Administer medication as ordered . Notify physician of signs of cardiac distress such as chest pain, irregular heart rate, fainting, chest pain, dizziness, decreased activity tolerance. Obtain vital signs as indicated. Review of R5's Progress Note dated [DATE] at 5:36 AM, documented, [CNA1] witnessed that rolled his wheelchair behind [R5] and began to choke him while choking him aide ask [R4] to let him go and he refused aide had to get up and remove resident hand from around [R5] neck. resident has been separated. DON has been notified. Further review of R5's Progress Notes revealed a note dated [DATE] at 8:00 AM, which documented, Note Text: Late Entry: During rounds, CNA alerted nurse patient not [sic] was not responding to verbal stimuli. Nurse rushed to room to assess patient, after verbal stimuli and physical stimuli initiated, patient found to by pulseless. Patient was DNR. EMS arrived on site to assist, and pronounced patient expired at 0740. Coroner on site. Review of the facility's video footage, in the presence of the Director of Nursing (DON), Administrator, Operations Manager, Regional Director of Clinical Services (RDCS)1 and RDCS2, revealed the following timeline on [DATE]: 4:43 AM - R4 starts rolling towards R5, through the common area. R4 moves directly behind R5 and leans forward and places his arm around R5's neck. R5 responds by grabbing R4's arm with both hands. R4 continues to choke R5, as R5 was unable to get R4 to release his hold around R5's neck. R5's head begins to lean backwards by the force applied to his neck. Certified Nursing Assistant (CNA)1 comes into view from off screen and approaches both residents. CNA1 grabs R4's arm and R4 released his hold. CNA1 than moves R5 to a desk in the corner of the room, where CNA1 was sitting and CNA1 has a seat back at the desk, with R5 next to the desk. And R4 still in the common area next to the nursing station. 5:03 AM - CNA1 gets up from the nursing station. CNA1 puts on gloves and rolls R5 to his room. 5:07 AM - CNA1 exits the room. 7:33 AM - CNA5 enters R5's room. 7:35 AM - CNA5 rushes out of R5's room and continues down the hall. CNA5 and Licensed Practical Nurse (LPN)2 return to the room. 7:40 AM - Emergency Medical Services (EMS) and fire rescue arrive on scene. 7:51 AM - Police officer arrive on scene. 8:00 AM - Two more police officers arrive on scene. 8:44 AM - Coroner arrives on scene. During an interview on [DATE] at 1:36 PM, the Administrator stated, The nurse was in the area of the resident. He [R5] wasn't assessed. I did not see the resident get assessed. During an interview on [DATE] at 1:42 PM, RDCS2 stated, Body audits, assessments should be done to assess for any injuries. The agency nurse and CNA just didn't do them. During an interview on [DATE] at 1:37 PM, the DON stated, A body audit was conducted after he (R5) expired. When asked if an assessment or body audit was conducted after the physical altercation, the DON responded, Not that I know of. During an interview on [DATE] at 3:18 PM, CNA5 stated, I got to [R5's] room about 7:15 AM, he was laying on his stomach. The other nurses were down there (in the hallway), they had to see that. I just peaked in there. I told the roommate [R5's roommate] I would be back. I did the rest of my rounds. I walked back down and I turned the light on in [R5's] room, the roommate told me to check on him cause he wasn't talking. I called his name and he didn't say anything. I gave him a little shake and he was unresponsive. Stuff was coming out of his mouth, like drool. The drool was bubbly and his eyes were closed. I ran and asked the nurse, the nurse said he should be fine from the report I got. She went and checked, she said he was getting cold. I got the vital machine and we couldn't get none (referring to the residents pulse). During an interview on [DATE] at 4:39 PM, CNA1 stated, His roommate rung his bell at 6:57 AM, I told him to give me a minute. I looked over at [R5] and he was laying on his side and I walked out. The nurse didn't do any vitals. I looked at him, there was no changes in his breathing. During a follow up interview on [DATE] at 1:12 PM, CNA5 stated, When I first saw him, he was laying on his stomach, like he was trying to get off the bed, he always does that. He was laying flat, his bed was low. No, the head of the bed was not elevated. The bed was flat. 2. Review of the facility policy titled, Wound Care, last revised [DATE] states, Purpose, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Reporting: 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice. Review of R8's Face Sheet revealed the facility admitted R8 on [DATE], with diagnoses including but not limited to: Lupus, bacteremia, sepsis, osteomyelitis of vertebra, sacral and sacrococcygeal region, immunodeficiency, stage 3 pressure ulcers of the right and left buttocks, stage 4 pressure ulcers of the sacral region, colostomy and paraplegia. Review of R8's admission MDS with an ARD of [DATE] revealed R8 had a BIMS score of 15 out of 15, indicating R8 was cognitively intact. Further review revealed R8 had two (2) stage 3 pressure ulcers, one (1) stage 4 pressure ulcer and was a risk for pressure ulcers/injuries and required care for pressure ulcers/injuries. Review of R8's Care Plan revealed Focus: Skin: Resident has a pressure ulcer to coccyx and left and right buttocks and is at risk for further breakdown and/or slow, delayed healing. Interventions included, administer treatment as ordered. Review of a Consultation Report dated [DATE], documented, To whom it may concern at [name of facility] facility, I had the pleasure seeing [R8] today for routine postoperative visit stage IV sacral wounds .Please continue local wound care .Recommendations: . Cleanse wounds x3 with Dakins and then apply collagen and calcium alginate with dry dressing over the wound. Exchanged every other day or as needed for saturation/soiling or dislodgement or more. Review of R8's Physician's Orders dated [DATE] with a start date of [DATE] revealed the following: WOUND CARE - Coccyx clean with Dakins, place collagen in wound bed and pack with calcium alginate [every other day] QOD and [as needed] PRN. every day shift for wound care. WOUND CARE LEFT BUTTOCKS clean with Dakins, place collagen on wound bed and pack calcium alginate QOD and PRN every day shift for wound care. WOUND CARE right buttocks clean with Dakins, place collagen on wound bed and pack calcium alginate QOD and PRN every day shift for wound care. All three orders were entered for daily dressing changes instead of every other day. Review of R8's Progress Note dated [DATE] at 1:00 AM, documented, Chief Complaint / HPI: patient being seen for wound care. Additional Notes . patient will need close monitoring of wounds by skilled nursing staff as all wounds will be difficult to care for independently secondary to size and location of the wounds. Review of R8's Medication Administration Note dated [DATE] at 14:42 documented, Wound Care Coccyx .resident did her own wound care. Review of R8's Medication Administration Note dated [DATE] at 14:43 documented, Wound Care right buttocks .resident did her own wound care. Review of R8's Orders Administration Note dated [DATE] at 14:43 documented, resident refused to let staff do her wound care and insisted that she do it herself. Review of R8's Medication Administration Note dated [DATE] at 14:44 documented, Wound Care left buttocks .resident did her own wound care. During an interview on [DATE] at 11:54 AM, R8 stated that Yesterday, the Wound Care Nurse (WCN) refused to change her dressing and told me that since I know so much, do it myself. R8 states that she keeps her own dressings and supplies at the bedside for when she has to change her own dressings. She stated that since the WCN refuses to use Dakins to cleanse her wounds and instead uses a different wound cleanser, she does it herself with Dakins, that she got from a nurse, here at the facility. During an interview on [DATE] at approximately 12:30 PM, Licensed Practical Nurse (LPN)4 stated that WCN is responsible for changing R8's daily wound care dressings and if it is a weekend, the nurse assigned is responsible. LPN4 further stated that R8 sometimes does some of her own care herself, like dressings . LPN4 lastly stated that to her knowledge, R8 has only refused care once or twice. During an interview on [DATE] at approximately 1:00 PM, the WCN stated, To her knowledge, R8 has only refused a dressing change only once, stating that it had already been done. The WCN then stated that she is only aware of R8 changing her own dressing, if it was soiled or accidentally removed, during evenings or weekends, when she is not there. The WCN is unaware whether R8 has any wound care supplies at her bedside, though R8 should have active orders for meds and supplies at the bedside. The WCN notes that R8's wound care orders were just changed yesterday afternoon from wound cleanser to Dakin's solution. During an observation and interview on [DATE] at 1:35 PM, R8 was observed in her room, in her bed with her buttocks exposed and her wound visible. R8 did not have gloves. R8 then placed gauze over the wound and stated, I had been waiting for the WCN to come and change my dressings. R8 also stated that the WCN had refused to change her dressings the day prior and stated to her since you know how to, you do it and then left without changing them. R8 stated that she frequently changes her own wound dressings. R8 reported she was using a Dakin's wound cleaner solution, provided by a nurse and then pointed to an unlabeled white spray bottle with the words BUBBLES written in black sharpie across the top. R8 said, Open it up and smell it, and you will see it's Dakins. R8 noted that the WCN currently does not use Dakin's to cleanse her wounds, but some other kind of wound cleaner. During an observation and interview of R8's dressing change on [DATE] at 2:50 PM, R8 stated to the WCN, You know you didn't change my dressings yesterday, and you told me since I know so much, do it myself, and then you left. The WCN became visibly upset and sighed. The WCN later asked R8, How long have you had your wounds? and R8 responded, Why you asking me this, you know I had these when I came, they been there a long time. When the WCN asked when the wound became so big, R8 replied, Did you not read my hospital notes, it says I had a surgery and they cut it. During an observation and interview on [DATE] at 3:35 PM, the Director of Nursing (DON) stated that her expectation was for the WCN to follow physician orders. The DON stated that she was not entirely sure if R8 was doing her own dressing changes, but knew she would assist at times, but if so, she would have orders to do so. DON was then asked to come to R8's room with surveyor. DON was shown the wound care supplies at R8's bedside. R8 then stated to the DON that she got the Dakins from a nurse here at the facility and stated that the WCN refuses to change her dressing at times and that she would do it herself. On [DATE], the facility provided an acceptable IJ Removal Plan, which included the following: Resident 5 was involved in a resident to resident altercation on 4-24-26 and placed in bed by the CNA at approximately 503am. Nurse did not assess the resident or follow up with the resident after the physical altercation. Resident 8 was here for short term rehab and has wounds to her sacrum that are chronic and were present on admission. She admitted with wound supplies she preferred to keep at bedside. her discharge plan is to discharge home. She has orders for wound care to be performed daily and staff have been doing this however, on a few occasions she has refused to allow staff to perform the wound care stating she had done it herself. This was documented in nurses notes. IMMEDIATE ACTION TAKEN: 1) Resident 5 expired at facility on 4-24-26. 2) Resident 8 remains at the facility and orders in place for every other day wound care. 3) Education initiated with all licensed nurses by DON and RDCS on 5-1-26 to ensure understanding of following physician orders, providing treatments as ordered, documenting any refusals of care or treatment and non-compliance with any care and ensuring that residents have no medications at bedside. All education will be provided to newly hired staff and agency staff prior to next shift worked. ADHOC QA MEETING HELD 5-1-26 Members present were: [name] - Operations Manager, [name] RN Director of Nursing, [name] LNHA Members via phone: Dr. [name] and Dr. [name] Root Cause: Facility failed to document adequately resident reference to keep wound supplies at bedside and failed to care plan refusals of care. Education initiated on 5-1-26 by DON and RDCS for all licensed nurses via phone and blast text via [NAME] as well as education provided in person to staff in the facility for both day shift and night shift on 5-1-26 regarding following physician orders, ensuring that resident's do not have medications at bedside and that any refusals or non-compliance must be documented. Education will be provided to all newly hired nurses and agency nurses will be provided prior to next shift worked. Audit of Resident 8 TAR complete by RDCS on 5-1-26 to ensure that any refusals of wound care for March and April were documented. Resident 8 was educated that she cannot have medications at bedside and requested that she give the Dakins to the DON and she did on 5-1-26@7:30pm. Checklist for resident to resident altercations was provided to DON and Admin on 4-30-26 by RDCS and will be utilized for each facility reported altercation to ensure all documentation and evaluations are complete. Education provided to DON by RDCS on 5-1-26 to ensure that each day Monday - Friday a review of missed documentation will be compete [sic] during clinical meeting to ensure any refusals of care have appropriate documentation. The above components have been implemented as of 5-1-26 by 8 pm.

Based on review of facility policy, record review, interviews, and review of video footage, the facility failed to protect Resident (R)5 from physical abuse by R4. Specifically, on [DATE] at approximately 4:43 AM, R4, while in a wheelchair, rolled behind R5 placed his arm around R5's neck and began to choke R5. Certified Nursing Assistant (CNA)1, who witnessed the incident, separated both residents. Furthermore, the facility neglected to provide care and services to R5, following the physical altercation. Specifically, the altercation occurred on [DATE] at approximately 4:43 AM, R5 was placed in his room at approximately 5:03 AM. R5 was found in his room unresponsive and with no pulse at approximately 7:35 AM. During this time frame, the facility failed to assess R5, failed to conduct a body audit of R5, and failed to follow up with R5, after the physical altercation.On [DATE] at 3:58 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation.On [DATE], the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D.An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care.Findings include:Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of [DATE], documented, Residents have the right to be free from abuse, neglect . This includes but is not limited to . physical abuse .Review of the facility policy titled, Abuse and Neglect - Clinical Protocol with a revised date of [DATE], documented, Definitions 1. Abuse is defined . as the willful infliction of injury, . Instances of abuse of all residents, irrespective of any mental or physical condition . It includes . physical abuse . Neglect . means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Assessment and Recognition 1. The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment (bleeding, bruising deformity, swelling etc.); b. Pain assessment; . g. Vital signs; . 2. The nurse will report findings to the physician .Review of the facility's video footage, in the presence of the Director of Nursing (DON), Administrator, Operations Manager, Regional Director of Clinical Services (RDCS)1 and RDCS2, revealed the following timeline on [DATE]:4:40 AM - R5 was sitting at the nursing station on the [NAME] Unit, in his wheelchair. R4, also in a wheelchair, was sitting in the common area directly across the nursing station on the [NAME] Unit, near the entry doors to the court yard.4:43 AM - R4 starts rolling towards R5, through the common area. R4 moves directly behind R5 and leans forward and places his arm around R5's neck. R5 responds by grabbing R4's arm with both hands. R4 continues to choke R5, as R5 was unable to get R4 to release his hold around R5's neck. R5's head begins to lean backwards by the force applied to his neck. CNA1 comes into view from off screen and approaches both residents. CNA1 grabs R4's arm and R4 released his hold. CNA1 than moves R5 to a desk in the corner of the room, where CNA1 was sitting and CNA1 has a seat back at the desk, with R5 next to the desk. R4 is still in the common area next to the nursing station.4:47 AM - Licensed Practical Nurse (LPN)1 comes into view and makes her way to the nursing station. CNA1 begins talking with LPN1, while CNA1 was still seated at the desk in the corner. LPN1 turns her attention to R4 and they begin to have a conversation. 4:51 AM - LPN1 sits down at the nursing station.4:52 AM - CNA1 sits down at the nursing station. R4 starts to move pass the tables in the common area to the hallway.5:03 AM - CNA1 gets up from the nursing station. CNA1 puts on gloves and rolls R5 to his room.5:07 AM - CNA1 exits the room.5:07 AM - 7:32 AM - Revealed no staff members entered R5's room to follow up with R5 after the physical altercation. At 7:07 AM and 7:12 AM, staff members were in the area of R5's room, however the angle of the video footage could not verify, entry into R5's room. 7:33 AM - CNA5 enters R5's room.7:35 AM - CNA5 rushes out of R5's room and continues down the hall. CNA5 and LPN2 return to the room,7:40 AM - Emergency Medical Services (EMS) and fire rescue arrive on scene.7:51 AM - Police officer arrive on scene.8:00 AM - Two more police officers arrive on scene. 8:44 AM - Coroner arrives on scene.Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses including but not limited to, hereditary and idiopathic neuropathy, dementia, moderate, with other behavioral disturbance, insomnia, and hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease.Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed R4 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated R4 suffered from moderate cognitive impairment. Further review of the MDS revealed R4 had no physical or verbal behavioral symptoms directed toward others. Review of R4's Progress Note dated [DATE] at 5:16 AM, revealed a behavior note which documented, Per [CNA1] she witnessed that rolled his wheelchair behind [R5] and began to choke him while choking him aide ask [R4] to let him go and he refused aide had to get up and remove resident hand from around [R5's] neck. Resident started picking with another resident and just wanted to argue with the staff.Review of R4's Care Plan with an initiated date of [DATE], revealed a focus on Insomnia: Resident has difficulty sleeping related to insomnia. The interventions directed staff to, Observe for side effects and effectiveness of antidepressant med use and report to physician as indicated. Further review of the Care Plan revealed a focus on Medication - Antidepressant: Resident requires Antidepressant medication related to sleep/insomnia. with an initiated date of [DATE]. The interventions directed staff to, Observe and report signs of . confusion, agitation. Observe the resident's mood and response to medication. Further review of the Care Plan revealed a focus on Psychosocial - Well-being: Resident is at risk for psychosocial well-being concerns related to Dementia with an initiated date of [DATE]. The interventions directed staff to, Observe for . increased agitation .Review of R5's Face Sheet, revealed R5 was admitted to the facility on [DATE], with diagnoses including but not limited to, age-related osteoporosis with current pathological fracture, chronic obstructive pulmonary disease, atherosclerotic heart disease, presence of xenogenic heart valve, dementia, epilepsy, spondylosis and need for assistance with personal care.Review of R5's 5-day MDS with an ARD of [DATE], revealed R5 had a BIMS score of 5 out 15, which indicated R5 suffered from severe cognitive impairment. Review of R5's Progress Note dated [DATE] at 5:36 AM, documented, [CNA1] witnessed that rolled his wheelchair behand [R5] and began to choke him while choking him aide ask [R4] to let him go and he refused aide had to get up and remove resident hand from around [R5] neck. resident has been separated. DON has been notified.Further review of R5's Progress Notes revealed a note dated [DATE] at 8:00 AM, which documented, Note Text: Late Entry: During rounds, CNA alerted nurse patient not [sic] was not responding to verbal stimuli. Nurse rushed to room to assess patient, after verbal stimuli and physical stimuli initiated, patient found to by pulseless. Patient was DNR. EMS arrived on site to assist, and pronounced patient expired at 0740. Coroner on site.During an interview on [DATE] at 1:36 PM, the Administrator stated, The nurse was in the area of the resident. He [R5] wasn't assessed. I did not see the resident get assessed.During an interview on [DATE] at 1:37 PM, the DON stated, There was an altercation with [R4] and [R5]. [R4] put his arm around [R5] and the CNA had to pull them apart. She only said he put his arm around his neck. She told me it looked like he was being choked. A body audit was conducted after he expired. When asked if an assessment or body audit was conducted after the physical altercation, the DON responded, Not that I know of.During an interview on [DATE] at 1:42 PM, RDCS2 stated, Body audits, assessments should be done to assess for any injuries. The agency nurse and CNA just didn't do them.During an interview on [DATE] at 3:18 PM, CNA5 stated, I got to [R5's] room about 7:15 AM, he was laying on his stomach. The other nurses were down there, they had to see that. I just peeked in there. I told the roommate [R5's roommate] I would be back. I did the rest of my rounds. I walked back down and I turned the light on in [R5's] room, the roommate told me to check on him cause he was talking. I called his name and he didn't say anything. I gave him a little shake and he was unresponsive. Stuff was coming out of his mouth, like drool. The drool was bubbly and his eyes were closed. I ran and asked the nurse, the nurse said he should be fine from the report I got. She went and checked, she said he was getting cold. I got the vital machine and we couldn't get none (referring to the residents pulse). We verified DNR. The EMS did their thing. During shift change, I was told he was sitting up front in his wheelchair. [R4] and [R5] were arguing. [R4] is always arguing with people. He [R4] gets physical with staff and patients.During an interview on [DATE] at 1:31 PM, the DON stated, The night it happened we had an agency nurse and clearly we saw that she did not do any assessments. Everything had already occurred by the time I got here. I did not do any follow up till I got here. We have to do extensive training.During an interview on [DATE] at 4:39 PM, CNA1 stated, [R5] was sitting in the dining room talking to me. [R4] started talking and rambling. [R4] rolled up behind [R5] and placed his arm around his shoulder and neck. I got up and released his hand from around his neck. [R5] was talking trash. I notified the nurse. I asked him if he was ok, he said Yes. I took him [R5] down the hall, got to his room, he stood up on his own, took his pants off, and got in his bed himself. He didn't show any signs. He told me thank you for handling that man for me. I covered him up and started doing my rounds. His roommate rung his bell at 6:57 AM, I told him to give me a minute. I looked over at [R5] and he was laying on his side and I walked out. The nurse didn't do any vitals. I looked at him, there was no changes in his breathing.On [DATE], the facility provided an acceptable IJ Removal Plan, which included the following: . Summary of Incident:On 4-24-26 at approximately 4:;43am [sic] Resident 4 while in a wheelchair, rolled behind Resident 5, who was also in a wheelchair, and placed his arm around R5's neck and began to choke R5. CNA1 who witnessed the incident, separated both residents and remained in the common area with both of the residents. Neither resident appeared to be in any distress. CNA assisted Resident 5 to bed at approximately 5:03am.Immediate Action Taken:1) Resident 5 expired on 4-24-26. Coroner was at the facility.2) Resident 4 remains at the facility and was seen by NP on 4-24-26 with psych and medical director collaboration and new orders noted.3) Education initiated with all staff by DON and RDCS on 4-30-26 to review abuse and neglect and reporting policy and procedure if abuse or neglect occurs, specifically with regard to separating residents and staff will ensure that they are safe and kept apart and assessment and evaluation of resident following an altercation and notifications and documentation. Blast test sent via [NAME] as well as phone calls - if staff did not answer voicemails were left with education information and will obtain wet signature from staff on next scheduled shift. All agency staff will be [sic] received the education on their next scheduled shift at facility.4) Per audit of staff in facility - 2 nurses were identified with agency who had not received the education at start of their shift and they were brought in and education done by RDCS on [DATE] at 3:15 pm.5) Audit of FRIs for last 30 days complete by RDCS on 4-30-26 to ensure that all evaluations and assessments were complete and that residents were kept separated. 6) Audit tool for resident to resident altercations reviewed with Operations Manager and Administrator and DON by RDCS on 4-30-26 to ensure understanding of follow up after a reportable event or altercation to ensure all evaluations and assessments are complete and residents are kept safe.7) Education will be provided to all newly hired staff and agency staff prior to next scheduled shift.ADHOC QA MEETING HELD ON 4-30-26.Members present: [name] LNHA, [name] Operations Manager, [name] RN-DON, [name] RN RDCS.Members via phone were: [name] Medical Director. [name] Medical Director* Root Cause of Issue is identified as failure of facility to ensure a resident was protected from abuse and following a resident to resident altercation there was failure to assess the resident for injury.* Education was initiated for all staff on 4-30-26 by DON and RDCS regarding abuse and abuse reporting and steps to follow following a resident to resident altercation. Abuse and Neglect Policy reviewed.* Audit complete by RDCS on 4-30-26 on Facility Reportable Incidents in last 30 days to ensure that all notifications and evaluations were complete.* DON and Administrator educated on 4-30-26 by RDCS regarding checklist to utilize following each resident to resident altercation to ensure all evaluations are complete.* Education will be provided to all newly hired staff and agency staff prior to next scheduled shift.The above components have been implemented as of 5-1-26 by 10am.

Based on review of the facility's policies, document review, and interviews, the facility failed to ensure all staff, to include agency staff, received orientation, training, and in-services on facility policies and procedures, prior to working with residents. Specifically, the facility had agency staff working as a charge nurse, floor nurse, and aide without the proper training. This deficient practice had the potential to effect all residents in the facility.Findings include:Review of the facility's policy titled, In- Service Training, All Staff, revised in August 2022, revealed Policy Statement: All staff must participate in initial orientation and annual in-service training. Policy Interpretation: 1. All staff are required to participate in regular in-service education. In-service education participation is considered working time for which staff are paid their regular wages. 7. Training requirements are met prior to staff providing services to residents, annually, and as necessary based on the facility assessment. 8. Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.Review of the facility's policy titled, Staffing, Sufficient and Competent Nursing revised April 2025 revealed Policy Interpretation and Implementation: Sufficient Staff. 1. Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: c. assessing, evaluating, planning, and implementing resident care plans . 2. A licensed nurse is designated as a charge nurse on each shift. b. A charge nurse is a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordination, provider or physician support, and direct care.On 04/30/26 at 12:15 PM, while in the Administrator's office watching video footage of an incident, in the presence of the Operations Manager and the Regional Director of Clinical Services (RDCS)2, orientation documentation and training were requested for agency staff currently working in the building. In the video footage, Licensed Practical Nurse (LPN)1, who was an agency staff member, was observed interacting with residents. Further review of the footage revealed LPN3, who is also an agency staff member, interacting with residents.During an interview on 05/01/26 at 11:40 AM, LPN5 indicated it was her first day at the facility. She stated she had not been given any training, or orientation, or in-services; she had only been given a clipboard and login.Multiple attempts were made to contact LPN1 via telephone, with no success.During an interview on 05/01/26 at 11:41 AM, Certified Nursing Assistant (CNA)4 indicated she was an Agency CNA and it was her first time back at the facility in a few weeks. She stated, upon hire, she did not obtain any training, orientation, or in-services from the facility. When asked if she had in-services based on the ongoing survey findings, she stated she did not. She indicated that her shift had begun at 7:00 AM that day.During an observation of a document for LPN5, provided by the Administrator on 05/01/26 at 4:00 PM, indicated LPN5 had a Certificate of Signature with a timestamp of 01 May 2026 18:45:48 UTC. When asked, the Administrator stated, I learned UTC is five hours ahead of Eastern Standard Time (EST), so the document was signed at 3:45 PM. When asked when did LPN5's shift began for the day, the Administrator acknowledged LPN5 had just signed the orientation document and had been working with residents since 7 AM that morning.During an interview with the Administrator on 05/01/26 at 12:01 PM, he entered the conference room with a binder, that contained multiple facility policies. He stated, This is the Nurses' quick guide, that agency staff are to review, when time allows. When asked, who monitors that staff have completed required in-services, orientation and training, the Administrator stated, We do not have any sign-in sheets to prove these have been completed. Staff are supposed to complete prior to starting, but we use a lot of agency staff. This is something we are just going to have to work on.At the conclusion of the survey on 05/01/26, the Administrator still had not yet provided documentation of orientation completion or training and in-services for LPN1 and LPN3.

Based on a review of the facility policy, observations, interviews, and record review, the facility failed to ensure that self administration of medications was clinically appropriate as required for Resident (R)8, 1 of 1 resident reviewed for self administration. Two medications, a nasal spray and an albuterol inhaler, were found at R8's bedside without an assessment or authorization for self administration. This failure placed the resident at risk for medication errors and adverse health outcomes.Findings Include: Review of the facility policy titled Self Administration of Medications, last revised February 2012, states: Residents have the right to self administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self administering medications is safe and clinically appropriate for the resident . 3. If it is deemed safe and appropriate for a resident to self administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self administer medications is re assessed periodically based on changes in the resident's medical and/or decision making status . 8. Self administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. 9. Any medications found at the bedside that are not authorized for self administration are turned over to the nurse in charge for return to the family or responsible party. Review of R8's Face Sheet revealed the facility admitted R8 on 03/04/26, with diagnoses including but not limited to: Paraplegia, muscle weakness, chronic obstructive pulmonary disease (COPD), interstitial pulmonary disease, asthma, sleep apnea, sleep deprivation, cognitive communication deficit and a need for assistance with personal care. Review of R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/26 revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R8 was cognitively intact. Further review revealed R8 experienced shortness of breath or trouble breathing when lying flat. Review of R8's Care Plan revealed, Focus: Resident is at risk for complications with the respiratory system due to Asthma, Chronic Obstructive Pulmonary Disease (COPD), Interstitial [NAME] Disease, and Sleep Apnea. Interventions/Tasks: Administer medications as ordered. Monitor for side effects/adverse reactions and effectiveness. No care plan for self-administration of medications noted. Review of R8's Physician Orders revealed: Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for SOB/Wheezing, and Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 1 inhalation in each nostril in the morning for Rhinitis. No orders for self-administration of medications noted. During an observation and interview on 05/01/26 at 11:54 AM, a container on R8's bedside dresser contained a Ziploc bag with one Fluticasone Propionate (nasal spray) and one Albuterol Sulfate inhaler. R8 stated that she administers the medications herself as the facility did not provide them for her. R8 also stated that she was not provided any education for her to self-administer her medications. During an interview on 05/01/26 at approximately 12:30 PM, Licensed Practical Nurse (LPN)4 stated Yes, R8 administers her own nasal spray. When asked if R8 had an order allowing self-administration, LPN4 said No, I do not see one. LPN4 also stated she was unaware of what the facility's policy was regarding residents administering their own medications. During an interview and observation on 05/01/26 at 3:35 PM, the Director of Nursing (DON) stated that R8 should have an order to self administer medications. The DON explained that the facility usually places an order for self administration, and when it is time for the resident to self administer, the nurse typically witnesses the administration. This allows the nurse to verify and document that the medication was administered. The DON stated that the process to have medications at the bedside would be the same and included in the order for self-administration. She also stated that the nurses should know what to do when medications are found at the bedside. They should take the medications and inform the resident that an order is required. The DON noted that staff should explain to the resident why the medication is being removed, the process for obtaining the appropriate order, and that the medication can be returned to the bedside once the order is in place, including how that process works. The DON observed the nasal spray and inhaler at R8's bedside and confirmed the findings. R8 stated that she had to use and supply her own medications, as the facility did not provide them to her.

Based on review of the facility policy, observations, interviews, and record review, the facility failed to maintain appropriate infection prevention and control practices during wound care for 1 of 1 residents reviewed for wound care, Resident R (8). This failure had the potential to expose the resident to cross contamination, delayed wound healing, and increased risk of infection, including the possibility of developing a preventable wound infection or worsening of the existing wound. Findings Include: Review of the facility policy titled, Enhanced Barrier Precautions, last revised December 2024, states, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. Enhanced barrier precautions apply when . b. A resident .has a wound or indwelling medical devices. 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . j. wound care (any skin opening requiring a dressing).Review of the facility policy titled, Wound Care, last revised October 2010 states, Purpose, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Steps in the Procedure . 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 8. Pour liquid solutions directly on gauze sponges on their papers. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water.Review of R8's Face Sheet revealed the facility admitted R8 on 03/04/26, with diagnoses including but not limited to: Lupus, bacteremia, sepsis, osteomyelitis of vertebra, sacral and sacrococcygeal region, immunodeficiency, stage 3 pressure ulcers of the right and left buttocks, stage 4 pressure ulcers of the sacral region, colostomy and paraplegia. Review of R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/26 revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R8 was cognitively intact. Further review revealed R8 had 2 stage 3 pressure ulcers, 1 stage 4 pressure ulcer and was a risk for pressure ulcers/injuries. Review of R8s Care Plan revealed Focus: Skin: Resident has a pressure ulcer to coccyx and left and right buttocks and is at risk for further breakdown and/or slow, delayed healing related to Cardiovascular disease, decreased mobility, and incontinence. Interventions included, administer treatment as ordered, and utilize EBP's during high-contact resident care activities.During an observation and interview on 05/01/26 at 2:50 PM, the Wound Care Nurse (WCN) was observed conducting a dressing change for R8's wounds. The WCN and her helper both donned gowns in the hallway before entering R8's room. The WCN then washed her hands, donned new gloves, grabbed an already opened gauze from a plastic cup labeled Dakins, and began cleaning the wound bed. The WCN then opened a plastic trash bag attached to the bedside table and discarded that gauze. The WCN then grabbed another gauze from this cup without completing hand hygiene or changing her gloves and continued to touch and clean R8's wound. She then removed her gloves and washed her hands and donned a new pair of gloves. The WCN was noted to be opening the plastic trash bag multiple times and moving the bedside around before grabbing gauze to cover and dress the wound. Throughout this process, an Air conditioner turned on and begun to blow on the bedside table with the supplies to complete the dressing change was. This process was observed for all three of R8's dressings that the WCN changed, all confirmed by the WCN.

Based on review of facility policy, record review, and interviews, the facility failed to ensure the accurate transcription of physician orders for 1 of 2 resident (R8) reviewed. R8's wound care order was entered incorrectly on the Medication Administration Record (MAR) as daily, while the Physician's instruction required treatment every other day (QOD). This failure created the potential for incorrect treatment frequency and adverse outcomes. Findings Include:Review of the facility policy titled Medication Orders, last revised November 2014, states Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Supervision by a Physician: . 2. A current list of orders must be maintained in the clinical record of each resident . Recording Orders .6. Treatment Orders-When recording treatment orders, specify the treatment, frequency and duration of the treatment. Example: Apply 4X4 duoderm with border to stage 1 ulcer on coccyx; change every 3 days and as needed per wound care protocol.Review of R8's Face Sheet revealed the facility admitted R8 on 03/04/26, with diagnoses including but not limited to: bacteremia, sepsis, osteomyelitis of vertebra, sacral and sacrococcygeal region, stage 3 pressure ulcers of the right and left buttocks and stage 4 pressure ulcers of the sacral region. Review of R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/26 revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R8 was cognitively intact. Further review revealed R8 had 2 stage 3 pressure ulcers, 1 stage 4 pressure ulcer and was a risk for pressure ulcers/injuries. Review of R8's Care Plan revealed Focus: Skin: Resident has a pressure ulcer to coccyx and left and right buttocks and is at risk for further breakdown and/or slow, delayed healing. Interventions included, administer treatment as ordered.Review of a Consultation Report dated 04/28/26, documented, To whom it may concern at [NAME] Island Post Acute Rehab facility, I had the pleasure seeing [R8] today for routine postoperative visit stage IV sacral wounds .Please continue local wound care .Recommendations: . Cleanse wounds x3 with Dakins and then apply collagen and calcium alginate with dry dressing over the wound. Exchanged every other day or as needed for saturation/soiling or dislodgement or more.Review of R8's Physician's Orders dated 04/30/26 with a start date of 05/01/26 revealed the following: WOUND CARE - Coccyx clean with Dakins, place collagen in wound bed and pack with calcium alginate [every other day] QOD and [as needed] PRN. every day shift for wound care. WOUND CARE LEFT BUTTOCKS clean with Dakins, place collagen on wound bed and pack calcium alginate QOD and PRN every day shift for wound care. WOUND CARE right buttocks clean with Dakins, place collagen on wound bed and pack calcium alginate QOD and PRN every day shift for wound care. All three orders were entered for daily dressing changes instead of every other day. During an observation and interview on 05/01/26 at 2:50 PM, the Wound Care Nurse (WCN) reviewed R8's wound care orders prior to the WCN changing R8 dressings. The WCN read the order and then proceeded to enter R8's room. The WCN was asked by surveyor to once again review the orders and re-confirm them. The WCN read the order and confirmed it was entered for daily dressing changes, but the instructions stated every other day. The WCN was then notified by the surveyor of the contradicting orders and informed the WCN to review the consultation report. The WCN then opened the report and stated that she had not reviewed this. When asked if this was normal practice for the WCN to not review orders for wound care she stated No and the staff typically place the report on my desk. The WCN then confirmed that R8's orders should have been entered to be completed every other day and not daily.During an interview on 05/01/26 at 3:35 PM, the Director of Nursing (DON) stated that her expectation was for the WCN to follow physician orders. The DON stated that when R8 comes back from an appointment with a consult sheet, the nurse will review it. She further stated that the WCN reviews the orders in great detail. When asked about the conflicting orders for R8, the DON said she wasn't sure why it said that, unless the provider saw it and changed it would be the only thing that I can think of. The DON then reviewed and confirmed both the consultation report and physician's order.

Based on record review, interviews, and review of facility policy, the facility failed to ensure the comprehensive care plan was updated and revised to reflect changes in condition and care needs for 1 of 2 residents (R8) reviewed for care plans. The care plan was not updated when R8's peripherally inserted central catheter (PICC) line was removed, and it did not include interventions related to self administration of medications. This failure created the potential for unmet needs and inconsistent care. Findings Include: Review of the facility policy titled, Care Plans - Comprehensive with a revised date of September 2010, documented, Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident . 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. 3. Each resident's comprehensive care plan is designed to: a. incorporate identified problem areas; . e. Reflect treatment goals, timetables and objectives in measurable outcomes; . 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 9.The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition . Review of the facility policy titled Self Administration of Medications, last revised February 2012, documented: Residents have the right to self administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self administering medications is safe and clinically appropriate for the resident . 3. If it is deemed safe and appropriate for a resident to self administer medications, this is documented in the medical record and the care plan.Review of R8's Face Sheet revealed the facility admitted R8 on 03/04/26, with diagnoses including but not limited to: Lupus, cognitive communication defect, paraplegia, and a need for assistance with personal care. Review of R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/26 revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R8 was cognitively intact. Further review revealed R8 received Intravenous (IV) medications and had IV access while a resident of this facility and within the last 14 days. Review of R8's Care Plan revealed, Focus: Vascular Access: Resident is at risk for complications due the presence of a [] Central line [] Midline [] Peripheral line [x] PICC line [] Port-A-Cath with (enter number of lumens) for the treatment of long term IV antibiotic therapy r/t osteomyletitis [sic] initiated on 3/10/26. No care plan for self-administration of medications noted. Review of R8's Progress Note dated 04/27/26 at 7:27 AM, documented a Medication Administration Note that documented, OK to DC PICC line PICC Line was removed on 4/28/26 at her ID appointment. Review of a Consultation Report dated 04/28/26 documented, Diagnosis: PICC line was D/c'd today and removed.During an interview on 05/01/26 at 11:54 AM, R8 stated, My PICC line had been removed a few days ago, on Tuesday by the surgeon.During an interview on 05/01/26 at approximately 12:45 PM, Licensed Practical Nurse (LPN)4 stated [R8] does not have a PICC, LPN4 was unaware when R8's PICC was removed, and said She should have an order in her chart for when it was discontinued, but I'm not seeing one. She further stated that R8 was still care planned for having a PICC line. LPN4 also said Yes, when asked if R8 self-administers her nasal spray. LPN4 also stated she was unaware of what the facility's policy was regarding residents administering their own medications. During an interview on 05/01/26 at 3:35 PM, the Director of Nursing (DON) stated in order for R8 to have meds at the bedside she would have orders and be care planned. DON confirmed what R8's care plan and that she no longer had a PICC. The DON also stated the Minimum Data Set Nurse (MDS) was responsible for managing the care plans, with the exception of the behaviors part and that they should know what to do.

Based on review of facility policy, record review, and interviews, the facility failed to create a Comprehensive Person Centered Care plan for Resident (R)4, related to his aggressive behaviors and R8 related to self administration, for 2 of 3 residents reviewed for Care Plans.Findings include:Review of the facility policy titled, Behavioral Assessment, Intervention, and Monitoring with a revision date of February 2025, documented, Policy Statement 1. Residents will have minimal complications associated with the management of altered or impaired behavior . Policy Interpretation and Implementation . 2. As part of the comprehensive assessment, staff evaluate (based on input from the resident, family and caregivers, review of the medical record, and general observations): a. the resident's usual patterns of cognition, mood, and behavior; . 3. The nursing staff identify, document, and inform the physician about specific details regarding changes in the an individual's mental status, behavior, . 5. New onset or changes in behavior are evaluated and documented, regardless of the degree of risk to the resident or others. Interventions and Management 1. The IDR evaluates behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develops a plan of care accordingly. 3. The care plan includes, as a minimum: a a description of the behavioral symptoms, . b. targeted and individualized interventions for the behavioral and/or psychosocial symptoms; . d. specific and measurable goals for targeted behaviors; and e. how the staff will monitor the effectiveness of the interventions. 4. Interventions are individualized and part of an overall care environment . Monitoring 1. The IDR monitors for and documents any new, worsening, or improved symptoms in the resident's behavior, mood, and function .Review of the facility policy titled, Care Plans - Comprehensive with a revised date of September 2010, documented, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident . 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. 3. Each resident's comprehensive care plan is designed to: a. incorporate identified problem areas; . e. Reflect treatment goals, timetables and objectives in measurable outcomes; . g. Aid in preventing or reducing declines in the resident's functional status . 4. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools . 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes . 6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, .Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses including but not limited to, hereditary and idiopathic neuropathy, dementia, moderate, with other behavioral disturbance, insomnia, and hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease.Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/26, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated R4 suffered from moderate cognitive impairment. Further review of the MDS revealed R4 had no physical or verbal behavioral symptoms directed toward others. Review of R4's Care Plan dated with an initiated dated of 07/28/25, revealed a focus on Insomnia: Resident has difficulty sleeping related to insomnia. The interventions directed staff to, Observe for side effects and effectiveness of antidepressant med use and report to physician as indicated. Further review of the Care Plan revealed a focus on Medication - Antidepressant: Resident requires Antidepressant medication related to sleep/insomnia. with an initiated date of 07/28/25. The interventions directed staff to, Observe and report signs of . confusion, agitation. Observe the resident's mood and response to medication. Further review of the Care Plan revealed a focus on Psychosocial - Well-being: Resident is at risk for psychosocial well-being concerns related to Dementia with an initiated date of 08/25/25. The interventions directed staff to, Observe for . increased agitation . Further review of R4's care plan did not reveal a targeted individualized care plan related to R4's aggressive behaviors, prior to the resident to resident physical abuse on 04/24/26.Review of R4's Care Plan with a date initiated on 04/24/26, revealed a focus on Psychosocial- Behavior: Exhibits or is at risk for behavioral symptoms grabbing others/ invasion of privacy due to: dementia. Review of this care plan revealed it was initiated after the resident to resident physical abuse on 04/24/26.Review of R4's Progress Note dated 04/24/26 at 5:16 AM, revealed a behavior note which documented, Per [CNA1] she witnessed that rolled his wheelchair behind [R5] and began to choke him while choking him aide ask [R4] to let him go and he refused aide had to get up and remove resident hand from around [R5's] neck. Resident started picking with another resident and just wanted to argue with the staff.Review of R5's Progress Note dated 04/24/26 at 5:36 AM, documented, [CNA1] witnessed that rolled his wheelchair behind [R5] and began to choke him while choking him aide ask [R4] to let him go and he refused aide had to get up and remove resident hand from around [R5] neck. resident has been separated. DON has been notified.Review of R4's Progress Note dated 03/03/26 at 6:41 PM, revealed a nurse's note which documented, Resident and roommate [name] were observed arguing this morning after shift change. Both resident and roommate were making threats towards each other. Staff separated the two men at this time. This has been an ongoing problem, being that both men believed the other was the problem .During an interview on 04/30/26 at 3:18 PM, CNA5 stated, [R4] is always arguing with people. He gets physical with staff and patients. A CNA gave him his lunch tray and [R4] came out the room with the lunch tray on the bedside table and he was cursing, like he always does, and he was running the bedside table into the CNA. I think this happened the same day (referencing the resident to resident altercation involving R5). From what I see, he is always that aggressive. Months ago, when [name of former roommate] was his roommate, he took a shoe helper and smacked [roommate] in his face. [R4] does have behaviors. He's mean to everyone. They tell us to keep it simple, don't say too much.During an interview on 04/30/26 at 3:36 PM, CNA2 stated, This morning, [R4] was eating his breakfast, he was cussing at me when i asked if he was done. One day he kept pushing his table into my legs pretty hard. He is angry and aggressive on a daily basis. The nurses are aware of his behaviors.During an interview on 05/01/26 at 11:38 AM, CNA6 stated, Recently he's (referencing R4's behaviors) been aggressive a lot, verbally.During an interview on 05/01/26 at 11:41 AM, CNA4 stated, He (referencing R4's behaviors) is very stern and has a harsh attitude. He is verbally aggressive.During an interview on 05/01/26 at 11:48 AM, the Licensed Medical Social Worker (LMSW) and the Social Worker Assistant (SWA) both revealed they were not aware of R4's behaviors and have not observed R4's behaviors.During an interview on 05/01/26 at 12:00 PM, the MDS Coordinator stated, I do medical care plans. I oversee and review all care plans. I complete the MDS and social services completes behavior MDS. I don't look at everyone of them, but I make sure things are in place. When asked about R4's lack of behavior care plan and indications in the MDS, the MDS Coordinator stated, Good question. I can assume the Psychosocial was put in to cover a broad spectrum.During an interview on 05/01/26 at 1:31 PM, the Director of Nursing (DON) stated, I wouldn't know why he (R4) wasn't care planned for behaviors. Care plan is done by MDS or SS. I'm not sure, there has to be a disconnect, cause when I see him, he is very pleasant.During a follow up interview on 05/01/26 at 2:49 PM, the DON stated, I'll have someone look. MDS does the care plans. It's (referencing R4's behaviors) discussed in our IDT meetings and then the care plans are updated.

Based on review of facility policy, record review, and interviews, the facility failed to thoroughly investigate an incident of resident to resident physical abuse involving Resident (R)4 and R5, for 1 or 3 residents reviewed.(Cross Reference F600 and F726)Findings include:Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of April 2021, documented, Residents have the right to be free from abuse, neglect, . This includes but is not limited to . physical abuse . Policy Interpretation and Implementation The resident abuse, neglect, . prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 3. Ensure adequate staffing and oversight/support . 6. Provide staff orientation and training/orientation programs . 8. Identify and investigate all possible incidents of abuse, neglect, . 9. Investigate and report . 10. Protect residents from any further harm during investigations .Review of the facility's video footage revealed that on 04/24/26 at 4:43 AM, R4 starts rolling towards R5, through the common area. R4 moves directly behind R5 and leans forward and places his arm around R5's neck. R5 responds by grabbing R4's arm with both hands. R4 continues to choke R5, as R5 was unable to get R4 to release his hold around R5's neck. R5's head begins to lean backwards by the force applied to his neck. CNA1 comes into view from off screen and approaches both residents. CNA1 grabs R4's arm and R4 released his hold. CNA1 than moves R5 to a desk in the corner of the room, where CNA1 was sitting and CNA1 has a seat back at the desk, with R5 next to the desk. And R4 still in the common area next to the nursing station.Review of the facility's reportable folder revealed a typed Witness Statement signed on 04/24/26, the statement documented, [CNA1] was sitting at the nurse's station and [R5] was sitting by the desk. [R4] was sitting in his wheelchair and approached [R5] from the back, reached around him, placing his arms around [R5's] shoulder area. [CNA1] jumped up from chair to help assist separate [R5] and [R4] meanwhile [R5] was saying Get off of me, get off of me. [CNA1] was able to separate [R5] and [R4], rolling [R5] away from [R4] [CNA1] then wheeled [R5] back to his room to assist him back to bed. After locking his wheelchair [R5] stood up and took his pants off, and got into the bed while stating, Thank you for helping me. [CNA1] placed the covers on [R5] and walked away to assist another resident. Around 0557 [CNA1] went down the hall to answer the call light in room [ROOM NUMBER]. [R5's roommate], the roommate of [R5], hit the call light but during this time [R5] was facing the left side towards the window and appeared to be sleeping. The witness statement was signed by CNA1 and the Operations Manager on 04/24/26. Further review of the reportable folder revealed it's content to include: 2 hour and 5 day reportables, a summary of events, residents' Face Sheet, summary of video footage, and two other witness statements that both documented, I did not witness the incident.During an interview on 05/01/26 at 1:31 PM, the Director of Nursing (DON) stated, This is the statement when we all watched the video, I was typing and CNA1 signed. We wanted to make sure we had an accurate statement from her. She was really nervous and shaking really bad. The other signature looks like the Administrator's. [CNA1] was the only one who witnessed the actual incident. We did not interview any other residents, cause there were no other residents around when we viewed the footage. During an interview on 05/01/26 at 2:01 PM, the Administrator stated, I didn't sign it (referencing the typed witness statement) so I can't make a statement to how it was produced. They reviewed the footage with [DON] to help her compose a statement. There was no follow ups with other residents on the unit because it was a resident to resident.During an interview on 05/01/26 at 2:07 PM, the Operations Manager stated, It (referencing the typed witness statement) was produced after we called her back about what she had witnessed. We wanted to talk with her about what she saw. I was here with [[NAME] Director of Clinical Services (RDCS)2] and (DON), one of them had typed it up while watching the footage. We kept asking her questions about what she saw. We wanted to make sure we had all the details. I was the other signature. We did not guide or coerce her witness statement.

Based on review of facility policy, record review, and interviews, the facility failed to report to the State Agency (SA), two incidents of resident to resident phsyical abuse, in a timely manner. For 2 of 3 residents reviewed.(Cross Reference F600)Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of April 2021, documented, Residents have the right to be free from abuse, neglect, . Policy Interpretation and Implementation The resident abuse, neglect, . program consists of a facility-wide commitment and resource allocation to support the following objectives: . 9. Investigate and report any allegations within timeframes required by federal requirements . Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses including but not limited to, hereditary and idiopathic neuropathy, dementia, moderate, with other behavioral disturbance, insomnia, and hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease. Review of R4's Progress Note dated 04/24/26 at 5:16 AM, revealed a behavior note which documented, Per [CNA1] she witnessed that rolled his wheelchair behind [R5] and began to choke him while choking him aide ask [R4] to let him go and he refused aide had to get up and remove resident hand from around [R5's] neck. Resident started picking with another resident and just wanted to argue with the staff. Review of R5's Face Sheet, revealed R5 was admitted to the facility on [DATE], with diagnoses including but not limited to, age-related osteoporosis with current pathological fracture, chronic obstructive pulmonary disease, atherosclerotic heart disease, presence of xenogenic heart valve, dementia, epilepsy, spondylosis and need for assistance with personal care. Review of R5's Progress Note dated 04/24/26 at 5:36 AM, documented, [CNA1] witnessed that rolled his wheelchair behand [R5] and began to choke him while choking him aide ask [R4] to let him go and he refused aide had to get up and remove resident hand from around [R5] neck. resident has been separated. DON has been notified. Review of the facility's video footage revealed that on 04/24/26 at approximately 4:43 AM, R4 starts rolling towards R5, through the common area. R4 moves directly behind R5 and leans forward and places his arm around R5's neck. R5 responds by grabbing R4's arm with both hands. R4 continues to choke R5, as R5 was unable to get R4 to release his hold around R5's neck. R5's head begins to lean backwards by the force applied to his neck. CNA1 comes into view from off screen and approaches both residents. CNA1 grabs R4's arm and R4 released his hold. CNA1 than moves R5 to a desk in the corner of the room. Review of the facility's reportable Accident/Incident dated 04/24/26, revealed a 2 hour reportable for physical abuse with the date and time of Reportable Incident documented as 04/24/26 at 8:01 AM. During an interview on 04/30/26 at 1:42 PM, the Regional Director of Clinical Services (RDCS)1 stated, It did not get to me in time. It was reported to the DON, she's new, the phone call didn't come to me till about 8:00 AM. At that point it was already late, so we needed to figure this all out before we report. During an interview on 05/01/26 at 1:31 PM, the Director of Nursing (DON) stated, I called the Administrator, the disconnect was the day prior, that Thursday and he called the nurse consultant to do the reportable. When I called the Administrator, I though he was going to do it [in reference to reporting the resident to resident physical abuse]. I should have called and followed up that the nurse consultant was notified. The nurse consultant does the reportables for all our buildings. During an interview on 05/01/26 at 2:01 PM, the Administrator stated, Our abuse coordinator is [name of Operations Manager], they called [DON], [DON] called [Operations Manager] and [Operations Manager] did not communicate the information out timely. Review of a 2 Hour Report revealed an incident submitted to the SA alleging physical abuse between R6 and R7 on 04/23/26 at 3:45 PM. Review of a submission report had a timestamp of 04/23/26 at 4:04 PM. Review of a Five-Day Follow-Up Report submitted to the SA on 04/29/26 at 04:01 PM via email indicated a physical abuse incident occurred between R6 and R7 on 04/23/26 at 3:45 PM. Review of the R6's Electronic Medical Record (EMR) indicated a Social Services Note dated 04/23/26 at 12:31 PM that read, Late Entry:Note Text: SSD notified of incident with roommate in common area. SSD spoke to resident to confirm that he was okay and had been checked out by nursing staff. An additional note dated 04/23/26 at 1311 (1:11 PM) read, Resident at DR table after eating lunch, Party B came over to table and begin to use bad words toward resident A, separation took place at this time. During a telephone interview with Licensed Practical Nurse (LPN)6 on 04/30/26 at 2:56 PM, she stated R7 had rolled up to R6 in the dining room table, started cussing and kicked him in his shin. LPN6 confirmed this incident happened right after lunch time, approximately 1:00 PM. During an interview with the Social Services Director on 05/01/26 at 11:30 AM, she stated, she was unsure of the exact time of the incident. She stated her times may have been incorrect, but she sure it occurred after 11:15 AM, due to having held a care plan meeting with one of the residents earlier that day. During an interview with the DON on 05/01/26 at 12:54 PM, she stated the incident occurred around 1 PM, following lunch. She confirmed the incident had been reported late and stated the Regional Director of Clinical Services (RDCS)1, who is a DON at another facility typically does their reporting for them. During an interview with RDCS1 on 05/01/26 at 5:15 PM, she acknowledged the incident was reported late due to her having to log into the system and report off of the nursing notes and what is in the medical record.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)137 was discharged from the facility to a safe environment.Per a phone interview with R137 and the Local Ombudsman, R137 revealed he was discharged from the facility on 01/22/26 to a home without utilities (water/electricity).R137 indicated this failure has caused his health to decline due to lack of adequate Durable Medical Equipment (DME-devices and supplies that are intended for repeated use and are essential for managing health conditions at home) and appropriate community services (Home Health), for 1 of 2 residents, reviewed for discharge. The Administrator and Director of Nursing (DON) were notified on 02/24/26 at 12:41 PM of an Immediate Jeopardy (IJ) at F627 at a Scope and Severity (S/S) of J in the area of Transfer and Discharge, specifically, appropriate discharge procedures. The IJ was determined to exist on 01/22/26 when the facility discharged Resident (R)137 to a home without adequate utilities (water/electricity). An acceptable IJ Plan of Removal was provided on 02/24/26 at 4:25 PM and was validated by the survey team on 02/25/26 at 12:28 PM. After the removal of the Immediate Jeopardy, the deficient practice remained at a scope and severity (S/S) of a D. Findings include:Review of facility policy titled Discharge Summary and Plan last revised September 2012, revealed, When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Policy interpretation and Implementation include, when the facility anticipates a resident's discharge to a private residence, another nursing care facility, a discharge summary and post-discharge plan will be developed which will assist the resident to adjust to his/her new living environment. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's .special treatments or procedures (treatments and procedures that are not part of the basic services provided). The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his/her family. The resident or representative should provide the facility with a minimum of seventy-two (72) hour notice of a discharge to ensure that an adequate discharge plan can be developed. The Social Services Department will review the plan with the resident and family twenty-four (24) hours before the discharge is to take place.Review of R137's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses, including but not limited to; burn of third degree on right hand, encounter for surgical aftercare following surgery on the skin, burn of third degree of buttock, burn of third degree of abdominal wall, chronic pain, and need for assistance with personal care. Review of R137's Discharge with Return Not Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/26 revealed that R137 has the Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicates that he is cognitively intact. Further review of the Discharge MDS in the Participation in Assessment and Goal Setting revealed active discharge (yes); has referral been made to the local contact agency (yes). Review of R137's Hospital Discharge Summary with a Date of Service Date of 01/12/26 at 10:46 AM revealed R137 with a Past Medical History (PHM) significant for hypertension who presents with burns to the right hand, bilateral buttocks, bilateral posterior thighs, and right flank (side region of the torso between the lower ribs and the top of the hip bone, also known as the lumbar region). The patient states that the burn occurred this morning around 10 AM when he was turning his back to a propane-fueled heater and accidentally cut himself on fire. He states that he presented to an outside emergency department for evaluation, given the severity of his burns. He was subsequently transferred to MUSC for a higher level of care. He is a relatively poor historian and states his only medical problems are chronic pain and high blood pressure. Family history: history reviewed, no pertinent family history. Hospital Course: R137 presenting with a flame burn to the right hand, buttocks, bilateral thighs, and right flank that occurred on 12/07/25 by when his clothes caught on fire after backing into a propane heater, patient admitted to Burn Surgery Service for further evaluation and management of burn wounds .Patient not willing to go to neighbor for assistance, accepted to Skilled Nursing Facility.Review of R137's Discharge Planning Form with an effective date of 01/14/26 at 8:34 PM revealed Tentative discharge date : [DATE] discharge plan includes, resident's goal is to regain strength and endurance and heal his wounds. Home environment: lives alone, concerns about returning to home, four steps to enter home. Does the resident have family or a support network to provide assistance post-discharge: unknown. Primary caregiver for resident: self. Potential barriers to discharge: pending his progress in therapy, will discuss alternate discharge placement. Services/DME Needed After Discharge; will identify resources needed from resident and send referrals, DME needed after discharge: to be discussed, currently has a cane and walker, IDT to assist with discharge plans. Review of R137's Discharge Summary and Post-Care Instructions with an Effective Date of 01/19/26 at 2:12 PM revealed Social Services Discharge Notice, you are being discharged and his document is intended to inform you or your representative about the reason for your discharge and your next destination. Our goal is to provide you with the necessary information to help you prepare for a smooth transition to the greatest extent possible. Discharge information includes, date and time (01/22/26 at 12:00 PM). Reason for discharge: resident health has improved sufficiently so the resident no longer needs the services provided by the facility. Mode of transportation: other/NA; Home health services, no. Durable Medical Equipment (DME): wheelchair, DME ordered agency name and contact information: Home Medical 415 [NAME] Street [NAME] Corner SC 29461.Community Support Services: Salvation Army, Habitat for Humanities. Physical Functioning and Structural Problems, patient has made gains since working for therapy and contact guard for most physical function, patient remains a fall risk. Special Treatments, Devices and Procedures include dialysis (hemodialysis) and wound care. These Discharge Summary and Post Care Instructions were developed and reviewed by the Physician and Interdisciplinary Team (IDT) in coordination and participation with the resident and/or representative. This information was reviewed with a copy provided to the resident. This document was signed by Unit Manager (UM)1. Review of R137's Social Services Note dated 01/14/26 at 9:33 PM revealed admission Note, R137 was admitted on [DATE] from the Hospital, where he was being treated for extensive burns. He is alert and verbal and can make his needs known to staff. He scored a 15 out of 15 on his BIMS score and a 6 on his mood score, which indicates he has mild depression noted. Prior Level of Function (PLOF) was discussed, and he wishes to return to home on discharge with community resources. Prior to admission, he was able to do all self-care activities. His Mother (Resident Representative (RR)1) and neighbor (RR2) are available to assist if needed. Discussed R137 Primary Care Provider (PCP) and preferred Pharmacy, DME at home is a cane and walker, therapy will evaluate and treat to determine if any other DME is needed to return home safely. Copy of grievance policy and Ombudsman contact was provided to the resident. Review of R137's Social Services Note dated 01/21/26 at 10:32 AM revealed On the marginal date, Social Services talked with R137 regarding his living arrangements. R137 stated that he resides in his mother's house (RR1), which does not have electricity. R137 stated that the house has not had electricity in about five (5) years. R137 also mentioned how he would be able to get Social Security Disability. Review of R137's Onsite Primary Care Discharge Note dated 01/21/26 at 7:00 PM revealed Discharge Summary: Date of admit: [DATE], Estimated Date of discharge: [DATE]. R137 is discharging home today, patient has progress with therapy during his stay. Patent seen in wheelchair, awake, alert, and oriented times x4 (highest level of orientation). Patient is discharging home today and has progressed with therapy during his stay. Discharge instructions include please follow up with your primary care provider within one (1) to two (2) weeks for continued medication management and lab monitoring. New Equipment, DME, or Service Needs: cane: The patient has impaired mobility and gait instability related to recent injury and functional limitations. Patient requires the use of a cane to safely ambulate and perform activities of daily living. The cane is medically necessary to provide additional support, improve balance, and reduce the risk of falls. The patient is able to safely use the cane as instructed. Use of a cane will significantly enhance her mobility and safety within the home and community. Home Health Services: Home health for Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Home Health Aide (HHA), and Nursing for medication and disease management and education. This is a face-to-face visit. This patient is at a significantly increased risk due to acute/subacute issues on top of their underlying chronic conditions, which are also severe. They will require very close monitoring and frequent follow-up to avoid further complications if even possible. Home Health: The patient will need home health services due to due to homebound status. Homebound status is met due to the inability to tolerate any prolonged activity without requiring frequent resting, inability to tolerate prolonged ambulation, unsteady gait, inability to adequately ambulate on uneven terrain, and the need for general improvement, assistance, and strengthening. The patient also needs nursing for medication, disease management, and education.Review of a Progress Note dated 02/23/26 at 10:03 AM revealed, On the marginal date Social Worker (SW) received a telephone call from the Ombudsman regarding concerns from R137. R137 revealed he has not received his wheelchair, the remaining medications, the remaining of his wound care supplies, and home health. SW contacted R137 and revealed that Home Care came out to his house on Saturday. He is still waiting for his wheelchair. SW will follow up and return his call.A phone interview before the Recertification on 02/20/26 at 3:31 PM with the local Ombudsman revealed that they received a call from R137 stating the facility discharged him to an unsafe environment without running water or electricity. A phone interview on 02/23/26 at 2:39 PM with R137's RR1 revealed that they are currently residing in a skilled nursing facility and is non-interviewable. A phone interview on 02/23/26 at 2:41 PM with R137's RR2 revealed that R137 was admitted to the facility from the hospital after he accidentally set himself on fire. RR2 further stated that the resident is currently living in an unsafe environment that does not have electricity or running water, and the house is currently caving in (has structural issues). RR2 further stated that she is unsure if the resident left Against Medical Advice (AMA) or not, but stated that if he had been discharged appropriately, R137 would have called her to pick him up.A phone interview with R137 on 02/23/26 at 3:03 PM revealed R137 stated that he went through the proper procedure when it was time for him to discharge and spoke with the SW about his discharge and was told that he would have home health come to his house for services. R137 stated that no one has been to his house since he left the facility, and he still needs a wheelchair. R137 was able to find his discharge paperwork from the facility and stated that he signed the discharge summary and has a paper about post-care instructions. R137 further stated that the home that he is currently living in does not have running water or electricity. He stated, Before I had my accident and had to go to the hospital, I used to go to a nearby park to wash up and charge my phone, but now, I can barely walk, and I've been having a lot of falls. I also have been having a lot of pain with my wounds/scars.A follow-up interview with the local Ombudsman on 02/23/26 at 3:21 PM revealed that she spoke with the facility's SW related to R137 discharge. Ombudsman further stated that the SW wasn't able to find an exact date when she referred the resident to home health services, but Home Health visited the resident on 02/21/26. The Ombudsman finally stated that she spoke with the facility's Administrator about her concerns with R137 on last Wednesday, 02/18/26.A follow-up phone interview on 02/23/26 at 4:23 PM with R137 revealed that he did not go to his appointment with the burn clinic but was able to visit his PCP recently, and that is the provider who referred Home Health Services to visit him on 02/21/26. A phone interview with the Wound Care Nurse on 02/23/26 at 5:15 PM revealed that she was unable to recall R137 specifically, but was able to explain the facility's discharge process. She stated, Once rehabilitation coverage or insurance coverage ends, Social Services becomes involved to coordinate discharge planning. She stated that Social Services attempts to address any needs before discharge, including arranging home health services or assisting with housing if needed. She stated residents are provided a discharge packet, medications are explained, paperwork is signed, and residents generally provide their own transportation. An interview with the Unit Manager (UM)1 revealed that she explained the facility discharge process and stated that residents are typically sent home with two (2) to three (3) days worth of wound care supplies, if applicable. Residents are informed of the plan, including who will assist them, and staff communicate with residents throughout the stay. Home Health services and necessary DME should be arranged before discharge. She stated that family members are involved in reviewing the discharge paperwork at the bedside when appropriate. UM1 further stated that she was familiar with R137 and could recall him discharging from the facility. UM1 finally stated that she was unaware that the resident discharged to a home without running electricity and this information was brought to the IDT prior to R137 discharging from the facility. On 02/23/26 at 8:42 PM, a report was filed with the South Carolina Department of Social Services related to R137 being a vulnerable adult, living in an unsafe environment, without basic utility services. An interview on 02/25/26 with the facility's SW revealed that a few days prior from discharging from the facility, R137 reported to her that his current home did not have electricity and had been without electricity for the past five (5) years. The SW further stated that she made a referral to Salvation Army because they have services that assist with utility bills. The SW stated that the Ombudsman contacted her recently (02/18/26) because R137 reached out to the Ombudsman's Office due to still not receiving DME equipment/referral for Home Health services. The SW finally stated that she was unsure if she had communicated/updated R137's home background to the IDT team. A phone interview with the Home Health Company that was referred to R137 by his PCP on 02/25/26 at 10:30 AM revealed that Home Health attempted to provide services to R137 on 02/18/26 but was unable to accept him as a patient for caseload due to the condition of his home. The Company further stated that the nurse who went to visit the resident assisted him with wound care for his burns and provided him with canned groceries, such as soup and canned vegetables, so that the resident could have a few meals for a while. An interview with the Administrator and Director of Nursing on 02/25/26 at 1:02 PM revealed that they were not updated by the facility's SW on the condition of R137's home status and the lack of adequate utilities. A phone interview after the Recertification Survey with the local Ombudsman on 03/02/26 at 2:03 PM revealed that the resident still has not received adequate DME at this time and is still in need of Home Health Services.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure medications and biologicals were not expired, were properly stored, and were properly maintained for four (4) of six (6) medication carts reviewed and one (1) of one (1) wound care supply closet. Findings Include:Review of the facility policy titled, Storage of Medications last revised November 2020 revealed Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Observations conducted on 02/23/26 and 02/24/26 of medication storage areas revealed there was one (1) wound care supply closet and three (3) units: Angel Oak Unit, [NAME] Unit, and [NAME] Unit. Each unit maintained two (2) medication carts (A and B) for a total of six (6) medication carts reviewed. The following discrepancies were identified:02/23/26 at 1:20 PM on the Angel Oak Unit (Medication Cart B) with Licensed Practical Nurse (LPN)1: -Glucagon Injection 1mg (milligram)/2ml (milliliter) expired August 202502/23/26 at 1:30 PM on the [NAME] Unit (Medication Cart A) with LPN4: -COVID-19 Antigen Testing Kit expired November 4, 2025 -Amber/orange pill bottle with mixed pills labeled Rosuvastatin 10mg tabs.02/23/26 at 1:45 PM, on the [NAME] Unit (Wound Care Supply Closet) with LPN5: -Packing Strip Iodoform, Lot #C22184, expired March 2024. -Cotton-Tipped Applicators, Lot #21623060003, expired June 30, 2023. -Lemon Glycerin Swab sticks (Triple Pack), Lot #612211220080, expired December 2024. -Skintegrity Eco Paraben-Free Hydrogel (Single Patient Use), Lot #27923100005, expired October 2025; package appeared opened/used with no tamper-evident seal intact in-spite of single-patient use labeling. -Lidocaine 4% Topical Anesthetic Cream, Lot #112211A, expired November 2024. -Povidone-Iodine Prep Pads 10%, Lot #61222040061, expired April 2025 (three boxes). -COVID-19 AccessBio Test, Lot #CP23B20, expired November 6, 2024.The Director of Nursing (DON) observed and confirmed all the expired medications and biologicals collected from the Angel Oak Unit, [NAME] Unit, and the Wound Care Supply Closet during an interview on 02/23/26 at 4:15 PM.All expired medications and biologicals reviewed on 02/23/26 were returned to the Assistant Director of Nursing (ADON) on 02/23/26 at approximately 5:00 PM.Observations on 02/24/26 revealed the following:2/24/26 at 12:34 PM on the [NAME] Unit (Medication Cart A) with LPN3: -Ondansetron 4 mg tablets labeled Discard After January 27, 2026 was expired at the time of review.02/24/26 at 2:43 PM on the Angel Oak Unit (Medication Cart A) with LPN2: - Povidone-Iodine Prep Pads 10%, 2-Ply, Lot# 61222040061, expired April 2025 (100 count box with 37 remaining).All expired medications and biologicals pulled on 02/24/26 from the [NAME] and Angel Oak Units were reviewed, confirmed expired, and returned to the DON during an exit interview on 02/24/26 at approximately 4:15 PM.

Based on observation, interview and record review, the facility failed to provide necessary care and services to prevent a sheering injury for Resident (R)133, for 1 of 2 residents reviewed for quality of care. Findings Include:Review of R133's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including, aftercare following joint replacement surgery, presence of right artificial hip, systemic lupus erythematosus, Sjogren syndrome, mild intellectual disabilities, depression and urinary tract infection.Review of R133's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/26 revealed R133 is dependent with toileting hygiene and personal hygiene.Review of R133's Brief Interview of Mental Status (BIMS) performed on 02/20/26 revealed a score of 12 of 15, indicating moderate cognitive impairment.Review of R133's Baseline Care Plan dated 02/15/26 revealed that R133 is at risk for a decline in Activities of Daily Living/mobility and requires assistance to avoid significant decline. The Care Plan also states that R133 is incontinent and requires staff assistance and the use of pads and briefs for incontinent needs.During an interview with R133 on 02/22/26 at 11:46 AM revealed, They put diapers on me that were too tight and now I have a sore place. During an interview on 02/22/26 at 12:15 PM with R133's Power of Attorney revealed, She was forced to wear a brief that was too small for three to four days after she was admitted , which resulted in an open area that is bleeding in her right groin. The brief they have on her now is too big and they are pulling the brief too tight, which is causing pressure on that open area making it worse.An observation on 02/22/26 at 03:30 PM revealed an area to R133's right groin. There was an open area, approximately three inches in length, with a small amount of bright red drainage noted on the brief. R133 stated, The area is painful.On 02/25/26 at 10:08 AM, an interview with Wound Nurse/Infection Control Nurse revealed, To be honest, I think that she got that area from sheering from a diaper that was too tight. It is not that bad; it should heal up pretty quick. I am using a combination of a zinc cream with collagen mixed together with every brief change. I see her once a day to make sure it is there. Staff is good about letting me know when they run out. Residents are measured via their girth to determine sizing on briefing. The nurse or the CNA can do the measuring. I do not know if she has been measured. The brief that she has on now appears to be the appropriate size. She had no open areas when I saw her on 02/16/26. I see all new admissions the day after they are admitted . If the resident is admitted on a weekend, I will see them on Monday. I started treating her right hip/groin on 02/18/26. The abrasion is improving.On 02/25/26 at 10:30 AM, an interview with Licensed Practical Nurse (LPN)5 revealed all nurses and CNAs are trained to measure residents for the appropriate size brief on admission.On 02/25/26 at 10:35 AM, an interview with Unit Manager (UM)1 revealed, We measure the girth of all residents on admission, regardless of the day of the week, or the time of day that the resident is admitted . R133 has not been measured yet. I will get on that right now and we will measure her.On 02/25/26 at 10:40 AM, an interview with the Director of Nursing (DON) revealed, Staff does a great job measuring resident's girth on admission to determine the appropriate brief size.On 02/25/26 at 10:50 AM, a second with the DON revealed, We also determine the correct size brief by using the resident's weight. I know that she had an agency CNA when she was admitted . I answered her call light on 02/13/26. The resident said her briefs were too tight. She told me what kind of briefs that she wears, and I went and got them. I asked staff to change her. I put the pack of briefs that I got for her in her closet.On 02/25/26 at 11:15 AM, the DON revealed, she was unable to locate a policy regarding measuring residents for appropriate brief size.On 02/25/26 at 11:40 AM, a second interview with UM1 revealed there is nothing pertaining to a resident's weight being utilized to determine the size brief that a resident wears. UM1 showed the surveyor a brief package, and it referenced measuring a resident's girth to determine the correct brief size for a resident.On 02/25/26 at 02:35 PM, the DON revealed that there is not a generalized Quality of Care Policy.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to follow the infection control policy by providing hand hygiene and usage of gloves, while providing resident care for Resident (R) 69. This failure had the potential to place R69 at risk for infection for the improper use of gloves while providing catheter care, for 1 of 4 residents reviewed for infection control.Findings include:Review of the facility policy titled, Handwashing/Hand Hygiene with a revision date of 2001 stated, All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene is indicated: immediately before touching a resident; before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); after touching a resident; after touching the resident's environment; immediately after glove removal. The following equipment and supplies are necessary for hand hygiene: Non-sterile gloves.Review of R69's face sheet revealed she was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, retention of urine, non-Alzheimer's Dementia, and vesicoureteral reflux with reflux nephropathy and bilateral hydroureter.Review of R69's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/26 revealed R69 had a Brief Interview for Mental Status (BIMS) score of 04 out of 15, which indicated R69 had severe cognitive impairment. The MDS also reveals R69 has an indwelling catheter, and the urinary continence is not rated.Review of R69's care plan, with an initiation date of 12/10/25, revealed R69 has an indwelling catheter with interventions including provide catheter care every shift. Further review of the care plan, with an initiation date of 07/25/23, revealed bladder incontinence: has mixed bladder incontinence and is related to dementia, diuretic use, difficulty with interventions to provide incontinence care on rounds, upon request and as needed.Review of R69's physician orders, dated 02/17/26, revealed resident requires enhanced barrier precautions during high contact resident care activities due to the presence of a foley. During an observation on 02/22/26 at 2:56 PM, R69's catheter was observed above her hip and clothes were wet, due to urine. She was sitting in the sitting area on her hall. During an observation on 02/23/26 at 8:51 AM, R69 was observed sitting in her chair, inside her room with her pants down, she removed her catheter bag, and it was sitting on the bedside table in front of her. Registered Nurse (RN)1 was observed touching R69's door and moving the bedside table with her gloved hands, before she helped R69 with the same gloves.During an observation on 02/25/26 at 8:51 AM, R69 was observed sitting in the chair in her room, appeared neat and clean and her catheter bag was positioned on her right leg.During an interview on 02/23/26 at 8:58 AM, RN1 revealed she put fresh gloves on prior to coming down the hall and entering the resident's room. She stated she is allergic to the gloves the facility supplies, so she has her own special gloves that she keeps on her cart. She also included she had just put her gloves on before going to the resident's room. RN1 stated she's never been told she couldn't put gloves on before entering the room to provide resident care. RN1 stated she receives yearly training on infection control, the most current training was October 2025.During an interview on 02/25/26 at 8:53 AM, R69 stated that she doesn't like her catheter bag and doesn't know what the bag is there for. She doesn't like wearing it and is aware she's not supposed to take it off, but does it anyway because it makes her uncomfortable.During an interview on 02/25/26 at 9:53 AM with the Infection Control Preventionist (ICP), she stated she recently completed random spot checks with staff related to hand hygiene. Staff receive annual training on hand hygiene and Personal Protective Equipment (PPE). She provides additional education and spot checks when she observes an infraction or identifies a need for improvement. The ICP reported that Evidence-Based Practice (EBP) training is provided regularly, including catheter care. Step-by-step instructions are posted outside residents' rooms to guide staff on proper handwashing, glove use, and care tasks. She stated that staff are not allowed to put on gloves in the hallway. Gloves must be applied inside the resident's room after performing hand hygiene and removed inside the room. Gloves applied in the hallway are considered contaminated. Staff are expected to wash their hands before donning clean gloves upon entering a resident's room. When changing a catheter bag, staff should remove gloves, wash their hands, apply a new pair of gloves, complete the task, remove gloves, and wash their hands again. Failure to follow these steps may increase the risk of infection. The ICP further stated that staff should not carry gloves in their pockets, but instead bring needed supplies into the resident's room and apply gloves after performing hand hygiene.During an interview on 02/25/26 at 11:12 AM with the Director of Nursing (DON), she stated her expectation is that staff follow infection control protocols to prevent the spread of infection. Staff receive training on PPE at least annually and as needed. Staff also receive annual training on skilled catheter care, with additional education provided if concerns are identified. The DON reported that on 02/24/26, she reminded staff not to put on gloves in the hallway and to perform hand hygiene between glove use. When a nurse was identified as not following proper practice, she provided one-on-one education. The DON stated infections can occur during catheter bag changes if proper procedures are not followed. She stated gloves and necessary supplies are available, and staff are expected to bring supplies into the room and apply gloves after performing hand hygiene to maintain infection control standards.

Based on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)1 was free from neglect. Specifically, R1 did not receive care and services, to address the residents therapeutic diet, resulting in R1 expiring. For 1 of 1 resident reviewed for neglect. On 10/23/24 at 3:36 PM, the Administrator and Director of Nursing were notified that the failure to provide care and services to a resident, who was on a therapeutic diet, resulting in death, constituted Immediate Jeopardy (IJ) at F600. On 10/23/24 at 3:36 PM, the Survey Team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 10/20/24. The IJ was related to 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. On 10/23/24 at 6:20 PM, the facility presented an acceptable IJ Removal Plan. On 10/23/24 the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility policy titled Recognizing Signs and Symptoms of Abuse/Neglect states as the policy statement, Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. The policy interpretation and implementation states, 2. Neglect, is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. b. Signs of Actual Physical Neglect: 9. Leaving someone unattended who needs supervision. Review of R1's Face Sheet revealed the facility admitted R1 on 09/03/24, with diagnoses including but not limited to: adult failure to thrive, protein calorie malnutrition, dementia, major depressive disorder, dysphagia, duodenal ulcer, gastric ulcer, gall stones, constipation, gastrostomy tube and pneumonia. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/24, revealed a Brief Interview of Mental Status (BIMS) score of 9 out of 15, indicating R1 had moderate cognitive impairment. Review of R1's Medical Record revealed R1 had a signed DNR (Do Not Resuscitate) by a legally appointed guardian. Review of the video footage from the incident on 10/20/24, revealed, R1 was sitting on a couch in the common area watching TV. There were no other residents around. Two Certified Nursing Assistants (CNA)s and a Licensed Practical Nurse (LPN) were at the nurses desk charting and talking among themselves. R1 got up from the couch and noticed a meal tray on a dining room table several feet away from where he was sitting. R1 walked over to the table, picked up the food from the tray and started placing the food into his mouth. It was unclear if R1 was chewing or swallowing the food. Further review of the video footage revealed R1 stopped placing the food in his mouth for a small amount of time and would drink milk from an opened carton of milk. R1 also opened a bottle of water and drank from the bottle of water. R1 then sat down at the table and continued placing food into his mouth. R1 got up from the table and took the tray with him back to the couch. R1 sat down on the couch and soon after, was slumped over on the couch. The staff at the nurses station did not notice R1 eating the food from the tray or slumped over on the couch. One of the nurses walked passed R1, went to the nourishment kitchen and came out with R1's bolus tube feeding and than noticed R1 was slumped over on the couch. The nurses station provided a direct line of site to the common area and the resident. Review of the reportable submitted by the facility revealed that R1 was observed ambulating in the hallway on 10/20/24 at 8:00 PM. Licensed Practical Nurse (LPN)1 came out of the nutrition kitchen 5 minutes later with R1's bolus tube feeding. The nurse noted the resident on the couch in the common area, slumped over with a bluish color to his face. She felt he possibly had something obstructing his airway so she initiated the Heimlich Maneuver. Other staff were assisting the nurse with the Heimlich and the suctioning. 911 was called. R1 was pronounced by EMS (Emergency Medical Services) staff at 8:15 PM. The Coroner was on the scene and the body was taken for further evaluation and cause of death. When LPN 1 was asked if anything came up when the Heimlich was performed, the nurse stated that a small piece of apple, and that was all. The investigation was initiated immediately. R1 had consumed a regular diet that was left on a dining room table, after another resident had finished eating earlier. R1 was ordered to receive a regular pureed diet with nectar thick liquids and a bolus tube feeding of Jevity 1.5. R1 receives a bolus feeding of 360 milliliters (mls) at 8:00 PM and a flush of 60 mls of water before and after the bolus. Review of R1's Physician Orders revealed an order with a start date of 09/03/24, for, Regular diet Dysphagia Puree texture, Thickened Liquid Nectar consistency. Further review revealed an order with a start date of 09/16/24, for, Enteral Feed Order one time a day Bolus Jevity 1.5, 360mL via PEG tube and flush with 60mL before and after. Review of the menu for 10/20/24 revealed a regular diet of: Herb lemon chicken, braised liver and onions, steamed zucchini squash, green peas, mashed potatoes with gravy, steamed rice, wheat bread, and cinnamon apple slices. Review of R1's Comprehensive Plan of Care included the following: Malnutrition - R1 has a diagnosis of protein calorie malnutrition. Resident is at risk for altered nutrition and hydration related to dysphagia, history of sufficient weight loss, depression, gastric and duodenal ulcers, adult failure to thrive, dementia and pneumonia. Interventions include: Observe for signs or symptoms of dysphagia, as evidenced by, pocketing, coughing, choking, drooling and holding foods in his mouth. Refer to Registered Dietitian as needed. Resident is at risk for aspiration, choking, and difficulty swallowing related to dysphagia. The goal: The risk of aspiration is minimized to the extent possible. Interventions: No straws. Position upright as possible for meals. Serve diet as ordered. Resident has a peg tube and is at risk for enteral nutrition complications related to dysphagia. Resident is at risk for elopement/exit seeking/wandering related to altered cognitive status, dementia or other cognitive behavior, exit seeking behaviors, mood or behavior disorders, psychotropic mood altering medications. The goal revealed, resident will not wander out of the facility. The interventions: Allow wandering in safe areas within the facility. Assess for pain and/or discomfort and medicate as needed. Monitor whereabouts frequently. During an interview on 10/23/24 at an unspecified time, the Director of Nursing (DON) and Administrator, the Administrator stated he was going to be open and straight forward about the incident. The Administrator stated that he and the DON was very upset and shed tears over the incident. The DON stated the nurse told them a piece of apple came out the residents mouth (confirmed by video footage). During an interview on 10/23/24 at 12:05 PM, Certified Nursing Assistant (CNA)2 stated that she was at the nurse's station charting prior to the incident. CNA2 stated the nurse told her she was going to the nourishment kitchen to get the tube feeding and medication for the resident, and I decided I would get him ready for bed at the same time. When the nurse came out of the nourishment kitchen she looked over to see the resident slumped over on the couch. CNA2 stated the nurse called his name and he did not answer, so they both ran over to help him. CNA2 had no further comments regarding the incident. During an interview on 10/23/24 at 12:07 PM, Licensed Practical Nurse (LPN)1 stated, I went to the nourishment kitchen to retrieve the tube feeding for [R1]. As I walked out of the nourishment kitchen I saw the resident on the couch, slumped over and blue. He was literally just sitting up watching TV. I called his name and he did not respond, so I ran over to help him along with the CNA. I asked the CNA to call the nurse from the [NAME] Unit and she did, when she arrived she called 911. I started the Heimlich Maneuver because I thought he might have something obstructing his airway. LPN1 further stated that the resident will put things in his mouth and did so all the time. The CNA was helping me, and we got the suction machine and tried to suction his mouth but nothing came out. Review of CNA1's statement documented, I worked on the Angel Oak hall on 10/20/2024 second shift. I was charting at the desk close to the bathroom. The resident was walking around as he normally does. The nurse stated that she was going to grab his medication and bolus feeding and then she entered the nourishment kitchen. I entered the restroom and when I came out the nurse was doing the Heimlich Maneuver on the resident. I assisted as well. I ran to grab the nurse from the [NAME] Unit for her assistance. We continued the Heimlich as the nurse from the [NAME] Unit called 911. Then EMS arrived. Multiple attempts were made to contact CNA1, but were unsuccessful. On 10/23/24 at 6:20 PM, the facility presented an acceptable IJ Removal Plan, which included: Immediate Actions Taken: -Statements were written by all staff on duty 10/20/2024. -Nurse on duty was interviewed via phone by RDCS and DON. She stated she noted him slumped over and bluish color to face and observed what she felt to be a possible obstruction to his airway, so she initiated the Heimlich and attempted to suction his airway until EMS arrived. -Camera footage was observed by Administrator and DON on 10/21/2024 in the AM to establish a timeline and confirm he had eaten food from a tray sitting in the common area. -Education was initiated with all staff on 10/21/2024 regarding picking up all trays timely and not leaving any food trays unattended on a unit. -Audits were initiated on 10/21/2024 of all resident who wander or have behaviors to ensure all are care planned for wandering and staff are aware of this behavior and risk for getting food that is not theirs. -An audit was initiated on 10/22/2024 for all residents on a mechanically altered diet to ensure orders are correct and tray cards and care plans also reflect correct diets as ordered. Actions Taken as a Result of ADHOC QA Meeting: Problem identified as tray was left sitting out in a common area after mealtime was over and not secured in kitchenette. -Standup/stand down imitated x2/day to track progress of the abatement plan. Audits initiated for the following: -All residents on a mechanically altered diet to ensure that orders are correct and correlate with tray cards and care plans to reflect current orders. -All residents who have behaviors of wandering and would be at risk to take food from other residents or areas that is not their ordered diet to ensure care plan is reflective of the behavior. Education initiated immediately for the following: -All staff to ensure understanding of timely removal of trays from the unit and not left unattended. All newly hired staff and or agency staff will receive the education prior to first shift worked. -Educations was sent to all staff via CORV on 10/23/2024. Wet signatures will be obtained as staff report for duty on next scheduled shift. -Education provided to all staff on 10/23/2024 related to neglect. -All newly hired staff and or agency staff will receive the education prior to their first shift worked. On going audits: -Administrative staff will be conducting audits of all units during meal times to ensure monitoring of all residents for safety during mealtime and to ensure that at the end of the meal or assisting residents with eating that the trays are removed timely and not left unattended and are returned to the tray cart and to the kitchen. -Audits will be completed for every meal for the first 72 hours, then three times per x2 weeks, then weekly x2 weeks then monthly x2 months then random thereafter. -All audits and data will be reported to the QA committee for review, recommendation, and follow-up. Date of Compliance: 10/23/24

Based on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)1 was adequately supervised and free from accident and hazards, for 1 of 1 residents reviewed for accidents. Specifically, R1, who was on a therapeutic diet, consumed food from another resident's meal tray that was left on a dining room table, resulting in R1 expiring. On 10/23/24 at 3:36 PM, the Administrator and Director of Nursing were notified that the failure to provide adequate supervision of a resident, who was on a therapeutic diet, resulting in death, constituted Immediate Jeopardy (IJ) at F689. On 10/23/24 at 3:36 PM, the Survey Team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 10/20/24. The IJ was related to 42 CFR 483.25 Quality of Life. On 10/23/24 at 6:20 PM, the facility presented an acceptable IJ Removal Plan. On 10/23/24 the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F689 at a lower scope and severity of D. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting did not contain any pertinent information. The facility did not provide a policy regarding prevention of accidents and reducing hazards for residents. Review of R1's Face Sheet revealed the facility admitted R1 on 09/03/24, with diagnoses including but not limited to: adult failure to thrive, protein calorie malnutrition, dementia, major depressive disorder, dysphagia, duodenal ulcer, gastric ulcer, gall stones, constipation, gastrostomy tube and pneumonia. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/24, revealed a Brief Interview for Mental Status (BIMS) of 9 out of 15, indicating R1 had moderate cognitive impairment. Further review of the MDS indicated R1 exhibited behaviors not directed towards others and an overall presence of behavioral symptoms that interferes with the resident's care, puts others at risk for physical injury, and significantly disrupts care or living environment. The MDS also indicated that R1 exhibited wandering behaviors. R1 also exhibited signs of loss of liquids/solids from mouth when eating or drinking, and coughing or choking during meals or when swallowing medications. Review of the video footage from the incident on 10/20/24, R1 was sitting on a couch in the common area watching TV. There were no other residents around. Two Certified Nursing Assistants (CNA)s and a Licensed Practical Nurse (LPN) were at the nurses desk charting and talking among themselves. R1 got up from the couch and noticed a meal tray on a dining room table several feet away from where he was sitting. R1 walked over to the table, picked up the food from the tray and started placing the food into his mouth. It was unclear if R1 was chewing or swallowing the food. Further review of the video footage revealed R1 stopped placing the food in his mouth for a small amount of time and would drink milk from an opened carton of milk. R1 also opened a bottle of water and drank from the bottle of water. R1 then sat down at the table and continued placing food into his mouth. R1 got up from the table and took the tray with him back to the couch. R1 sat down on the couch and soon after, was slumped over on the couch. The staff at the nurses station did not notice R1 eating the food from the tray or slumped over on the couch. One of the nurses walked passed R1, went to the nourishment kitchen and came out with R1's bolus tube feeding and than noticed R1 was slumped over on the couch. She starts asking for assistance while putting the tube feeding onto the counter at the nurses desk. Both CNAs come to help her with the resident. The nurse starts with the Heimlich Maneuver. The nurses station provided a direct line of site to the common area and the resident. Review of the reportable submitted by the facility revealed that R1 was observed ambulating in the hallway on 10/20/24 at 8:00 PM. Licensed Practical Nurse (LPN)1 came out of the nutrition kitchen 5 minutes later with R1's bolus tube feeding. The nurse noted the resident on the couch in the common area, slumped over with a bluish color to his face. She felt he possibly had something obstructing his airway so she initiated the Heimlich Maneuver. Other staff were assisting the nurse with the Heimlich and the suctioning. 911 was called. R1 was pronounced by EMS (Emergency Medical Services) staff at 8:15 PM. The Coroner was on the scene and the body was taken for further evaluation and cause of death. When LPN 1 was asked if anything came up when the Heimlich was performed, the nurse stated that a small piece of apple, and that was all. The investigation was initiated immediately. R1 had consumed a regular diet that was left on a dining room table, after another resident had finished eating earlier. R1 was ordered to receive a regular pureed diet with nectar thick liquids and a bolus tube feeding of Jevity 1.5. R1 receives a bolus feeding of 360 milliliters (mls) at 8:00 PM and a flush of 60 mls of water before and after the bolus. Review of R1's Physician Orders revealed an order with a start date of 09/03/24, for, Regular diet Dysphagia Puree texture, Thickened Liquid Nectar consistency. Further review revealed an order with a start date of 09/16/24, for, Enteral Feed Order one time a day Bolus Jevity 1.5, 360mL via PEG tube and flush with 60mL before and after. Review of the menu for 10/20/24 revealed a regular diet of: Herb lemon chicken, braised liver and onions, steamed zucchini squash, green peas, mashed potatoes with gravy, steamed rice, wheat bread, and cinnamon apple slices. Review of R1's Comprehensive Plan of Care included the following: Malnutrition - R1 has a diagnosis of protein calorie malnutrition. Resident is at risk for altered nutrition and hydration related to dysphagia, history of sufficient weight loss, depression, gastric and duodenal ulcers, adult failure to thrive, dementia and pneumonia. Interventions include: Observe for signs or symptoms of dysphagia, as evidenced by, pocketing, coughing, choking, drooling and holding foods in his mouth. Refer to Registered Dietitian as needed. Resident is at risk for aspiration, choking, and difficulty swallowing related to dysphagia. The goal: The risk of aspiration is minimized to the extent possible. Interventions: No straws. Position upright as possible for meals. Serve diet as ordered. Resident has a peg tube and is at risk for enteral nutrition complications related to dysphagia. Resident is at risk for elopement/exit seeking/wandering related to altered cognitive status, dementia or other cognitive behavior, exit seeking behaviors, mood or behavior disorders, psychotropic mood altering medications. The goal revealed, resident will not wander out of the facility. The interventions: Allow wandering in safe areas within the facility. Assess for pain and/or discomfort and medicate as needed. Monitor whereabouts frequently. Review of CNA1's statement documented, I worked on the Angel Oak hall on 10/20/2024 second shift. I was charting at the desk close to the bathroom. The resident was walking around as he normally does. The nurse stated that she was going to grab his medication and bolus feeding and then she entered the nourishment kitchen. I entered the restroom and when I came out the nurse was doing the Heimlich Maneuver on the resident. I assisted as well. I ran to grab the nurse from the [NAME] Unit for her assistance. We continued the Heimlich as the nurse from the [NAME] Unit called 911. Then EMS arrived. During an interview on 10/23/24 at an unspecified time, the Director of Nursing (DON) and Administrator, the Administrator stated he was going to be open and straight forward about the incident. The Administrator stated that he and the DON was very upset and shed tears over the incident. The DON stated the nurse told them a piece of apple came out the resident's mouth (confirmed by video footage). During an interview on 10/23/24 at 12:05 PM, Certified Nursing Assistant (CNA)2 stated that she was at the nurse's station charting prior to the incident. CNA2 stated the nurse told her she was going to the nourishment kitchen to get the tube feeding and medication for the resident, and I decided I would get him ready for bed at the same time. When the nurse came out of the nourishment kitchen she looked over to see the resident slumped over on the couch. CNA2 stated the nurse called his name and he did not answer, so they both ran over to help him. CNA2 had no further comments regarding the incident. Multiple attempts were made to contact CNA1, but were unsuccessful. During an interview on 10/23/24 at 12:07 PM, Licensed Practical Nurse (LPN)1 stated, I went to the nourishment kitchen to retrieve the tube feeding for [R1]. As I walked out of the nourishment kitchen I saw the resident on the couch, slumped over and blue. He was literally just sitting up watching TV. I called his name and he did not respond, so I ran over to help him along with the CNA. I asked the CNA to call the nurse from the [NAME] Unit and she did, when she arrived she called 911. I started the Heimlich Maneuver because I thought he might have something obstructing his airway. LPN1 further stated that the resident will put things in his mouth and did so all the time. The CNA was helping me, and we got the suction machine and tried to suction his mouth but nothing came out. On 10/23/24 at 6:20 PM, the facility presented an acceptable IJ Removal Plan, which included: Immediate Actions Taken: -Statements were written by all staff on duty 10/20/2024. -Nurse on duty was interviewed via phone by RDCS and DON. She stated she noted him slumped over and bluish color to face and observed what she felt to be a possible obstruction to his airway, so she initiated the Heimlich and attempted to suction his airway until EMS arrived. -Camera footage was observed by Administrator and DON on 10/21/2024 in the AM to establish a timeline and confirm he had eaten food from a tray sitting in the common area. -Education was initiated with all staff on 10/21/2024 regarding picking up all trays timely and not leaving any food trays unattended on a unit. -Audits were initiated on 10/21/2024 of all resident who wander or have behaviors to ensure all are care planned for wandering and staff are aware of this behavior and risk for getting food that is not theirs. -An audit was initiated on 10/22/2024 for all residents on a mechanically altered diet to ensure orders are correct and tray cards and care plans also reflect correct diets as ordered. Actions Taken as a Result of ADHOC QA Meeting: Problem identified as tray was left sitting out in a common area after mealtime was over and not secured in kitchenette. -Standup/stand down imitated x2/day to track progress of the abatement plan. Audits initiated for the following: -All residents on a mechanically altered diet to ensure that orders are correct and correlate with tray cards and care plans to reflect current orders. -All residents who have behaviors of wandering and would be at risk to take food from other residents or areas that is not their ordered diet to ensure care plan is reflective of the behavior. Education initiated immediately for the following: -All staff to ensure understanding of timely removal of trays from the unit and not left unattended. All newly hired staff and or agency staff will receive the education prior to first shift worked. -Educations was sent to all staff via CORV on 10/23/2024. Wet signatures will be obtained as staff report for duty on next scheduled shift. -Education provided to all staff on 10/23/2024 related to neglect. -All newly hired staff and or agency staff will receive the education prior to their first shift worked. On going audits: -Administrative staff will be conducting audits of all units during meal times to ensure monitoring of all residents for safety during mealtime and to ensure that at the end of the meal or assisting residents with eating that the trays are removed timely and not left unattended and are returned to the tray cart and to the kitchen. -Audits will be completed for every meal for the first 72 hours, then three times per x2 weeks, then weekly x2 weeks then monthly x2 months then random thereafter. -All audits and data will be reported to the QA committee for review, recommendation, and follow-up. Date of Compliance: 10/23/24

Based on record review, interview, and policy review, the facility failed to ensure eight of nine residents and their representatives (Resident (R) 22, R26, R42, R56, R94, R106, R111, R112 and R113) reviewed for facility initiated emergent hospital transfer from a total sample of 28 were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Additionally, the Ombudsman was not notified of hospital transfers for R22, R42, R94, R112, and R113. Findings included: Review of the facility policy titled, Transfer or Discharge, Facility-Initiated, dated 2001, revealed, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy . When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected .Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident . c. An immediate transfer or discharge is required by the resident's urgent medical needs . Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable . Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments . 1. Review of R22's Admission Record, from the electronic medical record (EMR) Profile tab, showed an admitted [DATE] with a primary medical diagnosis that included metabolic encephalopathy. Review of R22's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/12/24, showed a Brief Interview for Mental Status (BIMS) score of four out of a possible 15, indicative of severe cognitive impairment. Review of R22's Progress Notes tab, dated 01/10/24 at 11:04 AM, revealed that R22 was experiencing a change in mental status, refusing medications for two days, and hallucinating. The resident was taken to the emergency department. Review of R22's Progress Notes tab, dated 01/15/24 at 3:01 PM, revealed that R22 returned to the facility. Review of R22's Progress Notes tab, dated 03/11/24 at 6:45 PM, revealed that R22 had sustained a fall resulting in a wound to the left lower leg. The resident was taken to the emergency department. Review of R22's Progress Notes tab, dated 03/12/24 at 1:45 AM, revealed that R22 returned to the facility at that time with a dressing to the left lower leg and ice pack applied to hematoma to the right mid leg. Review of R22's Progress Notes tab, dated 10/01/24 at 9:56 AM, revealed that R22 was experiencing a change of condition and was sent to the hospital for evaluation. Review of R22's Progress notes tab, dated 10/03/24 at 4:30 PM, revealed that R22 returned to the facility at 4:30 PM. Review of R22's Documents, located under the Miscellaneous tab, did not include written notifications of emergent transfers and discharges to the hospital emergency department for R22 and/or their resident representative. The facility documents titled, Admission/Discharge To/From Report, for January through March 2024 hospital transfers, were not provided to this Surveyor for review. During an interview on 10/04/24 at 10:45 AM, the Social Services Director (SSD) confirmed that the Ombudsman was not notified of R22's hospitalization s on 01/10/24 and 03/11/24 but should have been. 2. Review of R26's Admission Record, from the EMR Profile tab, showed an admitted [DATE] and most recent re-admission on 02/24/24 with a primary medical diagnosis of non-ST elevation (NSTEMI) myocardial infarction (a type of heart attack that happens when a part of the heart does not get enough oxygen). Review of R26's quarterly MDS, with an ARD of 08/16/24, showed a BIMS score of 14 out of a possible 15, indicative of being cognitively intact. Review of R26's Progress Notes tab, dated 02/13/24 at 8:21 AM, revealed that R26 was experiencing low oxygen saturation levels, wheezing, and generalized abdominal pain with nausea and vomiting. The resident was taken to the emergency department. Review of R26's Progress Notes tab, dated 02/24/24 at 5:56 PM, revealed that R26 returned to the facility with diagnoses including angina (chest pain), pulmonary fluid overload, and pneumonia. Review of R26's Documents, located under the Miscellaneous tab, did not include written notification of an emergent transfer and discharge to the hospital emergency department. The facility document titled, Admission/Discharge To/From Report for February 2024 hospital transfers was not provided to this Surveyor for review. 3. Review of R42's Admission Record, from the EMR Profile tab, showed an admitted [DATE] and most recent re-admission on 06/20/24 with a primary medical diagnosis of senile degeneration of the brain. Review of R42's significant change MDS, with an ARD of 06/28/24, showed a BIMS score of three out of a possible 15, indicative of severe cognitive impairment. Review of R42's Progress Notes tab, dated 06/12/24 at 3:14 PM, revealed that R42 sustained a fall from his wheelchair and sustained a laceration over the right eye. The resident was taken to the emergency department. Review of R42's Progress Notes tab, dated 06/12/24 at 10:58 PM, revealed that R42 returned to the facility status post fall with negative computed tomography (CT) results of the brain. Review of R42's Progress Notes tab, dated 06/19/24 at 8:38 PM, revealed that R42 sustained a fall from his wheelchair and was experiencing blood spewing from the nasal cavity. The resident was taken to the emergency department. Review of R42's Progress Notes tab did not include R42 returning to the facility; however, the Census tab indicated R42 returned to the facility on [DATE]. Review of R42's Progress Notes tab, dated 06/23/24 at 12:33 PM, revealed that R42 sustained a fall from his wheelchair at 5:45 AM and was experiencing nasal bleeding. The resident was taken to the emergency department. Review of R42's Progress Notes tab, dated 06/23/24 at 12:34 PM, revealed that R42 returned to the facility at 10:45 AM with diagnoses including closed head injury and a nose fracture. Review of R42's Documents, located under the Miscellaneous tab, did not include written notifications of the emergent transfers and discharges to the hospital emergency department. Review of the facility document titled, Admission/Discharge To/From Report, dated 07/01/24 and provided by the Social Services Director (SSD), did not include notification to the Ombudsman for R42's hospital transfers on 06/12/24, 06/19/24, and 06/23/34. During an interview on 10/04/24 at 10:53 AM, the SSD stated that when residents are sent to the emergency department and return before midnight, the Ombudsman was not notified of the transfer/discharge, and if residents remain in the hospital past midnight, then the census was to be updated by the business office manager of hospitalization status. The SSD confirmed that the Ombudsman was not notified of R42's June 2024 hospital visits but should have been. 4. Review of R56's Admission Record, from the EMR Profile tab, showed an admitted [DATE] and most recent re-admission on 06/28/24 with a primary medical diagnosis of hypotension. Review of R56's quarterly MDS, with an ARD of 07/26/24, showed a BIMS score of 15 out of a possible 15, indicative of being cognitively intact. Review of R56's Progress Notes tab, dated 02/14/24 at 10:52 PM, revealed that R56 had experienced vomiting with blood clots. The resident was taken to the emergency department. Review of R56's Progress Notes tab, dated 02/16/24 at 10:410 PM, revealed that R56 returned to the facility at that time with diagnoses including gastrointestinal ulcers and hernia. Review of R56's Progress Notes tab, dated 04/23/24 at 4:19 PM, revealed that R56 was sent out to dialysis that morning and was nauseated and unable to follow simple commands. The resident was taken to the emergency department. Review of R56's Progress Notes tab, dated 05/01/24 at 10:48 PM, revealed that R56 returned to the facility at that time. Review of R56's Progress Notes tab, dated 05/10/24 at 12:25 PM, revealed that R56 was experiencing vomiting, lethargy, and an erratic pulse. The resident was taken to the emergency department. Review of R56's Progress Notes tab, dated 05/12/24 at 5:40 PM, revealed that R56 returned to the facility at that time. Review of R56's Documents, located under the Miscellaneous tab, did not include written notification of an emergent transfer and discharge to the hospital emergency department. Review of the facility document titled, Admission/Discharge To/From Report, dated 06/05/24 and provided by the SSD, did not include notification to the Ombudsman for hospital transfer on 05/10/24. The facility documents titled, Admission/Discharge To/From Report for February and April 2024 hospital transfers were not provided to this Surveyor for review. During an interview on 10/04/24 at 10:49AM, the SSD confirmed that the Ombudsman was not notified of R56's hospitalization s on 02/14/24, 04/23/24, and 05/10/24 but should have been. 5. Review of R94's Admission Record, from the EMR Profile tab, showed an admitted [DATE] with a primary medical diagnosis of peripheral vascular disease. Review of R94's quarterly MDS, with an ARD of 08/26/24, showed a BIMS score of zero out of a possible 15, indicative of severe cognitive impairment. Review of R94's Nursing: Bedhold Confirmation document, provided by the facility and dated 02/14/24, revealed that R94 was transferred to the emergency department. Review of R94's Census tab did not include hospitalization dates for February 2024. Review of R94's Einteract Transfer Form V5 document, provided by the facility and dated 07/12/24, revealed that R94 was transferred to the emergency department. Review of R94's Census tab indicated that R94 returned to the facility on [DATE]. Review of R94's Progress Notes tab, dated 08/15/24 at 12:05 PM, revealed that R94 had experienced behavioral problems, including throwing multiple items in his room. The resident was taken to the emergency department. Review of R94's Progress Notes tab, dated 08/24/24 at 2:14 PM, revealed that R94 returned to the facility at that time with admission to hospice services. The facility document titled, Admission/Discharge To/From Report for February 2024 hospital transfers was not provided to this Surveyor for review. During an interview on 10/04/24 at 11:21 AM, the SSD confirmed that the Ombudsman was not notified of R94's 02/14/24 hospital visit but should have been. 6. Review of R111's Admission Record, from the EMR Profile tab, showed an original admitted [DATE] and re-admission on 05/01/25 with a primary medical diagnosis of unspecified severe protein -calorie malnutrition. Review of R111's significant change MDS, with an ARD of 08/12/24, showed a BIMS score of 99 out of a possible 15, indicative of severe cognitive impairment. Review of R111's Progress Notes tab, dated 01/23/24 at 1:32 PM, revealed that R111 had experienced abnormal vital signs and altered mental status. The resident was taken to the emergency department. Review of R111's Progress Notes tab, dated 01/23/24 at 6:31 PM, revealed that R111 returned to the facility with no new orders. Review of R111's Progress Notes tab, dated 02/24/24 at 7:46 PM, revealed that R111 had experienced seizure-like activity. The resident was taken to the emergency department. Review of R111's Census tab revealed that R111 returned to the facility on [DATE]. Review of R111's Progress Notes tab, dated 04/30/24 at 10:01 PM, revealed that R111 had experienced a fall. The resident was taken to the emergency department. Review of R111's Progress Notes tab, dated 05/01/24 at 4:30 AM, revealed that R111 returned to the facility. Review of R111's Progress Notes tab, dated 05/18/24 at 12:41 PM, revealed that R111 had experienced a change in condition. The resident was taken to the emergency department. Review of R111's Progress Notes tab, dated 05/18/24 at 5:55 PM, revealed that R111 returned to the facility. Review of R111's Progress Notes tab, dated 07/29/24 at 2:28 PM, revealed that R111 had experienced a change in condition as evidenced by passing out on the commode. The resident was taken to the emergency department. Review of R111's Progress Notes tab dated 07/30/24 at 9:03 PM revealed that R111 returned to the facility at that time with admission to hospice services. Review of R111's Documents, located under the Miscellaneous tab, did not include written notification of an emergent transfer and discharge to the hospital emergency department. During an interview on 10/04/24 at 11:11 AM, the SSD confirmed the resident's representative had not been informed in writing of the reason for the resident's transfer to the hospital. 7. Review of R112's Admission Record, from the EMR Profile tab, showed an original admitted [DATE] and re-admission on 12/22/23 with a primary medical diagnosis of acute osteomyelitis of the right tibia and fibula. Review of R112's quarterly MDS, with an ARD of 08/12/24, showed a BIMS score of 14 out of a possible 15, indicative of being cognitively intact. Review of R112's Progress Notes tab, dated 05/24/24 at 11:50 PM, revealed that R112 had experienced a change in condition as evidenced by nausea and vomiting. The resident was taken to the emergency department. Review of R112's Progress Notes tab, dated 05/25/24 at 6:56 AM, revealed that R112 had returned to the facility with new diagnoses including urinary tract infection. Review of R112's Progress Notes tab, dated 06/22/24 at 9:30 PM, revealed that R112 had experienced a change in condition as evidenced by nausea as the nurse lowered the head of the bed. The resident was taken to the emergency department. Review of R112's Progress Notes tab, dated 06/25/24 at 6:59 PM, revealed that R112 had returned to the facility with new diagnoses including urinary tract infection. The facility document titled, Admission/Discharge To/From Report, dated 06/05/24 and provided by the SSD did not include notification to the Ombudsman for R112's hospital transfers on 05/24/24 and 06/22/24. During an interview on 10/04/24 at 10:52 AM, the SSD confirmed that the Ombudsman was not notified of R112's 05/24/24 and 06/22/24 hospital visits but should have been. During an interview on 10/04/24 at 12:29 PM, R112 stated that he had no know was not provided any paperwork that he was aware of regarding why he went to the hospital or how to appeal the decision if needed. 8. Review of R113's Admission Record, from the EMR Profile tab, showed an original admitted [DATE] and re-admission on 06/14/24 with a primary medical diagnosis of nontraumatic intracerebral hemorrhage in hemisphere, subcortical. Review of R113's PPS- Part A Discharge MDS, with an ARD of 08/30/24, showed a BIMS score of 10 out of a possible 15, indicative of being moderately cognitively impaired. Review of R113's Progress Notes tab, dated 06/10/24 at 9:22 AM, revealed that the resident was unresponsive and drooling. The resident was taken to the emergency department. Review of R113's Progress Notes tab, dated 06/14/24 at 3:47 PM, revealed that R113 returned to the facility with a new diagnosis of acute ischemic stroke. Review of R113's Progress Notes tab, dated 07/23/24 at 12:19 PM, revealed R113 had changes in behavior and mental status. The resident was taken to the emergency department. Review of R113's Progress Notes tab, dated 07/23/24 at 10:51 PM, revealed that R113 had returned to the facility with a new diagnosis of Covid and UTI. Review of R113's Progress Notes tab, dated 08/02/24 at 10:45 AM, revealed R113 had sustained a fall and had discoloration to the right eyebrow, right cheek, right shoulder, and right knee. The resident was taken to the emergency department. Review of R113's Progress Notes tab, dated 08/02/24 at 7:18 PM, revealed that R113 had returned to the facility. The facility document titled, Admission/Discharge To/From Report, dated 07/01/24, 08/01/24, and 09/06/24 and provided by the SSD, did not include notification to the Ombudsman for R113's hospital transfers on 06/10/24, 07/23/24, and 08/02/24. During an interview on 10/04/24 at 10:55 AM, the SSD confirmed that the Ombudsman was not notified of R113's 06/10/24 hospital visit but should have been, and hospital visits on 07/23/24 and 08/02/24 were not reported to the Ombudsman due to R113 returning to the facility before midnight on those dates. During an interview on 10/03/24 at 5:40 PM, the Administrator revealed that the facility had documentation for R22, R26, R42, R56, R94, R111, R112, and R113 of bed-hold notifications but did not have transfer notifications that were provided to the resident and/or the residents' representatives. The Administrator stated he felt that the residents and their representatives were well aware of the resident's status upon transfer to the hospital due to the nurses calling the representatives upon transfer to the hospital. The Administrator did not confirm or deny that the facility should have provided a written notification to the resident/representative at the time of transfer to the hospital. During an interview on 10/04/24 at 9:52 AM, Medical Records (MR) stated that when a resident was sent out to the hospital, the Business Office Manager (BOM) updated the Census line in the EMR, and her responsibility was to send out the Bed Hold notification, but she did not send out Transfer Notifications and was not sure whose responsibility that was. During an interview on 10/04/24 at 8:05 PM, the Administrator and Director of Nursing stated a joint expectation that written notices of transfer and discharge would be provided (to the Resident and/or Representative) at the time of transfer or as reasonably practicable in the case of an emergent transfer.

Based on interview, record review, and policy review, the facility failed to recognize and thoroughly investigate an injury of unknown origin for one of 28 sampled residents (Resident (R)52). This had the potential to cause residents to be at risk of abuse when injuries of unknown origin were not fully investigated. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, with a revision date of 09/2022, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, theft, or misappropriation of resident property were reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Review of R52's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included traumatic rupture of other ligament of the left wrist, need for assistance for personal care, and deaf non-speaking. Review of R52's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 08/15/24, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating R52 was severely cognitively impaired. Review of R52's Progress Notes, under the Prog Notes tab in the EMR and dated 06/30/24 at 2:53 PM, revealed, . lethargic today and became agitated each time staff attempted to provide care and change his brief . Review of R52's Progress Notes, under the Prog Notes tab in the EMR and dated 07/01/24 at 12:12 PM, revealed, . Resident is alert and took morning medications. Resident did not eat breakfast. NP [Nurse Practitioner] was notified. Resident was groaning of pain in right arm when trying to move arm. NP assessed resident and waiting on new orders. Will continue to monitor resident . Review of R52's Progress Notes, under the Prog Notes tab in the EMR, dated 07/01/24 at 10:43 AM, and written by the NP2 revealed, . increased agitation, altered mental status from baseline. Nursing staff report he is 'not himself the past days'. ls not his usual happy self, he is obtunded, non-interactive with staff, is not eating and only drinking a small amount of fluids. Unable to move [right] arm, grimaces, and moans with pain when touching. Recommendations included x-ray of right shoulder and arm. Review of R52's Progress Notes, under the Prog Notes tab in the EMR and dated 07/02/24 at 3:20 PM, revealed, . [R52] right arm flaccid and very painful. Patient can no longer reposition in bed or sit up in order to transfer to [wheelchair] R52 can no longer feed self-due to right arm flaccid/pain. X-ray of right arm yesterday negative . EMS transferred patient to [hospital name withheld] at approximately l0:00 today for further testing . Review of R52's Progress Notes, under the Prog Notes tab in the EMR, dated 07/02/24 at 9:05 PM, and written by the NP2, revealed, . Today [R52] found lying in bed continues to have acute discomfort with right upper extremity. X-ray results reviewed. Patient appears to be slightly more alert today with eyes open tracking in order to provide a smile to assess for symmetry. Speech continues to be incomprehensible; however, this [was R52's] baseline. Pain in right upper extremity was increasing and more generalized. Previous exam showed more localized discomfort and easily palpable, however today, [R52] complains of pain in his fingertips with any type of tactile stimulus. Radial pulses palpable capillary refill in fingernails tips of fingers is less than 3 seconds, increased swelling from shoulder to arm, not warm or hot to touch skin. it was decided to have patient transported to [hospital name withheld] for an additional high-level evaluation . Review of R52's Progress Notes, under the Prog Notes tab in the EMR and dated 07/03/24 at 4:33 PM, revealed, [R52] returned to [the facility] today at 8:00 AM [R52] diagnosed with [fracture] of right humerus and right clavicle. [R52] receiving Tylenol for pain and new order written for Noro 5/325 every 8 hr. Patient has right arm in sling. [R52] was a total assist with all ADL's (Activities of Daily Living). During an interview on 10/03/24 at 2:15 PM, Registered Nurse (RN)1 explained on the morning of 07/01/24, R52 was crying out in pain when his right arm was touched and was guarding his right arm. RN1 stated NP2 ordered an x-ray and tried to find out what happened that the arm was so painful, but the reason for the pain in the right arm was never determined. RN1 stated no one reported a fall or that R52 was hitting a wall. RN1 stated CNA staff did report when R52 was in a combative mood, he would strike out at staff when attempting to provide care. RN1 stated after the second x-ray, R52 was found to have a fracture and was fitted for a sling for the right arm. During an interview on 10/04/24 at 9:44 AM, the Certified Occupational Therapy Assistant (COTA) 1 explained treatment was started for R52 due to the clavicle fracture. COTA1 stated R52 was treated to decrease the pain for ADLs, like putting an arm through the sleeve of a shirt. COTA1 described R52's fracture as being like what would happen if someone had extended their arm to stop a fall. On 10/04/24, the Administrator was asked to provide the facility's investigation of the fracture. Review of the facility's investigation revealed the facility began the investigation when R52 had signs and symptoms of pain to the right arm. The investigation revealed the R52 had some combative episodes prior to onset of pain. Staff caring for the resident were interviewed, and no incidents were reported other than the combativeness. The resident's roommate was interviewed and denied knowledge of any incidents. The investigation concluded the pain was from the resident being combative and striking out at staff during cares; however, there was no documentation to show the facility investigated the fracture as an injury of unknown origin after learning of the fracture. During an interview on 10/04/24 at 12:37 PM, the Administrator, who was the facility's Abuse Coordinator, explained when he learned of R52's right arm pain, he began an investigation into the pain. The Administrator stated through the interview process, CNA staff explained that the resident was combative and striking out at staff when attempting to provide care for the resident. He stated R52 was not communicative and could not answer any questions about the reason for the pain in his right arm. The Administrator stated the pain began after 'something occurred' on 06/30/24 and a portable x-ray was obtained on 07/01/24, and the results were negative for fracture. The Administrator stated when the investigation began, he did not consider the pain might be from an injury; therefore, he did not trigger an abuse investigation for injury of unknown origin. During an interview on 10/04/24 at 12:55 PM, the Administrator confirmed that he did not further investigate after the fracture was identified. He stated he had felt the investigation into the pain was all that was needed. The Administrator confirmed the type of investigation done initially was not as in depth as an abuse investigation, and the investigation should have been an investigation for an injury of unknown origin instead of assuming the previous investigation was complete. The Administrator confirmed the facility's physiatrist and the interdisciplinary team were not involved in the investigation and should have been.

Based on observation, record review, interviews and review of facility policy, the facility failed to initiate effective interventions for the prevention of falls and failed to provide interventions as planned for two (2) of four (4) residents reviewed for falls (Resident #105 and #81). 1.Resident #105 had seven (7) falls from 9/8/2020 to 4/10/21 resulting in a [CONDITION(S)] after fall number five (5) and since his/her return to the facility on [DATE] the resident had two (2) more falls. Observation revealed the facility did not provide interventions as planned and record review revealed the facility did not assess for the causative factors of the falls in order to put effective interventions in place for the prevention of falls. 2. Resident #81 had seven (7) falls from 9/20/2020 to 5/7/21. Observation revealed the facility did not provide interventions as planned and the facility did not assess for the causative factors of the falls in order to put effective interventions in place for the prevention of further falls. Findings include: Review of the policy titled, Fall Risk assessment dated ,d+[DATE] listed the policy statement of, the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The policy stated the staff and attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that were not modifiable. Interview with the Director of Nursing (DON) on 5/21/21 at 9:18 a.m. revealed the facility Fall Program consisted of, at the morning meetings Monday through Friday the department heads discuss all the residents that had fallen since the last meeting. The DON stated they discussed what happened and what interventions to initiate to address the causative factor of the fall. The facility did not currently have a form to document their root cause analysis and the process to get to the root cause. After a fall the primary nurse working completed the incident report and would document if there were any witnesses. 1. Review of Resident #105's clinical record revealed an admitted [DATE] and the diagnoses included [CONDITION(S)], [CONDITION(S)] and Dementia. Review of Resident #105's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 with a score of eight (8) to 12 indicating moderate impairment in cognition. The resident displayed verbal behaviors one (1) to three (3) days during the seven (7) day observation period. The resident required extensive assistance of one (1) staff with bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene and bathing. The resident was not steady and only able to stabilize with staff assistance with moving from a seated to standing position, walking, turning around and facing the opposite direction, and moving on and off the toilet. The resident was frequently incontinent of bowel and bladder and utilized a walker and wheelchair. The MDS revealed the resident received Occupational Therapy (OT) and Physical Therapy (PT) four (4) days during the observation period. Review of the Falls Care Area Assessment (CAA) for Resident #105 revealed the resident was at risk for falls related to agitation, dementia, history of falls, impaired judgement, impaired safety awareness, incontinence, [CONDITION(S)], and Weakness. Review of Resident #105's Fall and [CONDITION(S)] Care Plan listed the interventions dated 8/30/2020: Fall Risk Assessment per policy to evaluate risk for falls Notify physician and power of attorney of all falls Observe for side effects from medications and if adverse effects that could increase risk for falls occurred, notify the physician Pharmacy to evaluate medication for side effects that may increase falls risk PT/OT to evaluate and treat as indicated Review of Resident #105's Fall Risk assessment dated [DATE] revealed a score of 20 with a score of 16 to 42 placing the resident at a high fall risk. Review of the Fall Investigations, Nurses' Notes and Care Plan revealed: On 9/8/2020 at 5:00 p.m. - resident tried to stand without the brakes engaged on the wheelchair, he/she grabbed the side rail but was unable to get his/her balance and was lowered to the floor. The resident was sent to the hospital for evaluation. No additional care plan interventions were initiated. On 9/28/2020 at 3:35 p.m. - the resident was yelling, and staff found the resident leaning on the side of bed with legs partially off the bed. Staff assisted the resident to the floor. Staff brought the resident to the day room for closer observations and initiated floor mats. On 1/9/21 at 9:16 p.m. - staff found the resident on the floor in his/her room. The resident had sustained a superficial abrasion on his/her left outer elbow. Staff reinforced resident teaching (for this moderately cognitively impaired resident) about the importance of remaining in bed for safety. On 1/23/21 at 11:07 a.m. - staff found the resident on the floor by his/her bed. Staff initiated increased rounding but did not specify the frequency. On 2/19/21 at 11:48 a.m. - staff observed the resident lower him/herself to the floor. Staff reeducated, this moderately cognitively impaired resident, to call for assistance. On 3/20/21 at 5:42 a.m. - resident slid out of the wheelchair and was crawling on the floor. Staff did not provide an investigation for this fall. On 4/10/21 at 7:44 a.m. - staff found the resident on floor next to his/her bed. The resident complained that his/her left hip hurt. The facility sent the resident to the hospital where he/she was diagnosed with a left hip fracture. The resident returned to the facility on [DATE]. Staff added a scoop mattress and on 4/12/21 and for the bed to be in the lowest position. On 4/24/21 at 11:33 a.m. - staff found the resident on the floor with a skin tear to his/her left hand and right lateral knee. The staff placed nonskid socks, floor mats, again, and placed the bed in a low position again. On 5/19/21 at 11:53 p.m. - staff found the resident laying on his/her stomach on the floor. The resident had blood to the middle and ring finger and complained of hip pain. The facility sent the resident to hospital and returned with no new injuries identified. Staff added the intervention to keep the wheelchair at the side of the bed and the wheels locked. Observation on 5/18/21 at 1:21 p.m. revealed the resident lying in a low bed, a fall mat next to the bed on the right side and fall mat on the left side 18 inches away from the bed. Observation on 5/19/21 at 9:03 a.m. revealed the resident lying in a low bed, a fall mat on the right side next to the bed and the fall mat on the left side 18 inches away from the bed. Observation on 5/19/21 at 12:04 p.m., 12:36 p.m. and 12:51 p.m. revealed the resident in bed, with the right fall mat next to the bed and the left fall mat 18 inches from the bed. Further observation revealed the height of the bed at the regular height and not in the low position. Observation on 5/20/21 at 8:37 a.m., 8:49 a.m. and 10:32 a.m. revealed the resident lying in bed. The bed was 22 inches off the floor and the call light was on the floor. The right floor mat was 12 inches away from the bed and the left floor mat was next to the bed. Interview with Licensed Practical Nurse (LPN) #5 on 5/20/21 at 10:38 a.m. revealed the resident had a low bed to the floor and fall mats for the prevention of falls. He/she also stated the fall mats should be right against the bed. LPN #5 stated the resident went to the hospital last night due to a fall and had not returned. The surveyor asked LPN #5 to come to Resident #105's room to see who was in his/her bed. LPN #5 stated no one told him/her the resident had returned. LPN #5 checked the resident's chart and stated the resident had returned at 3:37 a.m. The resident had not been assessed or supervised by the nurse since his/her shift started at 7:00 a.m. Interview with Certified Nursing Assistant (CNA) #7 on 5/20/21 at 10:54 a.m. revealed Resident #105's fall prevention interventions included that they keep him/her occupied outside his/her room with activities, out of his/her room for meals, if he/she got agitated they knew he/she wanted to go to bed so they distracted him/her, and he/she liked milk and cookies. CNA #7 stated he/she had a low bed and a fall mat. Interview with the Director of Rehab on 5/21/21 at 11:59 a.m. revealed the therapy department screened the resident after each fall, even if they were on therapy services. He/she further stated the facility did not have a restorative program, so after therapy was completed the resident did not receive any more services. The Director of Rehab identified the resident was on therapy but was difficult to get the resident to follow directions. 2. Review of Resident #81's clinical record revealed an admitted d of 8/19/2020 and the diagnoses included: [CONDITION(S)] following Cerebral Infarction; Dementia with Behavioral Disturbance; Hereditary Motor and Sensory Neuropathy; Adjustment Insomnia; Anxiety Disorder; Muscle Weakness; and Major Depressive Disorder Severe, with Psychotic Symptoms. Review of Resident #81's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS score of nine (9) with a score of eight (8) to 12 indicating moderately impaired cognition. The resident displayed inattention and disorganized thinking continuously present that did not fluctuate and verbal behaviors one (1) to three (3) days of the seven (7) day observation period. The MDS also revealed the resident required extensive assistance of one (1) staff with bed mobility, dressing, toilet use, personal hygiene and bathing. The resident required extensive assistance of two (2) staff with bed mobility and required limited assistance of one (1) staff with walking, locomotion and eating. The resident had impairment on both sides of the lower extremities and was not steady but able to stabilize without staff assistance with moving from a seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet and surface to surface transfers. The MDS revealed the resident used a walker and wheelchair, was frequently incontinent of bowel and bladder and the staff were unable to determine the resident's history of falls prior to admission. The resident had no falls since admission and did not receive therapy services. Review of the Fall Care Area Assessment (CAA) dated 9/2/2020 revealed the resident was at risk for falls related to [CONDITION(S)], bilateral venous statis ulcers, [CONDITION(S)], and the resident tried to get up and ambulate but was very unsteady. Review of the Fall Risk assessment dated [DATE] revealed a score of 20 with a score of 16 to 42 placing the resident at a high fall risk. Review of the Care Plan listed the interventions dated 8/31/2020: Bed in lowest position Fall Risk Assessment per policy to evaluate risk for falls Non-skid socks or footwear Notify physician and power of attorney of all falls Observe for side effects from medications and if adverse effect that could increase risk for falls occurs, notify the physician PT/OT to evaluate and treat as indicated Re-orient as needed. Review of the Fall Investigations, Nurses' Notes and Care Plan revealed: On 9/20/2020 at 6:14 p.m. - staff found the resident on the floor in the locked employee bathroom with the intervention for staff to stay with the resident in the bathroom due to unsteadiness and dementia. On 10/24/2020 at 4:35 p.m. - staff heard the resident yelling and found him/her on the floor in his/her room. Staff added the intervention to remove the resident from his/her room after dressing. On 11/20/2020 at 7:10 p.m. - staff found the resident on the floor by his/her wheelchair. Staff added the intervention to offer to toilet and offer to put the resident to bed after supper. On 1/15/21 at 8:08 a.m. - the resident attempted to get out of bed unassisted, into wheelchair. The resident slid off the low bed onto the floor. The intervention included for staff to offer the resident to get out of bed into a wheelchair if he/she woke up early. On 2/2/21 at 5:31 a.m. - staff found the resident at the foot of the low bed and sustained a [CONDITION(S)] but did not receive sutures. Staff did not provide an investigation of this fall upon asking. On 3/18/21 at 10:42 a.m. - staff found the resident on the floor by the bed. Staff added the intervention for floor mats and to confirm the mats were in place every shift. The resident sustained a hematoma to the left eye and forehead. On 5/7/21 at 12:38 a.m. - staff found the resident on the floor mat by the bed. Staff added the intervention for frequent checks and a scoop mattress. Observation on 5/19/21 at 9:01 a.m. revealed the resident sat in a wheelchair in his/her room with the door to the room closed. Observation on 5/19/21 at 11:56 a.m. and 12:52 a.m., revealed the resident sat in a wheelchair in his/her room with his/her back to the door. Observation on 5/20/21 at 8:41 a.m. revealed the resident lying in bed with a wing mattress present. The privacy curtain was pulled between his/her bed and door, and the staff could not see the resident from the door/hallway. Further observation revealed no fall mats were present. Observation on 5/20/21 at 10:30 a.m. revealed the resident lying in a low bed and no fall mats were present. Observation on 5/20/21 at 12:06 p.m. revealed the resident lying in bed positioned at regular height and no staff present. Interview with LPN #5 on 5/20/21 at 10:47 a.m. stated the resident had a low bed, scoop mattress and a floor mat to the right side of the bed. Interview with CNA #7 on 5/20/21 at 11:00 a.m. revealed the resident required extensive to total assistance with care and for falls the resident utilized a low bed. Interview with the Director of Rehab on 5/21/21 at 11:59 a.m. revealed the therapy department screened the resident after each fall, even if they were on therapy services. He/she further stated the facility did not have a restorative program, so after therapy was completed the resident did not receive any more services. The Director of Rehab sated the resident required more supervision to prevent falls.