Every finding on record at Kit Carson Nursing & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to store, monitor, and serve food and beverages in accordance with professional standards for food service safety for 3 of 6 sampled residents (Residents 1, 2, and 3), when the facility:1. Failed to ensure milk served to Resident 1 was acceptable for consumption and failed to appropriately communicate, investigate, and follow up on repeated reports of sour-tasting milk to determine the cause and ensure the resident's safety.2. Failed to ensure opened food and beverage items stored for resident consumption were appropriately identified, labeled, and dated in accordance with established food-storage practices, including opened dairy products stored for Residents 2 and 3 and an opened carton of almond milk stored in the kitchen walk-in refrigerator without an identifiable opened date.3. Failed to consistently monitor and document refrigerator temperatures in accordance with the facility's established cold-storage monitoring process, as evidenced by missing temperature entries on the August 2026 Cold Storage Temperature Log (a written record showing that refrigerators and freezers are being checked to make sure food stays at a safe temperature), limiting the facility's ability to demonstrate that TCS (Time/Temperature Control for Safety Foods) foods (foods that must be kept at the right temperature to prevent harmful germs from growing and making people sick) stored for resident consumption were consistently maintained at 41 F or less.These deficient practices had the potential to expose Resident 1, Resident 2, Resident 3, and other residents in the facility who receive food from the kitchen to improperly stored or potentially unsafe food and beverages, increasing the risk for foodborne illness (sickness caused by eating or drinking something contaminated with harmful germs, toxins, or other unsafe substances).Findings:1.Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with diagnoses including, but not limited to, chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to work properly), muscle weakness, and constipation (difficulty passing stool or not having a bowel movement regularly).A review of Resident 1's clinical record titled, BRIEF INTERVIEW FOR MENTAL STATUS (BIMS - a short test used to check a person's memory and thinking abilities), dated 5/19/26, indicated a score of 13, meaning cognition (a person's thinking is considered intact with no or very little impairment) was mostly intact.During a concurrent observation and interview on 8/28/26 at 1:45 PM, Resident 1 stated that during the previous week, on two separate occasions, he was served milk that tasted sour. Resident 1 stated that he reported the concern and that the milk was replaced on both occasions. Resident 1 stated that the sour taste meant to him that the milk was not good, and he stopped drinking it because he was concerned it could cause an upset stomach. Resident 1 stated that following both occurrences, no facility staff followed up with him regarding the incidents or asked whether he had experienced adverse effects or health concerns after consuming the milk.During an interview on 8/28/26 at 10:27 AM, with the Activity Assistant (AA), the AA stated that during the previous week, a resident reported that low-fat milk served during lunch had started to taste sour. The AA stated that, based on her understanding, similar concerns occurred approximately twice. The AA stated that the Activity Director (AD) was present during the occurrence and immediately removed the milk, brought it to the kitchen, reported the concern, and requested replacement milk. The AA stated the milk that appeared to be sour should be replaced to ensure resident safety and that sour milk was not appropriate for consumption and could potentially result in health-related concerns if consumed.During an interview on 8/28/26 at 12:43 PM, with the AD, the AD stated that on two separate occasions during the previous week, Resident 1 reported that milk served during lunch tasted sour. The AD stated that on both occasions, she personally smelled the milk. The AD stated that the milk appeared normal, it smelled as though it was on the verge of being not good. The AD stated that she took the milk to the kitchen, reported Resident 1's concern to the Dietary Assistant (DA), and requested replacement milk. The AD stated that she was not aware whether additional follow-up or investigation occurred after she reported the concern.During an interview on 8/28/26 at 1:07 PM, the DA confirmed receiving reports during the previous week regarding a resident who had been served milk that reportedly tasted sour. The DA stated that replacement milk was provided. The DA stated that he did not know the identity of the affected resident and did not conduct follow-up with the resident after the milk was replaced. The DA stated that concerns involving potentially unacceptable milk should be investigated to determine what occurred and to ensure appropriate action was taken to prevent potential harm.During an interview on 8/28/26 at 3:38 PM, with the Director of Nursing (DON), the DON stated that she was unaware that a resident had complained about milk served by the facility. The DON stated that such a concern should have been reported so the interdisciplinary team could be made aware, investigate the concern, and determine the possible cause.During a telephone interview on 9/1/26 at 9:49 AM, with the Registered Dietitian (RD), the RD stated that she had heard about a concern involving a resident who had received bad milk. The RD stated that she expected the facility to identify the affected resident or residents, determine what occurred, and follow up to determine whether they developed symptoms. The RD stated that residents potentially affected by unsafe food or milk should be monitored for symptoms such as nausea, vomiting, diarrhea, or other adverse symptoms.Review of the facility's policy titled, Food Preparation and Service, revised 1/2026, indicated food and nutrition services employees prepared, distributed, and served food in a manner that complied with safe food-handling practices. The policy defined Time/Temperature Control for Safety (TCS) food as food requiring time and temperature control to limit the growth of pathogens or toxin formation and identified milk as a TCS food. The policy further indicated that potentially hazardous/TCS foods were to be maintained at or below 41 F.According to the Food and Drug Administration (FDA - A U.S. government agency that helps protect people by making sure food, medicines, and certain health products are safe and properly regulated) Food Code 2022, 3-101.11, .Safe, Unadulterated, and Honestly Presented, food shall be safe .2.Review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with diagnoses including, but not limited to, type 2 diabetes mellitus (a long-term condition where the person body is unable to process sugar in the blood effectively), adult failure to thrive (when adult becomes increasingly weak, loses weight, and has difficulty maintaining their overall health and daily functioning), and constipation.A review of Resident 2's BIMS, dated 7/9/26, indicated a score of 13, meaning cognition is mostly intact.During an interview on 8/28/26 at 11:47 AM, Resident 2 stated that his son brought milk for him during visits and that the milk was stored in the resident refrigerator. Resident 2 stated that he expected staff to properly identify and maintain his milk. Resident 2 stated, I don't need to drink expired milk.Review of Resident 3's admission RECORD indicated Resident 3 was admitted to the facility with diagnoses including, but not limited to, gastroesophageal reflux disease (a condition where stomach acid repeatedly comes back into the food pipe esophagus causing heartburn or irritation), chronic kidney disease, constipation, and irritable bowel syndrome with diarrhea (a bowel problem that causes frequent diarrhea and stomach pain or cramping).A review of Resident 3's BIMS, dated 6/1/26, indicated a score of 14, meaning cognition is mostly intact.During a concurrent observation and interview on 8/28/26 at 3:25 PM with Resident 3 in her room, Resident 3 was observed sitting on the left side of her bed. Resident 3 stated that she preferred to drink buttermilk ( a tangy, acidic dairy product) , which her son brought to the facility for her. Resident 3 stated that she did not like the milk served on her meal tray because she did not like its taste. Resident 3 stated, That's why I am throwing it [away]. When asked whether she had previously reported her concern regarding the taste of the facility-served milk to staff, Resident 3 stated that she could not remember if she had mentioned it to anyone. Resident 3 reiterated that she preferred her buttermilk which was kept at the nurse's station refrigerator.During a concurrent observation and interview on 8/28/26 at 8:56 AM, with the facility's [NAME] (CK), an opened carton of almond milk was observed inside the kitchen walk-in refrigerator without an opened date. The CK confirmed that the carton had been opened and was not labeled with the date it was opened. The CK stated that once a milk product was opened, staff were expected to label it with the opened date.During a concurrent observation and interview on 8/28/26 at 9:10 AM with Certified Nursing Assistant (CNA) 1, an opened, partially used gallon container of 2% reduced-fat milk was observed inside Station 2's Residents' Refrigerator. The container was marked 49D. CNA 1 stated that it did not contain the resident's name or date opened. CNA 1 inspected the container and confirmed that the milk had been opened and was not labeled with the resident's name or date opened. During the continued observation of Station 2's Residents' Refrigerator, the following additional items were identified: a) A plastic food container with a red lid marked 39A and dated 8/21/26, without the resident's name. b) An opened tub of Country Crock vegetable-oil spread marked with a resident's name, room [ROOM NUMBER]A, and dated 4/17/26, which remained in the refrigerator for more than four months after the documented date. c) A round plastic container marked 49A containing handwritten instructions but without a storage or preparation date. d) An opened container of whipped butter marked only 39A, without the resident's name or date opened. e) A closed foam takeout container marked with a resident's name but without a room number or date the food was stored. f) A partially consumed food item loosely wrapped in a clear plastic bag with paper napkins without the resident's name, room number, or storage date. g) A packaged ready-to-heat meal with a manufacturer's Best if Used By date of 8/26/26 that remained in the refrigerator on 8/28/26 and did not contain the resident's name or room number. h) A large clear plastic bag labeled with a resident's name and room [ROOM NUMBER] containing multiple partially used food containers; the individual containers did not contain dates indicating when they were prepared, opened, or placed in the refrigerator. CNA 1 inspected the items and confirmed that they lacked the identifying information and/or dates described above.During a concurrent observation and interview on 8/28/26 at 10:05 AM with CNA 2, an opened carton of cultured buttermilk (a thick, slightly sour milk made using helpful bacteria) was observed in Station 1's Residents' Refrigerator. The carton contained a resident's name and room [ROOM NUMBER] and had a manufacturer's Best if Used By date of 8/31/26. CNA 2 stated that it did not indicate the date opened. CNA 2 confirmed that the carton had been opened and was not labeled with the date opened. CNA 2 stated that documenting the date opened was important because milk and other dairy products had a limited shelf life after opening and could spoil. CNA 2 further stated that residents' food items were required to be labeled with the resident's name, room number, and the date placed in the refrigerator and that refrigerated food items were discarded after three days.During the interview on 8/28/26 at 3:38 PM, with the DON, the DON stated that resident food items stored in the resident refrigerators were expected to be properly labeled with the resident's name and the date the food was placed in the refrigerator. The DON stated that food stored for more than three days was expected to be removed and discarded. The DON further stated that opened milk containers were expected to be labeled with the resident's name and date opened and that proper labeling, dating, and timely removal were important for resident safety and to reduce the risk of foodborne illness.During the telephone interview on 9/1/26 at 9:49 AM, with the RD, the RD stated that large containers of milk or milk alternatives, including almond milk, were expected to be labeled with the date opened once the container was opened. The RD stated that documenting the date opened was important to determine whether a product remained appropriate for consumption.Review of the facility's policy titled, Refrigerators and Freezers, revised 4/2026, indicated that all food was to be appropriately dated to ensure proper rotation by expiration dates. The policy further indicated that expiration dates on unopened food would be observed and use by dates indicated once food was opened.Review of the facility's Food Storage policy, revised 1/2026, indicated food storage areas were to be maintained in a clean, safe, and sanitary manner. The policy indicated food was to be rotated using a First In, First Out method and items were to be dated upon receipt to facilitate the process.3.During a concurrent observation, interview, and record review on 8/28/26 at 8:56 AM, the CK reviewed the August 2026 Cold Storage Temperature Log posted in the kitchen. The log contained designated spaces for the AM and PM cooks to document temperatures for the three-door reach-in refrigerator, walk-in refrigerator, two-door reach-in refrigerator, and walk-in freezer, along with staff initials. Review of the log showed that AM temperature readings and staff initials were not documented on 8/5/26, 8/21/26, and 8/25/26 through 8/27/26. PM temperature readings and staff initials were not documented on 8/9/26. On 8/27/26, PM temperatures were documented, however CK stated that staff initials were missing. The CK reviewed the log and confirmed that the identified entries were missing.During a telephone interview on 9/1/26 at 9:49 AM, the RD stated that refrigerator temperature logs were expected to be completed without gaps. The RD stated that consistent refrigerator temperature monitoring was important for food safety and that inadequate temperature control could permit bacterial growth and potentially cause residents to become ill.Review of the facility's Refrigerators and Freezers policy, revised 4/2026, indicated acceptable refrigerator temperatures were 35 F to 41 F. The policy required food service supervisors or designated employees to check and record refrigerator and freezer temperatures daily at first opening and at closing in the evening. The policy further required immediate action when temperatures were outside the acceptable range and documentation of corrective action.Review of the facility's Food Storage policy, revised 1/2026, indicated cold foods were to be maintained at 41 F or below, and the food services manager or designee was to check refrigerators and freezers daily for proper temperatures.According to the FDA Food Code 2022, 3-501.16, Time/Temperature Control for Safety Food, Hot and Cold Holding, refrigerated TCS food is generally required to be maintained at 41 F (5 C) or less.

Based on interview and record review, the facility failed to report to the Department, an allegation of misappropriation of resident property for one of three sampled residents (Resident 4) when Resident 4's debit card was lost and there were unauthorized charges and ATM withdrawals from the account.This failure resulted in a delay in the Department's investigation into Resident 4' s allegation of misappropriation of resident property and had the potential for re-occurrence of misappropriation of property for Resident 4 and other residents in the facility.Findings:A review of Resident 4's admission RECORD, indicated that Resident 4 had diagnoses of, but not limited to, psychosis (inability to distinguish between what is real and not real), disorientation (temporary or long-term state of mental confusion where a person loses their awareness of time, place, or personal identity), adult failure to thrive (a gradual decline in a person's physical, mental, and functional health as they age), and delusional disorders (a mental health condition where a person firmly believes in things that are not real or true, even when given clear proof otherwise).A review of Resident 4's Brief Interview of Mental Status (or BIMS, determines the individual's attention, orientation and ability to register and recall new information), dated 8/17/26, indicated Resident 4 has a BIMS score of 7 (score of 0 to 7 means severe cognitive impairment).A review of Resident 4's progress notes dated 6/19/26, indicated, .Resident informed social services that she had lost her Way2Go Prepaid Mastercard [a prepaid MasterCard issued by state government agencies to distribute financial benefits like unemployment insurance, child support, or cash assistance] and needed to cancel card. Resident requested a new card to be sent. Social services called the automated system and reported the card lost. New card will be sent to facility.A review of a facility provided document titled, Monthly Account Activity, dated February 1-28, 2026, indicated Resident 4's bank account activity as follows: a cash purchase to a private company with the amount of $54.31, multiple ATM cash withdrawals on 2/22/26 for the amount of $203, and another $203 for the same day, gas purchase with the amount of $54.77 on 2/23/26, a pizza purchase in another city with the amount of $160.66 on 2/24/26. Beginning balance was $4,715.23 and ending balance was $3994.75.A review of facility provided document titled, Monthly Account Activity, dated March 1-31, 2026, indicated Resident 4's bank account activity as follows: a cash purchase to a private company with the amount of $46.19, ATM cash withdrawal on 3/7/26 for the amount of $403, gas purchase with the amount of $38.24 on 3/7/26, a cash purchase to a private company with the amount of $75.34 on 3/12/26, ATM cash withdrawal on 3/12/26 with the amount of $403 and a cash purchase to a private company with the amount of $185.14 on 3/12/26. Beginning balance was $3994.75 and ending balance was $1.72.During an interview on 8/28/26, at 10:47 AM, with Resident 4, Resident 4 stated she does not have any more money to buy make up or food from outside the facility.During a concurrent interview and record review on 8/28/26, at 12:04 PM, Resident 4's progress note dated 6/19/26 was reviewed with the social services assistant (SSA). The SSA confirmed that the progress note on 6/19/26 indicated that Resident 4 reported to her that she lost her card, and she helped her get it replaced. The SSA stated they cancelled the old card because there were unauthorized card transactions. The SSA stated they do not know who used Resident 4's debit card. The SSA stated that in the past Resident 4 used to give her debit card to the staff and have them buy stuff for her and have had a meeting with the ombudsman (resident advocate) in the past about that. The SSA stated CNAs (certified nursing assistants) told her that she gave her card to someone, but when she asked Resident 4, Resident 4 said she lost it. Resident 4 also said at one time that she gave the card to her son, but her son was incarcerated. The SSA stated Resident 4 has different statements each time they ask her but at the time on 6/19/26 she reported that she lost her debit card.During an interview on 8/28/26 at 1:43 PM, the SSA stated it has been months since Resident 4 has been out of bed, she never goes out to withdraw money from the ATM, and it was back in 2022 since she last left the facility to go out. The SSA stated Resident 4 has lost her card 3 times in the past. The SSA stated Resident 4 was no longer at risk for misappropriation of property because her money was gone, but when she had her card and available money, she was at risk.During an interview on 8/28/26, at 2:20 PM, with the Director of Nursing (DON), the DON stated if a resident lost their card, they either file a grievance or risk management, depending on what the resident said, they would do an investigation, notify the police, and the POA (power of attorney/responsible party) and put a stop on the bank card. The DON further stated that they would follow up with what happened and sometimes they would also notify APS (adult protective services). The DON stated it should be reported to the Department and/or the Ombudsman. The DON stated that reporting to the police also depends on the situation. The DON stated for this situation with Resident 4, they should have reported it. The DON stated Resident 4 was at risk for misappropriation of funds when her cards were lost.During an interview on 8/28/26, at 4:15 PM, with the Administrator (ADM), the ADM stated when they get a report that a resident lost their debit card and there were unauthorized charges, they ask the resident if they need help reaching out to the card company. The ADM stated it depended on the case if they would investigate but in the case of Resident 4, she articulated that it was her son that did the withdrawal. The ADM stated they cannot speculate about what happened to her card. The ADM stated he was not sure what happened when Resident 4 lost her card. The ADM stated there was nothing to investigate and report because they have no reason to believe that there was abuse, and they would just replace the card. A review of the facility's policy and procedure titled, ABUSE, NEGLECT, MISTREATMENT AND MISAPPROPRIATION OF RESIDENT PROPERTY, revised 10/2023, indicated, .The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements.REPORTING AND RESPONSE.It is the policy of this facility that abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion allegations are reported per Federal and State Law. The facility will ensure that.All alleged violations of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion must also be reported by the facility to officials in accordance with State law, including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities.Not later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment or misappropriation of resident property and does not result in serious bodily injury.If the suspected abuse does not result in serious bodily injury, the mandated reporter must: Report the incident by telephone within 24 hours to local law enforcement agency. Provide a written report to the local Ombudsman, the L&C [Licensing and Certification-The Department] Program and the local law enforcement agency within 24 hours.A review of the facility's policy and procedure titled, Theft and Loss, revised 1/2025, indicated, .The facility will make every effort to find property which has been reported as lost or stolen.The Administrator/SSD [social service director] will investigate the situation to determine whether the reported item can be found.The Theft and Loss Record report is to be forwarded to the SSD/Administrator immediately for follow-up investigation and actions.A review of the facility's policy and procedure titled, Resident Rights, revised 1/2024, indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.be free from abuse, neglect, misappropriation of property, and exploitation.

Based on interview and record review, the facility failed to ensure allegations of misappropriation of resident property were investigated, the findings of the investigations were reported to the appropriate parties, and protective measures were put in place to prevent further abuse for one of three sampled residents (Resident 4) when the facility was unable to provide evidence that the allegation of misappropriation of property for Resident 4 was investigated thoroughly and results of the investigations were reported to the Department and other appropriate parties.These failures had the potential to place Resident 4 and other residents in the facility at risk for further misappropriation of resident property and a negative psychosocial outcome (the changes in a person's mental health, emotions, and social relationships after an event).Findings:A review of Resident 4's admission RECORD, indicated that Resident 4 had diagnoses of, but not limited to, psychosis (inability to distinguish between what is real and not real), disorientation (temporary or long-term state of mental confusion where a person loses their awareness of time, place, or personal identity), adult failure to thrive (a gradual decline in a person's physical, mental, and functional health as they age), and delusional disorders (a mental health condition where a person firmly believes in things that are not real or true, even when given clear proof otherwise).A review of Resident 4's Brief Interview of Mental Status (or BIMS, determines the individual's attention, orientation and ability to register and recall new information), dated 8/17/26, indicated Resident 4 had a BIMS score of 7 (score of 0 to 7 means severe cognitive impairment).A review of Resident 4's progress notes dated 6/19/26, indicated, .Resident informed social services that she had lost her Way2Go Prepaid Mastercard [a prepaid MasterCard issued by state government agencies to distribute financial benefits like unemployment insurance, child support, or cash assistance] and needed to cancel card. Resident requested a new card to be sent. Social services called the automated system and reported the card lost. New card will be sent to facility.During an interview on 8/28/26, at 10:47 AM, with Resident 4, Resident 4 stated she does not have any more money to buy make up or food from outside the facility.During a concurrent interview and record review on 8/28/26, at 12:04 PM, Resident 4's progress note dated 6/19/26 was reviewed with the social services assistant (SSA). The SSA confirmed that the progress note on 6/19/26 indicated that Resident 4 reported to her that she lost her card, and she helped her get it replaced. The SSA stated they cancelled the old card because there were unauthorized card transactions. The SSA stated they do not know who used Resident 4's debit card. The SSA stated that in the past Resident 4 used to give her debit card to the staff and have them buy stuff for her and have had a meeting with the ombudsman (resident advocate) in the past about that. The SSA stated CNAs (certified nursing assistants) told her that she gave her card to someone, but when she asked Resident 4, Resident 4 said she lost it. Resident 4 also said at one time that she gave the card to her son, but her son was incarcerated. The SSA stated Resident 4 has different statements each time they ask her but at the time on 6/19/26 she reported that she lost her debit card.During a concurrent interview and record review on 8/28/26, at 1:43 PM, Resident 4's bank account activity for the month of February and March was reviewed with the SSA. The SSA stated there were multiple ATM cash withdrawals in February and March 2026, two transactions of $203 from an ATM cash withdrawal on 2/22/26, a $403 ATM cash withdrawal on 3/7/26, and another transaction of a $403 ATM cash withdrawal on 3/12/26. The SSA confirmed that Resident 4's ending balance was $1.72. The SSA stated Resident 4 never goes out of the facility to withdrawal from the ATM, and the last time she left the facility was back in 2022. The SSA further stated it had been months since Resident 4 was even out of bed. The SSA stated the facility did not investigate the alleged misappropriation of property aside from asking Resident 4 how she lost the card. The SSA stated Resident 4 was not at risk for misappropriation of property anymore because the money was gone, but when she had her card, she was at risk.During an interview on 8/28/26, at 2:20 PM, with the Director of Nursing (DON), the DON stated if a resident lost their card, depending on what the resident said, they would conduct an investigation, notify the police, and the POA (power of attorney/responsible party) and put a stop on the bank card. The DON further stated that they would follow up with what happened and sometimes they would also notify APS (adult protective services). The DON stated Resident 4 was at risk for misappropriation of funds when her cards were lost.During an interview on 8/28/26, at 4:15 PM, with the Administrator (ADM), the ADM stated when they get a report that a resident lost their debit card and there were unauthorized charges, they ask the resident if they need help reaching out to the card company. The ADM stated it depended on the case if they would investigate but in the case of Resident 4, she articulated that it was her son that made the withdrawals. The ADM stated they cannot speculate about what happened to her card. The ADM stated he was not sure what happened when Resident 4 lost her card. The ADM stated there was nothing to investigate and report because they have no reason to believe that there was abuse, and they would just replace the card.A review of the facility's policy and procedure titled, ABUSE, NEGLECT, MISTREATMENT AND MISAPPROPRIATION OF RESIDENT PROPERTY, revised 10/2023, indicated, .The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements. An additional report of the results of all investigations will be reported to the Administrator and the State Survey Agency within five working days of the incident, if the violation is verified and appropriate corrective action taken.INVESTIGATION.It is the policy of this facility that reports of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, are promptly and thoroughly investigated.Investigation of abuse: When an incident or suspected incident of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. Investigation regarding misappropriation: Examples of reportable allegations of Misappropriation of resident property that will be investigated include, but are not limited to.Theft from bank accounts.Unauthorized or coerced use of resident's credit care or funds.For missing items, the administrator or designee will direct completion of an active search for missing item(s) including documentation of investigation.Results of all investigations of alleged violations must be reported within 5 working days of the incident.A review of the facility's policy and procedure titled, Theft and Loss, revised 1/2025, indicated, .The facility will make every effort to find property which has been reported as lost or stolen.The Administrator/SSD will investigate the situation to determine whether the reported item can be found.The Theft and Loss Record report is to be forwarded to the SSD/Administrator immediately for follow-up investigation and actions.A review of the facility's policy and procedure titled, Resident Rights, revised 1/2024, indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders for 3 of 3 sampled residents (Resident 1, Resident 2, and Resident 3) when:Resident 1's order for trazodone (sleep aid medication) was not transcribed according to the hospital's discharge instructions;Resident 2's inhaler (DuoNeb or albuterol and ipratropium, a prescription combination medicine used in a nebulizer machine to treat breathing problems) medication administration was not documented on 8/8/26 for two administration times; andResident 3 did not receive the treatment medication (lidocaine patch, a numbing agent) for pain relief at a specified time according to the physician's order. These failures placed Resident 1, Resident 2 and Resident 3 at risk for pain, unrelieved symptoms, unsafe medication use, and ineffective pain relief Findings:1. A review of Resident 1's, admission RECORD, indicated Resident 1 was admitted to the facility with diagnosis of, but not limited to, dystonia (a neurological movement disorder that causes involuntary, uncontrolled muscle contractions, leading to abnormal twisting, repetitive movements, or awkward postures), generalized muscle weakness, and pain.During an interview on 8/18/26, at 11:35 AM, with Resident 1, Resident 1 stated he was supposed to take trazodone at bedtime, and he was supposed to get it daily. During an interview on 8/18/26, at 2 PM, with Resident 1's family member (FM) 1 at bedside, FM 1 stated that Resident 1 has been taking trazodone for 26 years for his cervical dystonia, trazodone helped him with his sleep, and he was supposed to be taking it at bedtime. FM 1 stated Resident 1 was having a hard time sleeping because of his cervical dystonia, due to Resident 1 just facing one side and not able to move his head and neck on to the other side.During a concurrent interview and record review on 8/18/26, at 2:20 PM, with the Director of Nursing (DON), Resident 1's Patient Health Summary, from the hospital, dated 7/24/26, and Resident 1's medication administration record (MAR), dated 7/26 and 8/26, was reviewed. Resident 1's Patient Health Summary indicated that trazodone should be given once a day. Resident 1's MAR for the month of July and August, indicated that trazodone was to be given only as needed. The DON stated that she expected that 2 nurses should have checked the order from the hospital during admission and there should be a third check from the charge nurse on the following day of admission. 2. A review of Resident 2's, admission RECORD, indicated Resident 2 was admitted to the facility with diagnosis of, but not limited to, atherosclerotic heart disease of the native coronary artery without angina pectoris (fat and cholesterol buildup on the heart arteries without chest pain), myocardial infarction (heart attack), and Adult failure to thrive (a slow, steady decline in physical and mental health).During a concurrent interview and record review on 8/18/26, at 2:36 PM, with the DON, Resident 2's MAR, dated 8/26, was reviewed. The DON confirmed that Resident 2's DuoNeb inhaler medication for Resident 2 was left blank on 8/8/26 at 12 PM and 6 PM. The DON stated she expected the nurses to document each medication given. The DON stated it was important to document whether they gave the medication or not because it could be duplicated and could possibly overdose the resident. The DON further stated that without proper documentation, it could worsen the resident's condition, and it could also delay the treatment.3. A review of Resident 3's admission RECORD, indicated Resident 3 was admitted to the facility with diagnosis of, but not limited to, acute pain due to trauma.During an interview on 8/18/26, at 10:40 AM, with Resident 3, Resident 3 stated that she does not remember if the nurse provided her pain medicine and/or a lidocaine patch. During a review of Resident 3's MAR on 8/18/26, at 10:51 AM, the MAR indicated that lidocaine topical patch was administered on 8/18/26 at 9AM.During a concurrent observation and interview on 8/18/26, at 12 PM, with LN 1, Resident 3's back was observed without a lidocaine patch. LN 1 confirmed that Resident 3 did not have any lidocaine patch on her back. LN 1 stated it was a new order, and she forgot to give it to Resident 3. LN 1 stated she was probably going too fast when she was administering medications. LN 1 stated if the resident was in pain, she needed to assess the resident, and if the resident had an order for pain medicine, she would administer it. LN 1 stated if the pain was not addressed, the residents could suffer and have unnecessary prolonged pain.During a concurrent interview and record review on 8/18/26, at 2:20 PM, with the DON, the DON stated that when residents were in pain or complaining of pain, she expected the nurses to assess the residents and administer pain medication or call the doctor if the resident does not have any pain medication. The DON stated it was important to notify the doctor to address the resident's pain, if the medications were not effective, it would be the facility's responsibility to address their pain so that they are not worsening. The DON further stated that pain will decrease the resident's mobility and that could lead to bedsores and also if they are not breathing properly due to the pain that could also lead to pneumonia (infection of the lungs). The DON stated there would be a risk that the resident had uncontrolled pain. The DON stated if they already have the pain medicine order, she expected the nurses to give it. The DON stated it was important to give the medications on time because some medications were effective in a certain window period and some medications were time specific. The DON further stated that the nurses should administer it at the appropriate time. The DON stated the risk if the medication was not given or if the medications were not available, specifically when they need it or request for it, that could cause further issues that required interventions, it is time sensitive and it could get worse before they actually addressed the medical issue. The DON stated she expected the nurses to perform the treatment first before documenting it as given, just in case the resident refuses.A review of the facility's policy and procedure titled, Medication and Treatment Orders, revised 1/26, indicated, .Orders for medications and treatments will be consistent with principles of safe and effective order writing.Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis.A review of the facility's policy and procedure titled, Pharmacy Services, revised 1/26, indicated, .The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist .Pharmaceutical services consists of.the processes of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding.dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals.Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice.A review of the facility's policy and procedure titled, Pain Assessment and Management, revised 1/26, indicated, .Implementing Pain Management Strategies.The following are considered when establishing the medication regimen.Administering medications around the clock rather than PRN [as needed].The medication regimen is implemented as ordered.A review of the undated facility provided document titled, JOB DESCRIPTION AND PERFORMANCE STANDARDS Position Title Charge Nurse, indicated, .The primary functions and responsibilities of this position are as follows.Administer and document direct resident care, medications and treatments per physician's orders and accurately record all care provided.

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures when, staff did not wear appropriate Personal Protective Equipment (PPE - specialized clothing and equipment used by healthcare professionals to minimize exposure to infectious agents and hazardous material) when providing eye drops medication to Resident 4 on Enhanced Barrier Precautions (EBP- an infection control strategy used in nursing homes that requires targeted use of gowns and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms or MDROs).This failure had the potential to spread infection and cause health problems for the residents in the facility.Findings:A review of Resident 4's Medication Administration Record from 8/1/26 to 8/31/26, indicated Resident 4 had an order for artificial tears ophthalmic solution.During a concurrent medication administration observation and interview on 8/18/26, at 11:54 AM, with Licensed Nurse (LN) 1, LN 1 was observed administering eye drops medication to Resident 4's eyes without wearing gloves, gown and/or mask. LN 1 acknowledged the EBP signage on the door outside of Resident 4's room after she finished the eye medication administration. LN 1 stated she did not notice the signage on the door that Resident 4 was on Enhanced Barrier Precaution. LN 1 stated the EBP signage was a precaution and if residents were on EBP, the staff were supposed to wear PPE. LN 1 confirmed that she did not wear PPE. LN 1 stated that she should have worn the gown and the gloves when she administered the eye drops to Resident 4. LN 1 stated if they did not follow the EBP, there was a potential for cross contamination (spread of germs) between residents.During an interview on 8/18/26, at 2:40 PM, with the Director of Nursing (DON), the DON stated that when residents were on EBP, she expected the nurses to do hand hygiene, and they should be wearing gloves during eye drops administration. The DON further stated the nurses should also wear a gown because their clothes might come in contact with the resident's bed. The DON stated if staff did not wear appropriate PPE when they were providing care to residents on EBP, it could result in cross contamination between other residents.A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, revised 1/25, indicated, .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use 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). b. Personal protective equipment (PPE) is changed before caring for another resident.Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.A review of the undated facility provided document titled, JOB DESCRIPTION AND PERFORMANCE STANDARDS Position Title Charge Nurse, indicated, .The primary functions and responsibilities of this position are as follows.Observe infection control procedures.

Based on interview, and record review, the facility failed to identify and provide needed care and services that were resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice for one of two sampled residents (Resident 1), when Resident 1's request for daily finger sticks (a medical method to collect a tiny drop of blood on the side of the finger using a small sterile needle that give blood sugar levels), was not clarified with the physician upon Resident 1's admission to the facility.This failure had the potential risk for not meeting Resident 1's physical, mental, and psychosocial needs. There was also a potential risk for Resident 1 to experience episodes of hyperglycemia (elevated blood glucose levels), hypoglycemia (low blood sugar levels), or other negative health outcomes. Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2026 with diagnoses including type 2 diabetes mellitus (a long-term medical condition where the body does not make enough insulin or cannot use it the right way), and with diabetic kidney complication.A review of Resident 1's Minimum Data Set Record (MDS, a resident assessment tool use to guide care) dated 7/27/26, indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status exam (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, ability to register and recall information. A BIMS score of 13 to 15 is an indication of intact cognitive status).A review of Resident 1's Progress Notes titled, Dietary Notes, dated 7/27/26, indicated, .Would like her glu [glucose] checked daily.Nutrition Intervention.2. Recommend check glu level 1/d [glucose check one time daily] (resident request) .During an interview on 8/17/26, at 11:35 a.m., with Resident 1, Resident 1 stated she had been at the facility for three weeks. Resident 1 further stated she had complained several times to facility staff and did not get her diabetic finger sticks until a week ago. Resident 1 stated she was diabetic with diabetic kidney disease.During an interview on 8/19/26, at 8:34 a.m., with Licensed Nurse (LN) 1, LN 1 stated Resident 1 had spoken to one of the social services staff about one week after her admission to the facility and had mentioned to them about her blood sugar checks. LN 1 further stated Social Services (SS) placed a note on his desk informing him about Resident 1's request for blood sugar checks. LN 1 acknowledged Resident 1 did not get any treatment or care for her diabetes 12 days after her admission to the facility. During a concurrent interview and record review on 8/17/26, at 12:28 p.m., with the Clinical Compliance Nurse (CCN), Resident 1's electronic health record (EHR) and the hospital after visit summary was reviewed. The CCN confirmed she did not see any orders for glucose monitoring in July for Resident 1. The CCN further stated whatever the orders were, nursing staff should have transcribed them because Resident 1 was diabetic. The CCN stated the risk was that nursing staff would not be able to monitor Resident 1 for hypoglycemia or hyperglycemia symptoms. During a concurrent interview and record review on 8/17/26, at 1:06 p.m., with LN 1, Resident 1's hospital after visit summary was reviewed. LN 1 stated he was the one who transcribed the hospital after visit order summary for Resident 1. LN 1 further stated blood sugar checks should have been added at least as a one-time check, knowing that Resident 1 had a history of diabetes. LN 1 confirmed the physician should have been notified about Resident 1's past medical history of diabetes. LN 1 further confirmed Resident 1's diabetes orders were missed and they should have been carried out on the facility order set. During an interview on 8/17/26, at 2:16 p.m., with the Director of Nursing (DON), the DON stated it was her expectation for all nursing staff to follow through with a resident's transfer admission orders and to make sure they were following up with the medical provider after a resident was admitted to the facility. The DON further stated this allowed the provider to take over the resident care from the hospital. The DON stated the hospital's orders were good and acted as the facility's initial order set for Resident 1's care. The DON further stated that nursing staff should have contacted the physician to make sure Resident 1's diabetic management were addressed to get a baseline of Resident 1's blood sugar levels and to prevent further complications for the resident. The DON stated the facility placed Resident 1 at risk by not transcribing all her orders from the hospital.During an interview on 8/19/26, at 10:30 a.m., with the facility's Medical Director, (MD), the MD stated his expectation for nursing staff was to contact him or his team members and notify them of any resident admission to the facility. The MD further stated nurses should have reached out to clarify orders that were needed for the resident's care. The MD stated one reason for nursing staff to follow up on admission orders was to prevent residents from going to the hospital.A review of facility's policy and procedures (P & P) titled, admission Assessment, dated 1/2026, indicated, .Policy. It is the policy of the facility to admit and retain only residents it can adequately meet the needs and provide services to. It is regardless of race, sex, religion, age, language and the like. 1. Upon admission, resident will be assessed for basic needs and services necessary for the resident to attain or achieve his/her highest practicable well-being. 2. Assessment of basic needs and services shall be done by the members of Interdisciplinary (IDT) team, in conjunction with facility policy and procedure as well as federal and state regulation governing resident assessment.

Based on interviews and record review, the facility failed to provide notification to residents and their responsible parties (RP) regarding the date of change for the facility's Medical Director (MD) and attending physician, nor did it supply the contact information or specialty of the new physician for a census of 74 residents.This failure had the potential for residents, and responsible parties lacking essential information about the timing of the change, the specialty of the new MD, and the means to contact the attending physician when needed. Findings: During an interview and record review on 8/13/26 at 12:05 p.m. with the Business Office Manager (BOM), the BOM stated that she gave notices to residents in the facility who were self-responsible, regarding the MD change on 7/30/26. The BOM further stated that she mailed out the notices to RPs of residents who were not self-responsible. The BOM agreed that the notice did not have a date of the change, the phone number or a specialty of the new MD. During a concurrent interview and record review with the Administrator (ADM) on 8/13/26 at 12:25 p.m., the ADM confirmed that the notice lacked the date of the change, the phone number and a specialty of the MD. The ADM stated that the residents could not know the date of the change by looking at the notice. The ADM further stated that the residents could not have contacted the MD directly if needed and would have to go through the nurses to contact the new MD. Review of facility's policy and procedure (P&P) titled Physician Assignment, Change revised 01/26, the P&P indicated, .Physician Change.if the facility chooses to change their facility appointed physician.Notification of new facility appointed physician, and the date regarding the change of service.the attending physician's notification to terminate service; the name of the new physician; and the effective date .

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 2) when, Resident 2 was left outdoors in direct sunlight for an extended period of time without adequate monitoring or preventive measures to protect against heat-related illness and dehydration.This failure placed Resident 2 at risk for heat-related illness and dehydration.Findings:Review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with diagnoses including type 2 diabetes mellitus (high blood sugar), acute kidney failure (kidneys suddenly not working properly), muscle weakness, hypertensive heart disease with heart failure (heart weakened from high blood pressure), and disorders of electrolyte and fluid balance (abnormal levels of body fluids and minerals).Review of Resident 2's Staff Assessment for Mental Status, dated 7/26/26, indicated that Resident 2's Short-term Memory OK was marked 0, which indicated Memory OK. Resident 2's Cognitive Skills for Daily Decision Making was marked 0, which indicated Independent - decisions consistent/reasonable.During a concurrent interview and record review on 8/11/26 at 2:26 PM with Licensed Nurse (LN) 1, Resident 2's progress notes were reviewed. Resident 2's progress note, dated 7/23/26, at 8:44 PM, indicated that Resident 2 had nausea and vomiting four times during the shift and reported feeling weak. Resident 2's progress note, dated 7/24/26, at 6:11 AM, indicated that Resident 2 was monitored due to an unwitnessed fall and nausea and vomiting. Resident 2's progress note, dated 7/26/26, at 5:25 PM, indicated Resident 2 was found sleeping outdoors in direct sunlight for an extended period. Resident 2 was confused, dizzy, and lethargic (unusually sleepy and lacking energy), and his exposed skin was erythematous (red), warm, and hot to the touch. The physician ordered for Resident 2 to be transferred to the emergency department. LN 1 stated that he assessed Resident 2 on 7/26/26 and found Resident 2 had skin redness and was hot to the touch, which indicated that Resident 2 had been exposed to the heat, but he could not determine exactly how long Resident 2 had been outside. LN 1 stated that Resident 2's recent fall, nausea, and vomiting should have alerted staff to monitor Resident 2 more frequently, including his whereabouts. LN 1 further stated that staff were expected to frequently check residents in the courtyard, especially during the summer, and offer fluids to prevent heat stroke and dehydration.During a concurrent observation and interview on 8/11/26 at 3:29 PM, with the CR in the courtyard, the CR stated that the courtyard was too hot, especially if a resident was directly under the sun. The CR stated that staff were expected to monitor the courtyard during the summer, provide hydration, and remind residents to stay in covered areas.During an interview on 8/13/26 at 3:58 PM, with Certified Nurse Assistant (CNA) 1, CNA 1 stated that she worked the PM shift on 7/26/26 and was assigned to take care of Resident 2. CNA 1 stated that when she arrived at 2 PM, she did not see Resident 2, and thought Resident 2 was in the activity room, but did not check Resident 2's whereabouts. CNA 1 stated that around 4 PM, another resident reported to her that Resident 2 was outside in the courtyard. CNA 1 stated that when she checked the courtyard, Resident 2 was in his wheelchair under the sun and appeared sleepy . CNA 1 further stated that staff should frequently check the courtyard during the summer and have fluids available for residents in the courtyard to prevent heat stroke and dehydration.During an interview on 8/18/26 at 4:17 PM, with CNA 2, CNA 2 stated that she worked the AM shift on 7/26/26 and was assigned to take care of Resident 2. CNA 2 stated that the last time she saw Resident 2 on 7/26/26 was at 1:30 PM in Resident 2's room. CNA 2 stated that Resident 2 had direct access to the courtyard and may have used the sliding door in his room to go to the courtyard without staff noticing.Review of the facility's P&P titled Hydration - Clinical Protocol, revised 1/26, indicated, .staff will identify significant risk for subsequent fluid and electrolyte imbalance. The staff will provide supportive measures such as supplemental fluids and adjusting environmental temperature.

Based on interview and record review, the facility failed to provide timely psychiatric (mental health) evaluation and treatment as ordered for one of one sampled residents (Resident 1) when, Resident 1 expressed thoughts of suicide on 7/13/26 and received a physician's order on 7/13/26 for a psychiatric visit, re-evaluation, and treatment as indicated, but Resident 1 was not evaluated or treated by a psychiatric provider as of 8/11/26, and Resident 1 continued to express thoughts of suicide and threats to harm others, and had an attempted suicide on 7/30/26.This failure placed Resident 1 at risk for continued suicidal behavior, further self-harm, and serious injury and placed other residents and staff at risk for harm.Findings:Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with diagnoses including depression, acquired absence of the right leg below the knee (right leg removed below the knee), acquired absence of the left leg below the knee (left leg removed below the knee), and pain.Review of Resident 1's Minimum Data Set (MDS; an assessment tool), in the section titled Brief Interview for Mental Status (BIMS, an assessment of a resident's thinking and memory), dated 7/12/26, indicated Resident 1 had a BIMS score of 13, which reflected intact cognition (13-15 = Intact, 8-12 = Moderate Impairment, 0-7 = Severe Impairment).Review of Resident 1's Inappropriate Behaviors care plan, dated 7/13/26, in the section titled Interventions, indicated, .Received order to have resident placed on 1:1 for 3 days and refer to PA [Physician Assistant] Psych eval [psychiatric evaluation] .Date Initiated 07/13/2026 .Review of Resident 1's progress notes dated 7/13/26 through 7/30/26 indicated that on 7/13/26 at 7:45 AM, Resident 1 stated he was going to ram his head into the door and wanted to kill himself. Resident 1's progress note, dated 7/13/26, at 4:17 PM, indicated Resident 1 continued to verbalize wanting to kill himself. Resident 1's progress note, dated 7/16/26, at 11:21 AM, indicated that while Resident 1 was on continued 1:1, Resident 1 attempted to pull out his tooth with pliers, and staff found additional pliers in his nightstand. Resident 1's progress note, dated 7/18/26, at 2:25 PM, indicated Resident 1 eloped from the facility, refused to return when found, and verbalized suicidal ideation. Resident 1's progress note, dated 7/19/26, at 6:53 PM, indicated Resident 1 continued 1:1 due to sexual advances, self-harm, danger to others, and attempted elopement. Resident 1's progress note, dated 7/30/26, at 10:02 PM, indicated Resident 1 continued to receive 1:1 when Resident 1's family member (FM) reported to staff that Resident 1 had been hiding a knife in his room and Resident 1 stated he was going to kill himself with the knife and went to his room unsupervised. Resident 1 was later observed bleeding from his neck and continued to make suicidal statements. Police found Resident 1 in his room with the knife in his hand. Resident 1 was disarmed and transferred to the ED for suicidal ideation and acts of self-harm.Review of Resident 1's physician's order dated 7/13/26 at 6:12 PM indicated Resident 1 had an order for a psychiatric visit, re-evaluation, and treatment as indicated.During an interview on 8/11/26 at 3:29 PM with the Clinical Resource (CR), the CR verified that Resident 1 had not been evaluated or treated by a psychiatric provider following the physician's order on 7/13/26. The CR stated that Resident 1 needed to be evaluated by a psychiatrist to manage his suicidal behavior and threats to harm others, which placed Resident 1, other residents, and staff at risk for harm. The CR further stated that there was no plan to seek alternative placement for Resident 1. The CR acknowledged that Resident 1's mental health needs had not been addressed.During an interview on 8/11/26 at 5:12 PM with the Social Services Assistant (SSA), the SSA stated that Resident 1 had not been seen by a psychiatrist since the facility received the physician's order on 7/13/26. The SSA stated that she attempted to arrange an appointment with an outside psychiatric provider but was unable to obtain an immediate appointment and did not attempt to contact other psychiatric providers for an earlier appointment.Review of the facility's P&P titled Behavior Assessment and Monitoring, revised in 12/2025, the P&P indicated .Problematic behavior will be identified and managed appropriately.

Based on interview and record review the facility failed to ensure an allegation of resident-to-resident sexual abuse and the results of the investigation involving the allegation of resident-to-resident sexual abuse were reported to the State Agency (SA - state agency that helps protect the public's health and safety) within the required timeframes, as required, for 1 of 1 sampled resident (Resident 1) reviewed for abuse reporting.This deficient practice had the potential to delay regulatory oversight of the facility's investigation and corrective actions, placing Resident 1 and other residents in the facility at risk for continued abuse or inadequate protection from harm.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of, but not limited to dementia (a condition that causes problems with memory, thinking, and daily activities), muscle weakness, and pain.Review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with a diagnosis of, but not limited to depression (a condition causing persistent sadness and loss of interest), muscle weakness, and pain.During an interview on 7/29/26 at 8:24 AM, with the Certified Nursing Assistant (CNA), the CNA stated that on 7/12/26, between approximately 9:00 AM to 9:30 AM, she received a verbal report from Resident 3 regarding an allegation of sexual abuse involving Resident 1 and Resident 2 that she witnessed. The CNA further stated that after returning from her meal break, from approximately 10:30 AM to 11:00 AM on 7/12/26, she reported the allegation to the licensed nurse in charge.During an interview on 7/28/26 at 2:57 PM, with the Director of Nursing (DON), the DON stated that it was her expectation that any allegation of resident-to-resident sexual abuse be reported immediately, preferably within 2 to 4 hours, to the appropriate authorities, including the Ombudsman (a resident advocate), local law enforcement, and the State Agency. The DON stated that prompt reporting was essential, particularly for allegations of sexual abuse, to ensure Resident 1's safety. The DON further stated that delays in reporting had the potential to compromise Resident 1's safety and may delay the implementation of protective measures and regulatory oversight.During a concurrent interview and record review on 7/28/26 at 3:27 PM, with the Administrator (ADM), the ADM stated that it was his expectation that staff report any allegation of abuse immediately, or within two hours, in accordance with regulatory requirements. The ADM stated that he personally completed and submitted the SOC 341 (a report used to notify the authorities about suspected elder or dependent adult abuse) report. The ADM reviewed the SOC 341 and confirmed that the alleged resident-to-resident sexual abuse incident occurred on 7/12/26. The ADM further confirmed, based on the fax confirmation, that the SOC 341 was submitted to the SA on 7/13/26 at 9:35 AM. During review of the SOC 341, in the section titled, J. WRITTEN REPORT was observed to identify the agencies designated to receive the written report, including the local Police Department, the State Agency, and the Long-Term Care Ombudsman. The fields for Date Mailed and Date Faxed for each receiving agency were left blank, and the form did not document the date the written report was transmitted to those agencies. When asked why the allegation was not reported immediately or within two hours of the facility becoming aware of the incident, the ADM stated, I based it on the SOC 341. The ADM further reviewed the document titled 5-DAY FOLLOW-UP INVESTIGATION REPORT and confirmed that it was completed on 7/16/26. The ADM was unable to provide evidence that the report had been submitted to the SA timely. The ADM provided documentation showing that the Five-Day Follow-Up Investigation Report was submitted to the State Agency on 7/28/26 at 12:37 PM. The ADM acknowledged that timely submission of the Five-Day Follow-Up Investigation Report was a regulatory requirement and stated that it was important to inform the State Agency of the status and findings of the facility's investigation and, most importantly, to help ensure Resident 1's safety. A review of the facility policy and procedure (P&P) titled, ABUSE, NEGLECT, MISTREATMENT AND MISAPPROPRIATION OF RESIDENT PROPERTY, revised 10/23, the P&P indicated, . It is essential for facilities to prohibit and prevent abuse . The facility will have systems in place to encourage and support all residents . in reporting any suspected acts of abuse . exploitation of residents . i.e. sexual abuse . resident to resident . REPORTING AND RESPONSE . It is the policy of this facility that abuse . allegations are reported per Federal and State Law . All alleged violations involving abuse . are reported immediately to the Administrator . All alleged violations of abuse, neglect, exploitation of residents . must also be reported by the facility to officials in accordance with State law, including to the State Survey Agency . Immediately, but no later than 2 hours if the alleged violation involves abuse . Results of all investigations of alleged violations must be reported within 5 working days of the incident .

Based on interview and record review, the facility failed to ensure a thorough investigation was completed of an allegation of resident-to-resident sexual abuse for 1 of 1 sampled resident (Resident 1) reviewed for abuse by failing to timely interview the primary witnesses and promptly gather essential investigative information.This deficient practice had the potential to compromise the integrity of the investigation, delay appropriate corrective actions, and placed residents at risk for further abuse, neglect, exploitation, or mistreatment.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of, but not limited to dementia (a condition that causes problems with memory, thinking, and daily activities), muscle weakness, and pain.Review of Resident 1's clinical record titled, BRIEF INTERVIEW FOR MENTAL STATUS (BIMS - a short test used to check a person's memory and thinking abilities), dated 6/13/26, indicated, . Score: 5 . (0 to 7 points: Severe cognitive impairment, 8 to 12 points: Moderate cognitive impairment, 13 to 15 points: Cognition is intact) Review of Resident 1's clinical record titled, Physician Progress Notes, dated 6/12/26, indicated, . Decision-Making Capacity: Resident not capable of making decisions . The patient is a [AGE] year-old female with a medical history significant for dementia, inability to care for self . Patient required skilled nursing oversight due to impaired cognition, inability to independently manage care needs . ASSESSMENT AND PLAN . Maintain safety measures due to impaired judgment and inability to independently manage care .During a review of Resident 1's clinical record titled, Care Plan Report, dated 7/12/26, in the section titled Focus, indicated, .Risk for emotional distress and impaired sense of safety related to inappropriate physical contact by another resident . Further review of the document indicated, .Trauma from another resident touching private areas and being asked to remove clothing .Review of Resident 1's clinical record titled, Progress Notes (PN), dated 7/12/26, indicated, . This writer was told by a CNA [Certified Nursing Assistant] that a bystander resident witnessed a situation involving 2 other residents. This occurred in the hallway according to the CNA. This writer and the CNA did not witness the incident. The female patient presents with memory issue as baseline . The PN was documented in the clinical record dated 7/12/26 at 12:48 PM.Review of Resident 1's clinical record titled, Progress Notes, dated 7/12/26, indicated, . At approximately 18:25 [6:25 p.m.] hrs [hours], staff reported to me that another resident [Resident 2] had inappropriately touched this resident's [Resident 1] breast . CNA reported that this incident happened in AM shift . The incident was witnessed by another resident [Resident 3], who stated: I saw these two residents standing at the front door of room [ROOM NUMBER]A. The abuser reached out and touched the victim's breast, then asked her to turn to the other side and touched her breast. I also heard him ask her to pull down her pants and sit on my lap. The victim did not act like she heard him and left . Resident stated, Yes, he did touch my breast and I told him don't . Due to baseline cognitive impairment, the resident was unable to recall all details of the incident . Facility Administrator [Name] was notified and acknowledged the incident . Administrator [Name] instructed the undersigned nurse not to complete the Statement of Occurrence (SOC) form, as he would complete the SOC himself and submit/fax the required reports to [Name of Department] and the Long-Term Ombudsman in accordance with facility policy and regulatory requirements . The PN was documented in the clinical record dated 7/12/26 at 21:08 (9:08 PM).Review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with a diagnosis of, but not limited to depression (a condition causing persistent sadness and loss of interest), muscle weakness, and pain.Review of Resident 2's clinical record titled, BRIEF INTERVIEW FOR MENTAL STATUS (BIMS - a short test used to check a person's memory and thinking abilities), dated 5/21/26, indicated, . Score: 13 .Review of Resident 2's clinical record titled, Physician Progress Notes, dated 6/12/26, indicated, . Decision-Making Capacity: Resident is capable of making decisions . The patient is a [AGE] year-old male with a medical history . depression and chronic pain .During a concurrent observation and interview on 7/27/26 at 1:32 PM with Resident 3 in her room. Resident 3 stated that her room was directly across from room [ROOM NUMBER], where she personally witnessed Resident 2 touch the breasts of Resident 1. Resident 3 stated that the behavior was unacceptable because Resident 1 had dementia, while Resident 2 was cognitively intact and, in her opinion, was taking advantage of Resident 1. Resident 3 stated that she immediately reported the incident to the CNA assigned to her that morning and understood that the CNA promptly notified the AM licensed nurse and the Nurse Supervisor. Resident 3 further stated that no one from the facility's leadership interviewed her regarding the allegation. Resident 3 stated that, as the primary witness, she expected someone from the facility to speak with her as part of the investigation.During a telephone interview on 7/29/26 at 8:24 AM with the Certified Nursing Assistant (CNA), the CNA stated that between approximately 10:30 AM and 11:00 AM on 7/12/26, after returning from her 10:00 AM break, she reported to the licensed nurse in charge an allegation she had received from Resident 3. The CNA stated that Resident 3 reported witnessing Resident 2 touching the breasts of Resident 1 between approximately 9:00 AM and 9:30 AM. The CNA stated that she relayed the allegation exactly as it was reported to her. The CNA further stated that no one from the AM shift asked her to provide a written statement regarding the incident or request assistance with implementing protective measures, such as arranging a room change. The CNA stated that prompt intervention was important to prevent the recurrence of the alleged incident and to ensure resident safety. During a concurrent interview and record review on 7/28/26 at 1:20 PM with Licensed Nurse (LN) 3, the electronic medical record (EMR) was reviewed and LN 3 confirmed that she was the licensed nurse who received the CNA's report regarding the alleged resident-to-resident sexual abuse. LN 3 further stated that no one from the facility followed up with her regarding the incident or obtained a statement from her as part of the investigation until 7/28/26, when the Director of Nursing (DON) asked her what had occurred.During a telephone interview on 7/28/26 at 12:27 PM with Licensed Nurse (LN) 2, LN 2 stated that she was the PM Shift Supervisor on 7/12/26. LN 2 confirmed that the PM shift did not receive a handoff report (a shift change report) from the AM shift regarding the allegation of resident-to-resident sexual abuse. LN 2 stated that she first became aware of the allegation when a PM shift CNA informed her of the incident. LN 2 stated that after learning of the allegation, she immediately initiated the facility's abuse response process to ensure resident safety. LN 2 confirmed that the alleged incident occurred during the AM shift and stated that it should have been addressed by the AM shift without delay. LN 2 further stated that delaying the response created unnecessary risks to the residents and that prompt intervention was necessary to prevent additional harm. During an interview on 7/28/26 at 2:57 PM with the Director of Nursing (DON), the DON stated that allegations of sexual abuse should be addressed immediately and investigated promptly to ensure resident safety. The DON stated that it was her expectation that all individuals directly involved in the incident, including the primary witness and staff members who received or responded to the allegation, should be interviewed and have their statements obtained as part of the investigation. The DON further stated that she did interview the licensed nurse assigned to the residents involved and the primary witness on 7/28/26. The DON acknowledged that prompt follow-up and timely reporting were essential to ensure resident safety, preserve the integrity of the investigation, and reduce the risk of a similar incident occurring again if allegations were not addressed appropriately and without delay.During an interview on 7/28/26 at 3:27 PM with the Administrator (ADM), the ADM stated that it was his expectation that staff immediately notify him of any allegation of abuse, provide a summary of what occurred, describe the actions already taken, and collaborate with him to determine if any additional interventions were needed to ensure resident safety. The ADM stated that immediate action was necessary to protect residents from further harm. The ADM stated that it was his expectation that licensed nurses complete the required SOC 341 report and ensure it was submitted immediately, or within two hours when required, to the appropriate authorities. The ADM confirmed that he prepared and submitted the SOC 341 report. The ADM denied instructing any licensed nurse not to complete the SOC 341 and stated that his expectation was for trained nursing staff to prepare and submit the report in accordance with the facility's abuse reporting process. The ADM stated that he led the facility's investigation with assistance from other members of the interdisciplinary team. The ADM acknowledged that interviewing staff and witnesses was essential to obtaining an accurate understanding of the allegation, ensuring a thorough investigation, and protecting residents from further harm.A review of the facility policy and procedure (P&P) titled, ABUSE, NEGLECT, MISTREATMENT AND MISAPPROPRIATION OF RESIDENT PROPERTY, revised 10/23, the P&P indicated, . It is essential for facilities to prohibit and prevent abuse . The facility will have systems in place to encourage and support all residents . in reporting any suspected acts of abuse . exploitation of residents . i.e. sexual abuse . resident to resident . All alleged violations involving abuse . are reported immediately to the Administrator . It is the policy of this facility that reports of abuse . are promptly and thoroughly investigated . The investigation is the process used to try to determine what happened . The designated facility personnel will begin the investigation immediately . A root cause investigation and analysis will be completed . The investigation will include statements from all individuals involved to include . Statement from individual reporting alleged abuse . All involved staff who have or may have witnessed the abuse . A complete and thorough documentation of the entire investigation . The results of the investigation will be documented and attached to the report . Immediately upon receiving a report of alleged abuse . immediately protect the resident, and coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority . Staff witnessing abuse or when reported will immediately intervene . The alleged perpetrator will immediately be removed and resident protected . If the alleged perpetrator is a facility resident, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator and wait for further instruction from the administration .

Based on interview and record review, the facility failed to ensure that a physician-ordered psychiatric evaluation (a mental health checkup by a mental health doctor), identified as an intervention in 1 of 1 sampled residents (Resident 1) care plan (a personalized plan for the person's care and treatment) following a resident-to-resident sexual abuse allegation, was implemented, followed up on, or communicated to the ordering physician when not completed.This deficient practice had the potential to delay Resident 1's psychosocial assessment (a check of a person's emotional and social health), identification of trauma-related needs (support needed after a traumatic experience), and implementation of appropriate intervention following an alleged abuse incident.Findings:Review of Resident 1's clinical record titled, Order Entry, dated 7/14/26, indicated, Ordered by [Name of MD] . Description: May refer resident for psych [psychiatric] evaluation and treatment as indicated .Review of Resident 1's clinical record titled, Progress Notes, dated 7/14/26, indicated, . Received order from MD [Name]/PA [Physician Assistant Name] for Psych visit and evaluation and treatment as indicated. Resident and RP [Responsible Party's Name] informed of order and consented. IDT [interdisciplinary team] notified. Order carried out. Care plan updated .During a review of Resident 1's clinical record titled, Care Plan Report, in the section titled Focus, date initiated 7/13/26, indicated, .Trauma from another resident touching private areas and being asked to remove clothing . Further review of the document under the section titled, Interventions, date initiated 7/14/26, indicated, .May refer resident for psych evaluation and treatment as indicated .During a concurrent interview and record review on 7/27/26 at 3:26 PM with Licensed Nurse (LN) 1, LN 1 reviewed Resident 1's electronic medical record (EMR) and stated that Resident 1 was identified as the alleged victim in a resident-to-resident sexual abuse incident that occurred on 7/12/26. LN 1 reviewed the physician's orders and confirmed that the attending physician ordered a psychiatric evaluation (Psych Visit) on 7/14/26. LN 1 stated that, given the nature of the sexual abuse allegation, she expected the licensed nurses to promptly follow up on the physician's order and arrange the psychiatric evaluation without delay. LN 1 confirmed there was no documentation that any follow-up action had been taken to implement the physician's order, no documentation that the psychiatric provider had been contacted to schedule or perform the evaluation, and no psychiatric consultation note or progress note indicating that Resident 1 had been evaluated. LN 1 further confirmed that the physician-ordered psychiatric evaluation was incorporated into Resident 1's care plan as an intervention. LN 1 stated that it was important for the psychiatric provider to evaluate Resident 1 to assess any psychosocial or emotional impact resulting from the alleged abuse and to recommend appropriate interventions. LN 1 also confirmed there was no documentation that the ordering physician had been notified that the psychiatric evaluation had not been completed or that the physician's order had not been implemented.During an interview on 7/28/26 at 2:35 PM, with the Social Service Assistant (SSA), the SSA confirmed awareness of the physician's order for a psychiatric (Psych) evaluation for Resident 1 following the resident-to-resident sexual abuse allegation. The SSA stated that timely follow-up of the physician's order was essential due to the nature of the alleged abuse and the need to promptly assess Resident 1 for potential emotional or psychosocial trauma. The SSA stated that failure to ensure timely psychiatric evaluation placed Resident 1 at risk for unrecognized psychosocial or emotional effects that may have required further assessment, treatment, or intervention.During an interview on 7/28/26 at 2:57 PM, with the Director of Nursing (DON), the DON stated that it was her expectation that the physician-ordered psychiatric (Psych) evaluation for Resident 1 would be promptly followed up, communicated with the psychiatric provider, and completed without unnecessary delay, particularly in light of the resident-to-resident sexual abuse allegation. The DON stated that if there were barriers to scheduling or completing the psychiatric evaluation, the facility was expected to document the follow-up efforts in the progress notes, notify the attending physician, inform Resident 1's representative or Responsible Party (RP), and communicate the issue to nursing leadership to facilitate timely implementation of the order. The DON acknowledged that the facility failed to ensure implementation of the physician-ordered psychiatric evaluation for Resident 1.A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 1/26, the P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The interdisciplinary team (IDT) . develops and implements a comprehensive, person-centered care plan . The care plan interventions are derived from a thorough analysis of the information gathered . describes the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being, including . any specialized services to be provided . professional services . for each element of care . Services provided for or arranged by the facility as outlined in the comprehensive care plan .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of two sampled residents (Resident 1) when two medications that were used for breathing and eye irritation were not ordered and available for use.This failure caused Resident 1 to not receive medication as ordered by the doctor and had the potential to affect her breathing and vision.Findings:A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, is a long-term lung disease that makes it hard to breathe, usually caused by emphysema and chronic bronchitis), shortness of breath, acute congestive heart failure (a sudden, severe worsening of heart failure where fluid rapidly builds up in the lungs and body), and acute cough.During a review of Resident 1's Order Summary Report, dated 7/24/26, the Order Summary Report, indicated that Anoro Ellipla Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/ACT, (a prescription dry-powder combination inhaler containing umeclidinium [62.5 mcg] and vilanterol [25 mcg] per actuation. It is used as a once-daily maintenance treatment for chronic obstructive pulmonary disease) was ordered for Resident 1 on 10/1/25 with the following directions: .1 puff inhale orally one time a day for COPD .During a review of Resident 1's Order Summary Report, dated 7/24/26, the Order Summary Report, indicated that Polyvinyl Alcohol Ophthalmic Solution 1.4 %, (an over-the-counter artificial tear product used as an ocular lubricant to relieve dry, irritated eyes) was ordered for Resident 1 on 3/16/25 with the following directions: .Instill 1 drop in both eyes every 8 hours for dry, irritated eyes .During a review of Resident 1's Care Plan Report, (a form where you can summarize a person's health conditions, specific care needs, and current treatments) dated 10/1/25, the care plan indicated, .[Resident 1] has SOB [shortness of breath] related to COPD.Anoro Ellipta Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/ACT [Umeclidinium-Vilanterol] 1 puff inhale orally one time a day for COPD.During a concurrent medication pass observation and interview on 7/23/26, at 9:33 AM, with Licensed Nurse (LN) 1, medications were observed being given to Resident 1. LN 1 stated that she did not administer the following medications to Resident 1:Anoro Ellipla Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/ACTPolyvinyl Alcohol Ophthalmic Solution 1.4 %During an interview on 7/23/26, at 9:50 AM, with LN 1, LN 1 stated Resident 1 did not receive her medications as ordered. LN 1 further stated that the facility did not have an electronic method to directly order medications through their computer system. LN 1 further stated that Resident 1's breathing could worsen and her eyes could be impacted by not getting the prescribed medications.During an interview on 7/23/26, at 10:20 AM, with the Nurse Consultant (NC), the NC stated her expectation was for all medications that needed to be administered to the residents should have been readily available for use. The NC further stated the residents would not be at their optimal health by not getting their ordered medications. The NC confirmed that the facility did not have a method to order medications directly through their computer systems.During a review of Resident 1's July Medication Administration Record (MAR), dated 7/23/26, the July MAR, indicated that Anoro Ellipla Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/ACT was not given on 7/23/26 at the ordered timeframe of 9 AM.During a review of Resident 1's July MAR, dated 7/23/26, the July MAR indicated that Polyvinyl Alcohol Ophthalmic Solution 1.4 % was not given on 7/23/26 at the ordered timeframe of 8 AM.During a review of the facility's policy and procedure (P&P) titled, Pharmacy Services Overview, revised 4/26, the P&P indicated, .The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals.Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner .Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration.During a review of the facility's P&P titled, POLICY AND PROCEDURE IN MEDICATION ADMINISTRATION, revised 7/26, the P&P indicated, .Medications shall be administered in accordance with our established policies and procedures.Medications should be administered as MD order.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan related to antibiotic treatment and monitoring for one of three sampled residents (Resident 1) who was readmitted to the facility with a urinary tract infection (UTI).This deficient practice failed to provide staff with clear guidance regarding the resident's antibiotic therapy, monitoring for effectiveness and adverse reactions, infection management, notification requirements, and necessary interventions to address the resident's medical needs, which placed Resident 1 at risk for unresolved infection, worsening condition, complications, and decline. Findings:A review of Resident 1's clinical record titled, admission RECORD, indicated Resident 1 was admitted to the facility with diagnosis of, but not limited to chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it hard to breathe), unspecified cirrhosis of liver (severe scarring and damage of the liver), heart failure (the heart is not pumping blood well), hypertension (high blood pressure), and sepsis (a very serious infection that spreads through the body).During a review of Resident 1's clinical record titled, Order Summary Report, with an order date range from 12/1/25 to 12/31/25, there was a physician's order dated 12/17/25 which indicated, Bactrim DS Oral Tablet [antibiotic - a medicine used to treat bacterial infection] . Give 1 tablet by mouth . for Sepsis .During a review of Resident 1's clinical record titled, [Name of Hospital] HOSPITALIST DISCHARGE SUMMARY, dated 12/17/25, indicated, . admit date : [DATE] . discharge date : [DATE] . DISCHARGE DIAGNOSES: Principal Problem: Sepsis . Active Problems: Cellulitis [a skin infection], UTI [urinary tract infection].During a review of Resident 1s clinical record titled, Order Details, dated 9/7/25, indicated, . Order Summary: Cefpodoxime Proxetil Oral Tablet [antibiotic] . Give 1 tablet by mouth two times a day for UTI w/o [without] hematuria [blood in the urine] related to URINARY TRACT INFECTION .During a review of Resident 1's clinical record titled, [Name of Facility] Physician Progress Notes, dated 9/11/25, indicated, .[Resident 1] was sent out on 9/2/25 for further evaluation due to an elevated temperature. the patient returned to facility on 9/7/25 with a diagnosis of urinary tract infection. The patient [Resident 1] was prescribed antibiotic therapy including Cefpodoxime Proxetil 100 mg [milligram - unit of measurement] orally twice daily for 5 days and Metronidazole [antibiotic] 250 mg orally three times daily for 5 days.During a review of Resident 1's clinical record titled, [Name of Facility] Physician Progress Notes, dated 9/16/25, indicated, . ASSESSMENT: UTI . PLAN: #UTI Cefpodoxime Proxetil 100 mg PO BID x 5 days, Metronidazole 250 mg PO TID x 5 days, medication reviewed .During an interview on 5/8/26 at 9:29 AM with Resident 1, in her room, Resident 1 stated that she had been transferred to the hospital three times related to urinary tract infections (UTIs) that became worse. Resident 1 stated that during her most recent hospitalization, her condition became severe and she became septic at the hospital. Resident 1 further stated that before being transferred, she experienced chills, elevated temperature, and worsening condition, and described that her legs were ripping apart, referring to pain, redness, and skin problems involving her lower extremities. Resident 1 stated that the licensed nurse assessed her condition, checked her symptoms, and contacted the physician regarding the change in condition. Resident 1 stated that after the physician was notified, emergency medical services (911 paramedics) transported her to the hospital for further evaluation and treatment.During an interview with concurrent record review on 5/8/26 at 11:45 AM with Licensed Nurse (LN) 1, LN 1 stated that Resident 1 was admitted to the facility on [DATE] and, based on review of the electronic health record (EHR), Resident 1 had three hospital transfers on 6/21/25, 9/2/25, and 12/8/25. LN 1 reviewed the documentation related to each hospitalization and confirmed that Resident 1 was readmitted to the facility on [DATE] with diagnoses including acute cystitis (a sudden bladder infection); on 9/7/25 with a diagnosis of urinary tract infection (UTI); and on 12/17/25 with diagnoses including sepsis, UTI, and cellulitis. LN 1 further confirmed that antibiotics were ordered by the physician following each readmission. LN 1 stated that it was important for residents with repeated infections and multiple hospitalizations to be properly assessed, monitored, and care planned in order to guide staff regarding the resident's condition, antibiotic treatment, monitoring for effectiveness and adverse reactions, signs and symptoms of worsening infection, hydration needs, physician notification, and interventions necessary to help prevent another rehospitalization or decline in condition.During an interview with concurrent record review on 5/8/26 at 1:10 PM with Licensed Nurse (LN) 2, LN 2 stated that care planning was part of the admission and readmission process every time a resident returned to the facility from the hospital. LN 2 explained that it was important for licensed nurses to review the hospital discharge summary, admission orders, physician documentation, diagnoses, and newly ordered medications, especially antibiotics, in order to determine the resident's current needs and develop an appropriate care plan. LN 2 stated that when a resident had a new diagnosis or was started on antibiotics, the care plan should include the identified focus or problem, measurable goals, and interventions to guide staff regarding monitoring and care. During review of Resident 1's electronic health record (EHR), including hospital discharge reports and physician progress notes related to previous hospitalizations, LN 2 confirmed that Resident 1 received antibiotic treatment following each hospital readmission related to infections. LN 2 further confirmed that the resident's infection-related condition, treatment, and monitoring should have been reflected in the care plan. LN 2 stated that the licensed nurse assigned during the resident's readmission or the Licensed Nurse Supervisor was responsible for initiating or updating the care plan. LN 2 added that the care plan was important because it served as the resident's plan of care and guided all members of the interdisciplinary healthcare team regarding how to properly care for the resident, monitor the resident's response to treatment, recognize changes in condition, and help prevent future infections, complications, or rehospitalization. LN 2 reviewed Resident 1's care plan during the interview and confirmed that there were no care plans addressing Resident 1's September 2025 readmission related to urinary tract infection (UTI) and December 2025 readmission related to sepsis, UTI, and cellulitis. LN 2 confirmed that these conditions, including the physician-ordered antibiotic treatments, monitoring requirements, and interventions related to the resident's recurrent infections and risk for rehospitalization, should have been reflected in the resident's care plan in order to guide staff in providing appropriate care and services.During an interview on 5/8/26 at 3:11 PM with the Infection Preventionist (IP), the IP stated that it was his expectation for licensed nurses to assess residents and update or develop care plans when there were significant changes in condition, including hospital readmissions related to infections. The IP stated that when a resident returned to the facility with diagnoses such as urinary tract infection (UTI), sepsis, cellulitis, and physician-ordered antibiotic treatment, those conditions and related interventions should be reflected in the resident's care plan to guide staff regarding monitoring, treatment, infection management, and prevention of further decline or rehospitalization. The IP reviewed Resident 1's care plan during the interview and confirmed that there were no care plans addressing Resident 1's September 2025 readmission related to UTI and December 2025 readmission related to sepsis, UTI, and cellulitis. The IP further stated that the care plan was important because it guided all staff involved in the resident's care and helped ensure consistent care delivery, resident safety, monitoring of the resident's condition, and prevention of complications or additional hospitalizations.During an interview on 5/8/26 at 3:51 PM with the Director of Nursing (DON), the DON stated that she agreed with the Infection Preventionist (IP) and confirmed that it was also her expectation for a care plan to have been developed or revised following Resident 1's hospital readmissions related to urinary tract infection (UTI), sepsis, and cellulitis. The DON stated that when a resident experienced a significant change in condition, recurrent infections, hospitalization, or newly ordered treatments such as antibiotics, licensed nurses were expected to update the resident's care plan to reflect the resident's current medical condition, goals, monitoring needs, and interventions necessary to guide staff in providing appropriate care and services. The DON added that it was important for all healthcare staff, including licensed nurses and Certified Nursing Assistants (CNAs), to be on the same page regarding the resident's plan of care in order to help ensure consistent care delivery, prevention of further decline or rehospitalization, and most importantly resident safety.A review of a facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised 1/26, indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident . develops and implements a comprehensive, person-centered care plan for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . c. includes the resident's stated goals . and desired outcomes; . 9. Care plan interventions are chosen only after data gathering, . careful consideration of the relationship between the resident's problem areas and their causes, .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was treated with dignity and respect when Resident 2 was observed in bed without a cover over the lower body and was visible from the hallway wearing only an incontinent brief (disposable undergarment designed to absorb urine and stool).This failure had the potential to negatively affect Resident 2's psychosocial well-being (overall emotional and social health).Findings:Review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with diagnoses including congestive heart failure (a condition where the heart does not pump blood well), type 2 diabetes mellitus (high blood sugar), chronic pancreatitis (long-term inflammation of the pancreas), muscle weakness, pain, presence of a cardiac pacemaker (a device that helps control the heart rhythm), stage 3 chronic kidney disease (moderate kidney damage), and a personal history of transient ischemic attack (a temporary blockage of blood flow to the brain) and cerebral infarction (stroke) without residual deficits (no lasting weakness or problems).During a concurrent observation and interview on 4/22/26 at 1:51 PM with Licensed Nurse (LN) 2 and LN 3, upon entering Resident 2's room, Resident 2 was visible from the hallway through the entrance door to Resident 2's room. Resident 2 was in bed sleeping with no lower body clothing or lower body covering, which exposed the incontinent brief that Resident 2 was wearing. LN 2 and LN 3 acknowledged that Resident 2 was visible from the hallway through the entrance door to Resident 2's room without the lower lower body covered. Resident 2's bed was positioned next to a large glass window, and the blinds were raised, which allowed visibility from outside the room. LN 2 and LN 3 acknowledged that if someone stood outside near the window, Resident 2 could have been seen without the lower body covered. LN 2 stated that leaving the resident without the lower body covered was a dignity issue. LN 3 stated that Resident 2 should have been provided with lower body clothing to maintain dignity.Review of Resident 2's Minimum Data Set Assessment (MDS: an assessment tool) dated 2/1/26 in the section titled, Section C - Cognitive Patterns.Brief Interview for Mental Status [BIMS: to check a resident's thinking and memory], indicated that Resident 2 scored 7, which indicated Resident 2 had severely impaired cognition (the mental processes involved in acquiring, processing, and storing knowledge;13 to 15 = Intact, 8 to 12 = Moderate, 0 to 7= Severe).Review of Resident 2's [Facility Name] Documentation Survey Report v2 [version 2] Apr [April] 25, dated 4/1/26 through 4/22/26, in the section titled Dressing, indicated Resident 2 was totally dependent on staff with dressing 9 times in the AM shift, 7 times in the PM shift, and 14 times in the NOC shift, and it included dependence on staff for dressing during the AM shift of 4/22/26.During an interview on 4/22/26 at 1:55 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated that Resident 2 was forgetful and needed help with dressing. CNA 1 further stated it was important to provide Resident 2 with proper clothing to maintain Resident 2's dignity and self-respect. During an interview on 4/22/26 at 3:55 PM with the Director of Nursing (DON), the DON stated that residents were expected to be properly dressed to maintain residents' dignity and privacy.Review of facility's policy and procedure (P&P), titled Resident Rights revised in 1/26, the P&P indicated .Employees shall treat all residents with kindness, respect, and dignity.privacy and confidentiality.Review of facility's P&P, titled Dignity revised in 1/26, the P&P indicated .Each resident shall be cared in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Resident are treated with dignity and respect at all times.encouraged to dress in clothing that they prefer.Staff promote, maintain and protect resident privacy, including bodily privacy.Demeaning practices and standards of car that compromise dignity are prohibited.

Based on observation, interview, and record review, the facility failed to accommodate the needs of one of three sampled residents (Resident 1) when Resident 1 activated the call light (a device used to request assistance) and staff did not respond in a timely manner.This failure placed Resident 1 at risk for unmet care needs, increased risk for accidents or injury, and had the potential to negatively affect Resident 1's psychosocial well-being (overall emotional and social health).Findings:Review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with diagnoses including angina pectoris (chest pain from reduced blood flow to the heart), non-active primary progressive multiple sclerosis (a long-term condition affecting the brain and nerves causing weakness and disability), hypertensive heart disease with heart failure (heart problems caused by high blood pressure, where the heart does not pump well), osteoarthritis (joint pain and stiffness), muscle weakness, muscle spasm, headache, and chronic pain (long-lasting pain).During an observation on 4/22/26 at 1:15 PM in the hallway, the corridor call light above Resident 1's room door was illuminated. Resident 1's room was located approximately halfway down the hallway from the nurse's station, where two staff sat inside the nurse's station.During a concurrent observation and interview on 4/22/26 at 1:27 PM with Resident 1 in Resident 1's room, Resident 1 was in bed with a meal tray containing food that had already been eaten on an overbed table in front of him. Resident 1 stated his lunch was delivered at 12 PM, he finished eating at 12:15 PM, and staff had not yet removed the tray. Resident 1 further stated he activated the call light to request assistance with removing the meal tray and had been waiting approximately 10 minutes prior to the observation.During an observation on 4/22/26 at 1:33 PM in the hallway outside Resident 1's room, the call light above Resident 1's room door remained illuminated. Certified Nursing Assistant (CNA) 1 was in the hallway picking up a meal tray from a room across from Resident 1's room. During an interview on 4/22/26 at 1:38 PM with CNA 1, CNA 1 acknowledged that Resident 1's call light was activated above Resident 1's room door and stated that Resident 1 was not assigned to her care. During a concurrent observation and interview on 4/22/26 at 1:40 PM with CNA 2 in the hallway outside Resident 1's room, CNA 2 walked toward Resident 1's room and confirmed the light above Resident 1's room door was an activated call light. CNA 2 stated her assigned residents were on the opposite side of the hall and Resident 1 was the only resident on that side assigned to her. CNA 1 stated that all staff were expected to respond to call lights in a timely manner, regardless of assignment, and within five minutes. CNA 2 further stated that delays in responding to call lights could pose a safety risk, including falls. CNA 2 then entered Resident 1's room, and the call light was turned off.During a concurrent observation and interview on 4/22/26 at 1:45 PM with Licensed Nurse (LN) 1 at the nurse's station, one other staff member was sitting inside the nurse's station. LN 1 stated that staff were alerted when a resident activated a call light through the alarm system at the nurse's station and the light above the resident's door. LN 1 acknowledged that Resident 1's call light had been activated for more than 25 minutes and was not answered in a timely manner. LN 1 stated that any staff could respond to call lights and were expected to respond within a couple of minutes. LN 1 further stated that if call lights were not answered in a timely manner, resident needs could go unmet and residents could be at risk for injury.During an interview on 4/22/26 at 3:47 PM with the Director of Nursing (DON), the DON stated that staff were expected to respond to resident call lights as soon as possible, within three to five minutes, and that delays could pose safety risks to residents including falls and upset or anxious behavior.Review of facility's policy and procedure (P&P), titled CALL LIGHT/BELL, revised 1/26, the P&P indicated, .Answer the light within a reasonable time (3-5 minutes).

Based on interview and record review, the facility failed to ensure professional standards of care for pharmacy services were met for one of four sampled Residents ( Resident 1) when;Resident 1's anti-anxiety medication order administration times was not followed as written by the physician; andResident 1's medication was administered one hour and forty five minutes after the time it was scheduled.These failures caused Resident 1 psychosocial distress and had the potential to negatively affect her health and well-being.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included anxiety disorder (feelings of worry, anxiousness or fear that interfere with one's daily activities).During an interview on 4/15/26 at 10:45 AM with Resident 1, Resident 1 appeared visibly upset and stated on 4/10/26 the licensed nurse (LN) locked the keys inside the medication cart and could not access Resident 1's lorazepam (antianxiety medication) which was due at 3 PM. Resident 1 further stated she did not receive the medication until two and a half hours later. Resident 1 stated she needed the medication administered at a specific time to control her anxiety level.During a concurrent interview and record review on 4/15/26 at 1:39 PM with the Director of Nurses (DON), the DON confirmed the facility document titled, Medication Admin Audit Report, indicated Resident 1's lorazepam was scheduled to be administered at 3 PM and was not administered until 4:49 PM. The DON stated medications should be administered within 1 hour before or after their scheduled time. The DON further stated it was important to follow the scheduled administration times to ensure the therapeutic effect of the medication.During a review of Resident 1's Medication Administration Record (MAR) dated 4/1/2026-4/30/2026, the MAR indicated, .Lorazepam.Give 1 tablet by mouth every morning and at bedtime for M/B [manifested by] feeling anxious related to ANXIETY DISORDER. The MAR indicated the medication was to be administered at 3 AM and 3 PM.During a telephone interview on 4/16/26 at 11:31 AM with LN 1, LN 1 confirmed Resident 1's lorazepam order and the scheduled administration times did not match. LN 1 further stated the times written on the order should be followed to maintain accuracy. LN 1 stated the medication was scheduled to be administered at 3 PM per Resident 1's request even though the order indicated at bedtime.During a telephone interview on 4/17/26 at 11:41 AM with LN 2, LN 2 stated on 4/10/26 she accidently locked the keys to the medication cart inside the cart. LN 2 confirmed Resident 1's lorazepam was administered late on 4/10/26. LN 2 stated Resident 1 was always upset when she did not receive her medication on time. LN 2 stated the lorazepam was scheduled to be given at 3 PM per Resident 1's request. LN 2 confirmed the lorazepam order indicated the medication was to be given at bedtime and should not be given at 3pm without a physician's order.During a telephone interview on 4/16/26 at 11:28 AM with the Director of Staff Development (DSD), the DSD stated medication orders included the resident's name, date of order, name of the medication, the dose, and frequency of the medication, and the physician's signature. The DSD further stated medications should be administered per the time frame ordered by the physician.A review of a facility policy and procedure (P&P) titled, POLICY AND PROCEDURE IN MEDICATION ADMINISTRATION, dated 1/26 indicated, .Medications shall be administered in accordance with our established policies and procedures.1. Drugs must be administered in accordance with the written orders of the attending physician.3. Medication .must be administered within one hour before or after administration time per M.D. [medical doctor] order.

Based on interview and record review, the facility failed to provide quality care and services as per professional standards of practice for one of four sampled residents (Resident 4), when:1a. Facility staff did not assess, notify physician, and treated Resident 4 when she had abdominal pain and did not have a bowel movement for 3 days from 12/14/25 to 12/16/25, from 12/20/25 to 12/22/25, and for 6 days from 12/30/25 to 1/4/26 and had multiple bowel movements of foul odor,b. Licensed Nurses did not completely assess, address, and notify physician of Resident 4's change in condition of abdominal tenderness, increased weakness, and progressive decline in ADL (Activities of Daily Living) when Resident 4 was no longer able to shower herself on 2/5/26, dress herself on 2/6/26 and transfer herself on 2/7/26,c. Infection Preventionist (IP) did not complete a comprehensive assessment of Resident 4 when she had a change in condition on 2/10/26 with sign and symptoms including diarrhea, being in fetal position holding stomach, and decreased oral intake, and the IP did not inform the physician of Resident 4's entire condition, andd. A Registered Nurse (RN) did not assess Resident 4 when Resident 4 had a change in condition on 2/5/26 and 2/10/26, and Resident 4's weekly summary assessments were not completed on 12/10/25, 12/17/25, 12/24/25, 12/31/25, 1/21/26, 1/28/26, and 2/4/26.These failures resulted in Resident 4 requiring transfer to the hospital for evaluation and treatment of a worsening condition, where subsequent documentation indicated findings including perforated sigmoid colon (a medical emergency where a hole forms in the lower part of the colon, allowing fecal matter and bacteria to leak into the abdominal cavity) requiring surgical intervention and a hospital course complicated by septic shock and Resident 4 died on 2/25/26. Findings:1a. Review of Resident 4's admission Record, indicated Resident 4 had multiple diagnoses including but not limited to constipation, muscle weakness and chronic kidney disease (a condition where the kidneys do not filter blood properly).During an interview on 3/4/26 at 12:59 PM with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 4 frequently complained of abdominal pain, which she reported to the assigned nurse. CNA 2 stated she reported Resident 4's complaints of abdominal pain to the assigned nurse and was told Resident 4 would be given medications. CNA 2 stated that when she re-reported continued complaints of pain, she was told the nurse would follow up with Resident 4 and described the situation as repetitive and not fully addressed by nursing staff. CNA 2 stated that during Resident 4's last week in the facility before hospital transfer, Resident 4 had decreased oral intake, progressing from approximately 80% of meals to minimal intake, with occasional sips of fluids. CNA 2 further stated Resident 4 experienced ongoing gastrointestinal (GI, related to the stomach and intestines) symptoms, including intermittent diarrhea lasting approximately 2-3 days at a time, nausea, and abdominal pain. During an interview on 3/4/26 at 4:37 PM with CNA 4, CNA 4 stated Resident 4 frequently complained of abdominal pain and would point to the mid-abdominal area when reporting discomfort. CNA 4 stated she consistently notified the assigned nurse when Resident 4 complained of pain, as Resident 4 would request pain medication; however, she was not aware of the specific medications administered. CNA 4 stated Resident 4 was typically independent with toileting but observed an increase in bathroom use. CNA 4 stated Resident 4 reported abdominal pain during these episodes and that Resident 4's bowel movements had foul odor. CNA 4 stated she reported these observations to the assigned nurse. During a concurrent interview and record review on 4/15/26 at 1:49PM, Resident 4's Bowel Movement (BM) records titled Follow Up Question Report for the month of December 2025, January 2026, and February 2026 were reviewed with the DON (Director of Nursing). The DON verified record indicated Resident 4 had four BMs on 12/12/25, twice of soft consistency and other two times of dry/hard consistency. The DON verified further record review indicated Resident 4 had no BM for 3 days from 12/14/25 to 12/16/25, had two BMs on 12/17/25, one time of soft consistency, and once of loose/liquid consistency. The DON confirmed further record review indicated Resident 4 had no BM for 3 days from 12/20/25 to 12/22/25 and then had a loose/liquid BM on 12/23/25 and did not have a BM for six days from 12/30/25 to 1/4/26. The DON stated if CNAs would have reported that it was not Resident 4's normal bowel pattern, then they could have applied a bowel regimen (a structured plan using lifestyle adjustments, fiber, and laxatives to prevent or treat constipation, especially for those on pain medication or following surgery) and notify the physician.During a concurrent interview and record review on 4/14/26 at 2:24PM, the DON verified Resident 4's Bowel Movement (BM) records titled Follow Up Question Report for the month of December 2025, January 2026, and February 2026, indicated Resident 4 did not have a recorded BM on 12/3/25, 12/4/25, 12/6/25, 12/7/25, 12/14/25 to 12/16/25, 12/20/25 to 12/22/25, 12/27/25, 12/30/25, 12/31/25, 1/1/26, 1/2/26, 1/3/26, 1/4/26, 1/7/26, 1/8/26, 1/13/26, 1/15/26, 1/16/26, 1/19/26, 1/21/26, 1/22/26, 1/25/26, 1/26/26, and 1/29/26. The DON stated she expected CNAs to notify the Licensed Nurse(LN) when a resident didn't have a BM for 2-3 days, then LN should check with resident, assess for constipation, complete thorough assessment of abdomen including percussion (a diagnostic technique used to assess the size and density of the structures and organs inside of the abdominal cavity, and to detect the presence of air, fluid and masses), listen to bowel sounds to assess if resident really constipated so they could inform the doctor appropriately of resident condition. The DON confirmed there was no documentation in Resident 4's change of condition and progress notes indicating if Resident 4 was assessed, physician was notified or any interventions were taken when Resident 4 did not have a recorded BM for 3 days from 12/14/25 to 12/16/25, from 12/20/25 to 12/22/25, and for 6 days from 12/30/25 to 1/4/26. The DON stated staff should have assessed Resident 4 when she did not have a BM for 2 or more days in December 2025 and January 2026., The DON added staff should have notified the physician and start her on a bowel regimen per physician order. The DON stated Resident 4 did not have a recorded BM on multiple days in December 2025 and January 2026. The DON stated it was important to assess a resident when had no BM for 2 or more days and notify the physician so they could find out if resident was constipated, was not eating or drinking enough, had GI (Gastrointestinal tract) issues. The DON stated untreated constipation could lead to a lot of issues including GI issues, discomfort, reduced appetite, blockage, and infection. The DON added that a lot of elders (individuals aged 65 and older) were needed to be encouraged to hydrate. The DON stated they had standing bowel regimen orders from the physician that physician ordered when notified of a resident's BM issues. The DON verified none of those bowel regimens were implemented for Resident 4. The DON stated foul odor was not a normal characteristic of BM. The DON stated if staff noted a resident had a BM with foul odor, then they should notify the physician. The DON verified Resident 4's BM characteristic records titled Follow Up Question Report for the month of December 2025, January 2026, and February 2026, indicated staff documented Resident 4 had a BM with foul odor twice on 12/1/25, 12/8/25, 12/11/25, 12/12/25 and once on 12/10/25, 12/13/25, 12/18/25, 12/26/25, 12/28/25, 1/6/26, 1/9/26, 1/10/26, 1/11/26, 1/23/26, 1/24/26, 1/28/26, 1/30/26, 2/2/26, 2/5/26, 2/6/26, 2/9/26, 2/10/26, and 2/11/26. The DON stated, It's all foul odor. The DON stated she expected staff to notify the physician if a resident had a BM with foul odor. The DON verified there was no documentation in Resident 4's progress note that the physician was notified of Resident 4's recorded foul odor BM characteristics. The DON confirmed on rest of the days when Resident 4 had a BM, staff recorded BM characteristic as other. The DON stated she did not know what did other mean.During an interview on 3/30/26 at 2:25PM, CNA 5 stated it was not normal for Resident 4 to not have a BM for 3 days, she was very consistent. CNA 5 stated they would record BM characteristics as other when a resident had a BM of other color, had blood in stool or was not normal bowel movement that they needed to report to the nurse right away. During a concurrent interview and record review on 3/30/26 at 10:30 AM, Licensed Nurse (LN) 2 stated Resident 4 experienced multiple days without a BM and did not know if it was normal for Resident 4. LN 2 stated registry CNAs often did not inform nurses when residents had no BMs, causing nurses to miss information like that. LN 2 stated if a resident had no BM for 3 days, then nursing should assess the resident and initiate bowel regimen. LN 2 verified that there was no record that it occurred for Resident 4. LN 2 stated Resident 4 did not have a bowel regimen. LN 2 stated Resident 4 should have been on bowel regimen especially since she was on tramadol (a medication used for pain with possible side effects including constipation).During a concurrent interview and record review on 3/30/26 at 2:59PM, the Infection Preventionist (IP) stated Resident 4 did not have a BM for multiple days in January. The IP stated he would be concerned if a resident did not have a BM for 2 days and staff should offer more fluids, check for constipation and assess for impaction (a severe, solid mass of hardened stool stuck in the rectum due to chronic constipation, preventing normal defecation causing symptoms of severe abdominal cramping, inability to pass stool, and liquid leakage). The IP verified Resident 4 did not have a bowel regimen in place. The IP stated he was surprised that Resident 4 did not have a bowel regimen even though she received tramadol.1b. Review of Resident 4's SBAR (Situation-Background-Assessment-Recommendation: a communication mechanism used as a tool for framing any conversation, especially critical ones such as change in resident's condition, requiring a clinician's immediate attention and action) record dated 2/5/26, indicated, .SITUATION.Resident states I am to [sic] weak to shower by myself now. I need assistance. Lower back and abdominal pain. Resident moving slower.Blood Pressure: 116/48.Functional Status Changes 2a. Decreased mobility 2b. Needs more assistance with ADLs[Activities of Daily Living].Abdominal/GI Evaluation. Abdominal tenderness. APPEARANCE.Resident states she can no longer shower by herself. She is requesting ADL assistance because she feels weaker. She has chronic pain in lower back. Takes PRN[as needed] Tramadol 50mg and Tylenol Arthritis.Resident requesting to see [Physician name] to discuss her health the next time he is here for rounds. Further review indicated physician notified and awaiting for orders. Review of Resident 4's Nurses Progress Note dated 2/5/26 at 9:50 AM, indicated, .Resident states she is unable to shower by herself now and is requesting assistance during her showers. States she feels weaker. Decrease In ADL function. Has Chronic pain. PRN tramadol given at 0740 this morning for 5/10 lower back pain. States she would like to see Dr. [Name] the next time he is here for rounds. Non emergent left for Dr. [Name]. COC [Change of Condition] completed.Review of Resident 4's Nurses Progress Note dated 2/5/26 at 10:19 PM, indicated, .Alert. O[Oriented] x[times] 3. Verbal to needs. Monitored: ADL Decline. Resident insists needs help with Showers. Other ADLs remain unchanged. Resident fully participates.Review of Resident 4's Nurses Progress Note dated 2/6/26 at 4:10AM, indicated, .Monitored for decline in ADL abilities. Resident states/requesting help with showers, assist in getting dressed. Assistance provided by CNA as requested by resident. Further review of this record failed to show the physician was notified of Resident 4's progressed decline in getting dress.Review of Resident 4's Nurses Progress Note dated 2/6/26 at 10AM, indicated, . Resident states she needs help with showers now when she normally is able to take them on her own. She states she needs help getting dressed as well. She feels weaker. Assistance provided by CNA as requested by resident.Review of Resident 4's Nurses Progress Note dated 2/7/26 at 3:12AM, indicated, .monitored for ADL decline. Continues with increased weakness in transfers and need assistance to dress and ADL care. Further review of this record failed to show that Resident 4's progressive decline in ADLs of increased weakness in transfers was escalated to the physician.During a concurrent interview and record review on 3/30/26 at 10:30 AM, LN 2 stated, .non emergent left for MD. COC completed in Resident 4's SBAR dated 2/5/26 referred to placing a written communication in a non-emergent binder at the facility for the physician rather than direct notification. LN 2 stated non-emergent referred to non-urgent requests such as request for over-the-counter medication or routine discussion and not life-threatening situations. LN 2 stated that when a COC was categorized as non-emergent, staff left a written note in a binder at the facility for physician to review during his next on-site visit and did not notify the physician by phone. Resident 4's LATE ENTRY physician progress notes with effective date 2/6/26 at 5:22pm was reviewed with LN 2. LN 2 verified the physician notes indicated the reason for visit was for medical necessity due to medication review and ongoing cardiac and heart failure management. LN 2 confirmed the physician progress notes did not indicate that Resident 4's COC and progressive ADL decline was addressed.During a concurrent phone interview and record review on 4/2/26 at 1:35PM with the Medical Records Director (MRD) and LN 1, the MRD stated they were unable to locate a copy of non-emergent communication note reportedly written by LN 1 regarding Resident 4's COC on 2/5/26. LN 1 explained that a non-emergent communication referred to information staff wished to discuss with the physician that was not considered urgent. LN 1 stated that a decline in residents' ADLs was considered non-emergent. LN 1 stated she did not call the physician when Resident 4 had COC of decline in ADLs, decreased mobility and abdominal tenderness but instead left a non-emergent note in the communication binder. LN 1 stated Resident 4 got weaker and required increased assistance with ADLs. LN 1 stated the physician and Physician Assistant (PA) were aware of the Resident 4's elevated potassium level, and thought that was the cause of Resident 4's weakness. LN 1 verified Resident 4's SBAR dated 2/5/26 indicated a blood pressure of 116/48. LN 1 verified physician was not notified of Resident 4's low diastolic pressure (the bottom number, reflecting pressure when the heart is at rest). LN 1 stated physician should have been notified. LN 1 stated she did not include that information in the communication note and did not associate the low blood pressure with Resident 4's report of weakness. LN 1 stated she continued to consider Resident 4's change in condition non-emergent, as it was related to ADL decline, which staff believed was due to high potassium levels. LN 1 verified the temperature recorded on Resident 4's SBAR dated 2/5/26 was taken on previous day 2/4/26 at 7:48AM, and Respirations listed were from 3 days ago 2/2/26. LN 1 stated a fresh set of vital signs should have been taken when Resident 4 had a change in condition. During a concurrent interview and record review on 4/14/26 at 2:24PM, the DON stated when a resident had a decline in their ADLs such as no longer able to independently shower, dress, or transfer anymore and requested assistance then she expected staff to report the ADL decline to the physician right away. The DON verified Resident 4's SBAR and nurses progress notes from 2/5/26 to 2/7/26 indicated Resident 4 start to decline on 2/5/26 where she could no longer shower herself and started asking for assistant with the showers. The DON stated she believed the nurse notified the physician on 2/5/26 via phone of Resident 4's ADL decline and physician directed her to leave the non-emergent in the binder because nurse documented non-emergent message left for physician. The DON confirmed there was no documentation indicating that nurse spoke with the physician and physician directed her to leave non-emergent message in the binder. The DON stated physician visited Resident 4 on 2/6/26 as per late entry physician progress note for 2/6/26 and verified it did not indicate that Resident 4's change in condition of ADL decline and abdominal tenderness were addressed. The DON stated her expectation was for the nurse to notify the doctor right away on 2/5/26 and not to wait for the doctor to come to the facility next time. The DON verified Resident 4's nurses progress notes indicated on 2/5/26 at 9:50 AM Resident 4 was not able to shower herself anymore and then at 10:19PM it was recorded that she needed help with the showers but other ADLs remained unchanged, then on 2/6/26 at 4:10AM and 10AM it was recorded that Resident 4 was requesting help with showers and needed help with getting dressed as well and then on the 2/7/26 at 3:12AM it was recorded that Resident 4 also had increased weakness in transfers in addition to needing assistance with dressing and ADLs. The DON stated Resident 4 was on 72-hour monitoring after the COC on 2/5/26. The DON stated physician was notified of Resident 4's ADL decline as documented in SBAR on 2/5/26 that non-emergent left for physician. The DON verified SBAR on 2/5/26 indicated decline in showers and moving slower but did not indicate decline in dressing and transfer. The DON stated if a resident was getting worse progressively during the 72-hour monitoring then staff should notify the physician that the resident was getting worse.1c. Review of Resident 4's SBAR dated 2/10/26 indicated, .SITUATION.Resident experiencing diarrhea 2x a day and requested something to stop it.This started on: 02/09/2026.Abdominal/GI Evaluation. Diarrhea.APPEARANCE.Resident laying in fetal position holding stomach asking me if she could get something to help her stop having diarrhea.Review of Resident 4's Nurses progress note date 2/10/26 at 1:28PM, indicated, Resident was experiencing diarrhea 2x during the day and requested something to stop it. MD [Name]Notified. New order of imodium [medication used to stop diarrhea] 2mg tid [three times a day] PRN for 3 days added. Further review of this record failed to show that the physician was notified of Resident 4 being laying in fetal position holding her stomach. During a concurrent interview and record review on 3/30/26 at 2:59 PM, the IP stated he completed Resident 4's SBAR on 2/10/26. The IP stated he informed the physician that Resident 4 was experiencing diarrhea and requested medication to stop it and obtain an order for imodium. The IP stated he did not inform the physician that Resident 4 was in a fetal position holding her abdomen. The IP stated he did not obtain a new set of vital signs and instead added vital signs taken earlier in the morning in the SBAR report. The IP further stated he did not assess Resident 4, did not palpate her abdomen, did not auscultate bowel sounds, and did not assess Resident 4's pain level, which he stated was the reason no pain assessment was documented in the SBAR. The IP stated he did not assess Resident 4 for additional signs or symptoms because Resident 4 was alert and oriented and he relied on her report. The IP stated he received physician's order for Imodium 2mg on 2/10/26 but did not administer the medication. The IP stated he believed he endorsed the information to the oncoming nurse. The IP confirmed imodium was administered to Resident 4 the next day on 2/11/26 at 7:30 AM. The IP further stated that as needed pain medication was not administered or considered on 2/10/26, and no documentation was identified during review that Tramadol or Tylenol was administered at or around the time the SBAR was completed. Resident 4's meal intake record from 2/9/26 to 2/11/26 was reviewed with the IP. The IP verified that on 2/9/26 Resident 4 refused breakfast, consumed approximately 20% of lunch, and had no documented dinner intake, on 2/10/26, Resident 4 refused breakfast, with documentation indicating 100% total by category, which the IP reported was unclear, and Resident 4 refused lunch with no dinner intake documented, and on 2/11/26, Resident 4 refused breakfast. The IP confirmed that review of Resident 4's nurses progress notes for 2/9/26 through 2/11/26 did not include documentation of an assessment related to decreased intake. The IP stated a comprehensive assessment was not completed considering Resident 4's decreased intake, ADL decline, weakness, abdominal pain and diarrhea. The IP added based on Resident 4's presentation her signs and symptoms might have been related to gastrointestinal issues. During a concurrent interview and record review on 4/14/26 at 2:24PM, the DON stated she expected the CNAs to notify the nurse if a resident refused a meal or had decreased intake, then they should report it to the nurse, and the license nurse was expected to assess the resident and notify the doctor. The DON added if it was a single occurrence then staff should encourage the resident, assess their food preferences but if resident kept refusing meals or eating less than normal for multiple days like over 2-3 days then that was already alarming and staff were to report to the physician. The DON stated if a resident was refusing meals or had decreased intake and the nurse did not assess the resident then resident would have poor nutrition and could affect resident's health. 1d. During a concurrent interview and record review on 4/15/26 1:49pm, the DON verified Resident 4's weekly assessments were not completed weekly. The DON verified only one weekly summary assessment was completed for Resident 4 for the month of December 2025 on 12/3/25. The DON confirmed only two weekly summaries were completed for Resident 4 for the month of January 2026 on 1/7/26 and 1/14/26 and there were no weekly summaries completed for Resident 4 for the month of February 2026. The DON stated nurse was expected to complete weekly summary assessments every week on Wednesdays for Resident 4. The DON state a weekly summary assessment should have been completed on 12/10/25, 12/17/25, 12/24/25, 12/31/25, 1/21/26, 1/28/26, and 2/4/26 for Resident 4 and verified those were not completed. The DON stated resident's weekly summaries provided weekly progress of the resident such as how resident was doing, stable, it was one of the ways of monitoring resident as well. The DON stated when weekly summaries were not completed then resident would not be assessed or monitored weekly. The DON stated weekly summary assessment included the assessment of resident's status including weight, skin, mental status, bowels, eating, feeding, dietary, dressing, hygiene, ADLs, medications, fluids. The DON added it was actually comprehensive assessment, continuation of checking of resident's baseline. The DON stated if staff noticed any changes in resident status during weekly summary assessment, then they would complete a COC, notify the physician, and implement interventions accordingly. The DON stated a Registered Nurse (RN) would assess the resident when had a COC. The DON stated Licensed Vocational Nurse (LVN) would observe and monitor the resident and inform RN of collected data and her assessment and then RN would assess the resident. The DON stated RN would sign off on COC assessment with LVN. The DON further stated there were two distinguish roles of these two LNs. The DON verified there was no record indicating RN assessed Resident 4 when she had COC on 2/5/26 and 2/10/26. The DON verified Resident 4's SBAR for COC on 2/5/26 and 2/10/26 was completed by the LVN and not RN. The DON stated an RN should have assessed Resident 4 after COC on 2/5/26 and 2/10/26. The DON stated there would have been different clinical assessment if an RN would have assessed Resident 4 because they had different scope of practice. During a phone interview on 3/4/26 at 2:01 PM with the MD, the MD stated he did not recall being informed of Resident 4 experiencing abdominal pain. The MD stated he believed Resident 4 had loose stools and did not recall reports of significant or unusual abdominal pain from the facility. Review of Resident 4's nurses progress notes dated 2/11/26 at 11:05AM indicated, Resident requesting to go to the hospital for increased weakness/fatigue, nausea, diarrhea. Recent potassium level of 6.6.Resident states she cannot drink the kayexalate [a prescription medication used to treat high blood potassium level] due to it making her nauseous. [MD] office contacted spoke with [MD's] assistant.New order from [MD's assistant] to send resident to the hospital for further evaluation and treatment. Review of Resident 4's nurses progress notes dated 2/11/26 at 11:40AM indicated, Resident left the facility via ambulance. Review of resident 4's hospital record titled HOSPITALIST H&P (History and Physical) dated 2/11/26, indicated, .CHIEF COMPLAINT: Pain abdomen, diarrhea and weakness.Resident 4.presents withabdominal pain, diarrhea and increasing weakness. Patient reports the symptoms started about 3 weeks ago with lower quadrant abdominal pain and diarrhea. Complains of dysuria [painful urination]. Symptoms gradually worsened with increasingly weakness so she came into the ED [Emergency department] for evaluation. Reports she had UTI [urinary tract infection] 3 weeks ago but her provider refused to give her Cipro [an antibiotic medication used to treat infection]. In the ED patient was found to be borderline hypotensive[low BP]. Blood work significant for leukocytosis [abnormally high white blood cell count indicative of infection], elevated CRP[C-reactive protein indicates inflammation in the body, commonly caused by infections], lactic acidosis [a serious, often fatal, medical condition characterized by the overproduction or underutilization of lactic acid], anemia [low blood count], thrombocytosis [high platelet count], metabolic acidosis [a buildup of acid in the body often due to kidney failure, severe dehydration], BUN/ creatinine 76/2.58 [significantly elevated Blood Urea Nitrogen and creatinine ratio]. UA[urinalysis] suggestive of UTI.CT [ Computed Tomography scan] abdomen suggestive of colitis with possible microperforation [a tiny tear in the colon wall- a serious, potentially life-threatening medical condition]. Moderate to large stool in the colon proximal to the area of wall thickening likely due to constipation. surgery consulted. Review of Resident 4's hospital record titled Discharge Summary dated 2/25/26, indicated, .HOSPITALIST EXPIRATION SUMMARY.CAUSES OF DEATH: Perforated sigmoid colon [a medical emergency where a hole develops in the lower part of the colon, allowing fecal matter and bacteria to leak into the abdominal cavity, causes include sever constipation].HOSPITAL COURSE: Patient initially presented with abdominal pain and elevated leukocytosis. CT abdomen and pelvis demonstrated concern for colitis [inflammation of the inner lining of the colon, often causing diarrhea, abdominal pain, fever, and rectal bleeding, causes include infection] with question of pneumatosis [abnormal presence of gas within the bowel wall], ischemic colitis [inflammation of the colon caused by reduced blood flow] not excluded. Patient was seen by surgery and was then status post exploratory laparoscopy with left colon resection [an invasive procedure to remove part of the left/sigmoid colon] and colostomy[a surgical procedure that creates an opening in the abdominal wall, connecting the colon to the outside of the body to allow stool to exit when the rectum or lower bowel is damaged or removed] on February 12th, with findings of perforated sigmoid colon with fecal contamination. She was placed on Levophed drip [a medication used in critical care to rapidly increase blood pressure in patients with severe low blood pressure, shock or cardiac arrest], and taken back to the OR[operation room] onFebruary 15, unfortunately was noted to have necrotic fascia with mucopurulent serosanguineous fluid [a life-threatening, rapidly progressing soft tissue infection that destroys the fascia (connective tissue) and subcutaneous fat, often referred to as flesh-eating disease] at that time. She was successfully extubated on February 16, initiated on peripheral nutrition, however has required Vapotherm [non-invasive ventilator used to treat respiratory distress] since then. Patient passed away on 0321 on 02/25. Review of a facility policy titled Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, revised 1/2026, indicated nursing staff were to assess and document gastrointestinal symptoms, including a .quantitative and qualitative description of diarrhea (how many episodes.amount, consistency, etc). abdominal assessment, and onset, duration, frequency, and severity of signs and symptoms. The policy further indicated staff were to characterize symptoms, including location and nature of abdominal pain, and to monitor the resident's response and progression, including the frequency, severity, and duration of abdominal pain and bowel movements. Review of a policy titled Physician Notification, revised 1/2026, indicated licensed nursing staff were to promptly notify the physician of any significant change in a resident's condition, including changes in physical status such as pain, diarrhea, decreased intake, and abnormal laboratory results. The policy further indicated that if the physician did not respond within a reasonable timeframe, nursing staff were to notify an alternate physician. The policy indicated staff were to document all attempts to notify the physician, including, .date and time of physician notification. brief description of information communicated.and physician response. in the resident's clinical record. Review of a facility policy titled Change of Condition revised 7/2024, indicated, . It is the policy of this facility that all changes in resident condition will be communicated to the physician. PURPOSE To clearly define guidelines for timely notification of a change in resident condition for immediate intervention.Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician.All nursing actions/interventions will be documented in the licensed progress notes as soon as possible after resident needs have been met.All symptoms and unusual signs will be communicated to the physician promptly.Document resident change of condition and response in nursing progress notes, on Twenty-Four Hour Report and update resident Care Plan, as indicated. Review of a facility policy titled Licensed Nurses Notes revised 1/2025, indicated,.A nursing assessment shall be completed for each resident by a licensed nurse and coordinated with the Interdisciplinary Team.Changes in the resident's condition that require a telephone call to the physician shall be recorded by the nurse reporting. The physician shall be notified promptly, as well as the resident and the resident's personal representative or an interested family member (when appropriate), of the following events.Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a resident. All attempts to notify the physician shall be recorded in the resident's health record and shall include: date, time, name of the physician called, resident's condition, name of the person acknowledging contact, and the response to the call. Acute conditions of the resident shall have adequate follow-up notes concerni

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to meet resident needs on the evening shift of 2/21/26 for one of three sampled residents (Resident 2) when two certified nursing assistants (CNA) scheduled for the shift were unavailable, one having called off (CNA 8), and the second (CNA 9) leaving early without returning. No replacement staff were secured, and the facility was unable to produce accurate assignment documentation for the shift.This failure resulted in Resident 2, who was dependent on staff for toileting and always incontinent (no control of bowel and/or bladder), being left in a soiled condition for approximately two hours after activating the call light. This placed Resident 2 at risk for skin breakdown, infection, and loss of dignity. Findings: Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to meet resident needs on the evening shift of 2/21/26 for one of three sampled residents (Resident 2) when two certified nursing assistants (CNA) scheduled for the shift were unavailable, one having called off (CNA 8), and the second (CNA 9) leaving early without returning. No replacement staff were secured, and the facility was unable to produce accurate assignment documentation for the shift.This failure resulted in Resident 2, who was dependent on staff for toileting and always incontinent (no control of bowel and/or bladder), being left in a soiled condition for approximately two hours after activating the call light. This placed Resident 2 at risk for skin breakdown, infection, and loss of dignity.Findings:During a review of Resident 2's admission Record, the record indicated diagnoses including constipation and Ogilvie syndrome (a condition characterized by severe abdominal distention and dilation of the colon). The record also indicated Resident 2 resided in room [ROOM NUMBER]A (Station 1).A review of Resident 2's Brief Interview for Mental Status (BIMS, an assessment tool) dated 12/22/25, indicated a score of 14, reflecting intact cognition (the ability to think, learn, remember, and make decisions necessary to manage daily life without significant impairment).During record review of Resident 2's Minimum Data Set (MDS, an assessment tool), Section GG, the record indicated Resident 2 was coded as .Dependent. for toileting and hygiene. Further review of the MDS, Section H, indicated Resident 2 was .Always incontinent. of bowel.During a concurrent observation and interview on 3/4/26 at 9:56 AM with Resident 2 in Resident 2's room, Resident 2 reported that on the evening shift of 2/21/26, a registry CNA (temporary or day-to-day personnel provided by a placement agency or registry to work in facilities, most commonly in healthcare) assigned to her left early and did not return for the remainder of the shift. Resident 2 was observed to become teary while recounting the event. Resident 2 stated she learned of the registry CNAs early departure from another CNA (CNA 6), who assisted her despite not being assigned to her care. Resident 2 stated she had a medical condition resulting in uncontrollable bowel movements, which she stated can be difficult to manage. Resident 2 stated that after becoming soiled, she activated her call light and waited approximately two hours before receiving assistance.During a review of the facility's NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET, dated 2/21/26, the document indicated that CNA 8 was assigned to group 1 (Rooms 1C-9A); however, the assignment sheet reflected that CNA 8 called in for the evening shift. The document indicated that CNA 9 signed the assignment sheet for Group 2 (Rooms 9B-15B, 24A-25A) for the same date. During an interview on 3/4/26 at 10:17 AM with the Director of Nursing (DON) and the Director of Staff Development (DSD), the DON stated the facility was aware of ongoing staffing challenges. The DON further stated the facility utilized registry staff to address staffing needs and indicated that current staffing practices impacted the delivery of care and required improvement.During an interview on 3/4/26 at 12:02 PM with Licensed Nurse (LN) 2, LN 2 stated she typically responded when Resident 2 activated the call light. LN 2 stated the facility utilized a call light monitoring system at the nurses' station and that staff were also able to identify activated call lights through indicators located above resident room doors. LN 2 stated she had assisted Resident 2 on prior occasions. LN 2 stated that when staff called off and replacement staff were not available, staff work with available personnel and registry staff were utilized to meet staffing needs. LN 2 stated it was not ideal when only registry nursing staff were present, as additional time was required to orient registry staff to resident needs and unit processes. LN 2 further stated she had heard of occasions when only registry nursing staff were present in the facility without regular staff.During an interview on 3/4/26 at 12:59 PM with CNA 2, CNA 2 stated that when regular staff were not present, registry staff provided care, and she had observed differences in the consistency of care provided. CNA 2 stated that upon returning to work, she needed to address resident care needs that were not completed during prior shifts by registry CNAs. CNA 2 further stated that the registry staff might be less familiar with resident-specific care needs due to the temporary nature of their assignments.During an interview on 3/4/26 at 1:47 PM with the DSD, the DSD stated the facility had been transitioning away from allowing regular staff to work overtime, resulting in increased reliance on registry staff to meet staffing needs. The DSD stated CNAs and licensed nursing staff were frequently obtained through registry agencies. The DSD stated it was difficult to replace staff when call-offs occurred and that registry staff were utilized to fill vacancies. The DSD stated residents preferred care from regular staff due to familiarity and continuity. The DSD stated efforts were made to maintain sufficient staffing levels across shifts, however, when staff called off or were unable to complete full shifts, staffing levels might be reduced. During an interview on 3/4/26 at 2:24 PM with CNA 6, CNA 6 stated that on the evening of 2/21/26, she observed that call lights were not consistently answered and became aware of multiple unanswered call lights at times. CNA 6 stated that while walking down the hallway, she observed an activated call light for Resident 2 and responded, even though Resident 2 was not assigned to her. CNA 6 stated she found Resident 2 crying and in a soiled condition and she reported she had been waiting approximately two hours for assistance. CNA 6 stated Resident 2's skin appeared red when she changed her brief (adult underwear used for a lack of control of bowel and bladder).During a concurrent interview and record review on 3/4/26 at 4:47 PM with the Infection Preventionist (IP), the IP reviewed the NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET and confirmed that CNA 8 called in on 2/21/26, as documented. The IP stated that during staff shortages, CNAs might divide resident assignments among themselves to provide coverage.During a concurrent interview and record review on 3/4/26 at 4:54 PM with the DSD, the DSD stated that based on her recollection, CNA 9 left the facility early during that shift, resulting in reduced staffing on the unit. The DSD stated CNA 9 was a registry staff member obtained through an external staffing agency. During a concurrent phone interview and record review on 3/25/26 at 1:19 PM with the DON and DSD, the DSD stated the facility did not have documentation reflecting CNA staff assignments for Groups 1 & 2 after two of the scheduled staff were unavailable on 2/21/26. The DSD stated that when scheduled staff called in or left early, the facility process was to reassign residents by regrouping CNA assignments, which might be completed by the DSD or delegated to available staff, including in-house CNAs. The DSD stated that the nurse supervisor or floor nurse would have been responsible for staff assignment during that shift. The DSD stated she was responsible for coordinating staffing needs, including contacting staff and registry agencies when call-ins occurred, and stated communication might occur through group messaging for urgent staffing requests. During a concurrent interview and record review on 3/30/26 at 8:40 AM with the Human Resources/Maintenance Director (MAT), the MAT reviewed the NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET, and confirmed that CNA 8, from a registry agency, called in on 2/21/26 for the evening shift and stated a replacement staff member for CNA 8 was not identified. The MAT similarly confirmed that CNA 9, also from a registry agency, signed the NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET, on 2/21/26; however, CNA 9 left the facility early, and did not clock in or out, and a replacement staff member for CNA 9 was also not identified. The MAT confirmed documentation did not reflect CNA assignments for group 1 (rooms 1C-9A) and group 2 (rooms 9B-15B and 24A-25A) for the evening shift of 2/21/26, and there was no additional documentation reflecting staff regrouping to care for the residents in group 1 and group 2 after scheduled staff were unavailable. During a review of the facility policy titled Staffing, Sufficient and Competent Nursing, revised on 1/2026, the policy indicated the facility .provides sufficient numbers of nursing staff with he appropriate skills and competency necessary to provided nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. the policy further indicated that licensed nurses and certified nursing assistants are available .24 hours a day, seven (7) days a week to provide competent resident care services. including .responding to resident needs. and .assuring resident safety. The policy also stated that .staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment. and that staffing considerations include resident conditions, limitations and acuity.During a review of the facility's policy titled CALL LIGHT/BELL revised on 1/2026, the policy indicated the facility provides residents .a means of communication with nursing staff. the policy further indicated staff to .answer the call light within a reasonable time (3 - 5 minutes). and to .respond to the request.During a review of an undated facility's policy and procedure titled Registry / Agency Staff Utilization Policy, the policy indicated the facility ensures registry or agency personnel .utilized to supplement staffing meet federal, state, and facility regulatory requirements, possess appropriate qualifications, and adhere to the facility's standards of care, policies, and procedures. The policy further indicated that .registry personnel shall be used when necessary to maintain safe staffing levels and resident care standards. and that registry staff receive .orientation, supervision, and performance monitoring while working at the facility. The polity also indicated registry personnel must .follow all facility clinical protocols and documentation requirements. and are accountable for .accurate documentation.During a review of the facility's policy titled Resident Rights, revised on 1/2026, the policy indicated employees shall treat residents .with kindness, respect, and dignity. the policy further indicated residents have the right to .a dignified existence. and to .be treated with respect, kindness and dignity.

Based on observation, interview, and record review, the facility failed to ensure that foods available were consistent with the physician-ordered diet for 1 of 1 sampled resident (Resident 1) who was prescribed a pureed diet (food that is blended until smooth, like mashed potatoes), mildly thick liquids (nectar-thick liquids - drinks that are slightly thicker than water to make swallowing safer) and a consistent carbohydrate (CCHO - a meal plan where the amount of carbohydrates is kept about the same at each meal) diet when a jar of peanut butter and jelly was available for consumption at Resident 1's bedside.This failure placed Resident 1 at risk for choking (when something blocks the airway and makes it hard or impossible to breathe), and aspiration (when food, liquid, or saliva goes into the lungs instead of the stomach), which could lead to serious complications such as airway obstruction, aspiration pneumonia (a lung infection caused by food, liquid, or saliva going into the lungs), or respiratory distress (difficulty breathing or not getting enough air).Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses of, but not limited to diabetes mellitus (a condition where the body cannot control blood sugar levels), anemia (a condition where the body does not have enough healthy red blood cells), atrial fibrillation (an irregular and often fast heartbeat), acute respiratory failure with hypoxia (a sudden and serious problem where the lungs cannot get enough oxygen into the blood), and chronic kidney disease (long term damage to the kidneys that makes them not work properly).A review of Resident 1's physician orders showed that Resident 1 was prescribed a pureed diet with mildly thick liquids and a consistent carbohydrate (CCHO) diet on 9/21/25.During a concurrent observation and interview on 3/4/26, at 10:18 AM, in Resident 1's room, a jar of Smucker's Goober Strawberry Peanut Butter & Jelly Stripes was observed on Resident 1's bedside table within reach. Resident 1 stated that he did not like the food served at the facility and confirmed that he had difficulty swallowing. Resident 1 stated that his wife usually brought white bread and a jar of peanut butter and jelly when she visited. Resident 1 stated that he sometimes ate the peanut butter and jelly directly from the jar without the bread. Resident 1 stated that he could grab the jar, open it, and eat it directly from the container. Resident 1 stated that he had been eating peanut butter and jelly this way since last year. Resident 1 stated that no one told him that eating peanut butter and jelly in this manner could be unsafe, despite his swallowing problem. Resident 1 also stated that he could not remember being evaluated by a speech therapist (ST - a healthcare professional who helps people with speaking, understanding, and swallowing) recently and reported that no one had recently checked his swallowing ability.During a concurrent observation and interview on 3/4/26, at 10:54 AM, with the Licensed Nurse (LN), the LN confirmed that a jar of peanut butter and jelly was present at Resident 1's bedside. The LN stated that Resident 1 was on a pureed diet with nectar-thick liquids. The LN stated that Resident 1 was sometimes non-compliant with his prescribed diet. The LN also stated that she had seen the resident eating peanut butter and jelly and did not observe any immediate problem but acknowledged that she was not sure whether it was safe for the resident to eat it. The LN confirmed that Resident 1 was on aspiration precautions due to swallowing problems. The LN also confirmed that safe swallowing precautions (safety steps to prevent food or liquid from going into the lungs) were posted at the head of the resident's bed.During an interview on 3/4/26, at 12:51 PM, with the Certified Nursing Assistant (CNA), the CNA stated that Resident 1 did not like the pureed food served by the facility, although staff still provided the resident's meal tray according to his prescribed diet. The CNA stated that she had seen Resident 1 eating peanut butter and jelly as a snack and had observed the jar of peanut butter and jelly at the resident's bedside. The CNA stated that she was not sure who brought the peanut butter and jelly to the resident. The CNA stated that she was aware that Resident 1 was sometimes non-compliant with his prescribed diet, but she was not aware of the resident's swallowing precautions. The CNA also stated that she did not know that peanut butter and jelly could be unsafe for the resident to eat due to his swallowing difficulty.During a concurrent interview and record review on 3/4/26, at 2:19 PM, with the Certified Dietary Manager (CDM), the CDM reviewed Resident 1's electronic health record (EHR) and stated that Resident 1 was on a CCHO diabetic dysphagia (difficulty swallowing) diet with pureed texture and nectar-thick liquids. The CDM stated that she was aware that Resident 1 did not like the pureed diet, and dietary staff had tried to offer substitutes, such as pureed soup, to encourage the resident to eat. The CDM stated that she was not aware that Resident 1 had been eating peanut butter and jelly. The CDM stated that peanut butter and jelly did not meet the resident's physician-ordered diet. The CDM explained that the peanut butter and jelly texture was thicker than nectar consistency and was not appropriate for Resident 1's swallowing diet. The CDM stated that she had two concerns: the food texture and the sugar content, noting that the peanut butter and jelly was not safe for the resident's swallowing condition and was not appropriate nutritionally for a resident on a CCHO diet. The CDM stated that a speech therapist should assess Resident 1 to determine if the peanut butter and jelly was safe to eat.During an interview on 3/4/26, at 3:20 PM, with the Director of Staff Development (DSD), the DSD stated that if Resident 1 was on pureed diet with nectar-thick liquids and the family brought peanut butter and jelly, staff should have followed the facility's Stop and Watch (a simple way for staff to notice and report early changes in a resident's condition) process. The DSD stated the CNAs should have reported the concern to the licensed nurse. The LN should have spoken with Resident 1 and assessed the resident's swallowing and safety. The DSD stated that staff should have notified the physician, documented the situation in the progress notes, and updated the care plan if needed. The DSD explained that these steps were important because Resident 1 had a risk for choking and aspiration due to swallowing problems. The DSD also stated that peanut butter and jelly could affect the resident's blood sugar because the resident had diabetes. The DSD stated that following these steps would help protect Resident 1's safety and could help prevent complications that might lead to hospitalization.During an interview on 3/4/26, at 3:59 PM, with the Director of Nursing (DON), the DON stated that she expected staff to follow the proper process when a resident did not follow the physician-prescribed diet. The DON stated that if Resident 1 was not following the ordered diet, the LN should complete an SBAR (a structured communication used to report a situation) and notify the physician and the resident's responsible party. The DON also stated that the IDT should review and discuss the situation with the resident and the resident's family or responsible party. The DON stated that the care plan should clearly address the issue, including the resident's use of peanut butter and jelly, to ensure the resident's safety and proper dietary management.During an interview on 3/5/26 at 11:07 AM with Resident 1's significant other (SO), the SO confirmed that she was the one bringing the peanut butter and jelly for the resident. The SO stated that she started bringing it about three months ago. The SO stated that if she did not bring the peanut butter and jelly, Resident 1 would not eat and would be starving. The SO explained that Resident 1 was a picky eater. The SO also stated that staff told her she could bring any food she wanted for the resident. The SO stated that she only wanted Resident 1 to eat something, and that peanut butter and jelly was what he wanted. The SO stated that she was aware that there could be safety concerns, but explained that she had continued bringing the peanut butter and jelly because he liked it and had been eating it for some time.During an interview on 3/5/26, at 2:42 PM, with the ST, the ST stated that she had not evaluated Resident 1 for quite some time. The ST stated that she was not aware that Resident 1 had been eating peanut butter and jelly directly from the jar without bread. The ST stated that no staff had shared this information with her. The ST stated that she had never tested or evaluated Resident 1's ability to safely swallow peanut butter and jelly. The ST explained that peanut butter requires caution for residents with swallowing problems because it can be thick and sticky. The ST stated that when family members bring food from outside, they should show the food to the licensed nurse first. The ST explained that nurses usually notify her in these situations, and they could contact her directly or report it to the Director of Rehabilitation so the issue could be reviewed. The ST stated that this process was important to help ensure the resident's safety. The ST stated that staff should have brought this situation to her attention. The ST also stated that if she had known that the family was bringing peanut butter and jelly, she would have contacted the family to discuss the situation. The ST explained that this would have been a good opportunity to educate the family about which foods were safe and which foods were not safe for the resident's swallowing condition. Review of an undated facility policy and procedure titled, [Name of facility] - Resident Food Preferences, indicated, POLICY: It is the policy of this facility that nutritional assessments will include an evaluation of individual food preferences. PROCEDURES: . The dietitian will discuss resident food preferences with the resident [Resident 1] when such preferences conflict with a prescribed diet. The clinical dietitian and nursing staff, assisted by the physician, will identify any nutritional issues or dietary restrictions that might affect the facility's efforts to accommodate resident [Resident 1] preferences. In conjunction with the physician, the dietitian or nursing staff will document reasons why restrictions are necessary and/or why the facility cannot accommodate resident [Resident 1] preferences.

Based on interview and record review, the facility failed to provide quality of care (each resident must receive the necessary care and services to attain or maintain the highest practicable physical well-being) in accordance with professional standards of practice for one of three sampled residents (Resident 1) when,1.The facility staff did not implement in a timely manner the Wound (tissue injury) Doctor's (WD) verbal recommendation on [DATE] to transfer Resident 1 to an acute care hospital for a higher level of care to treat a worsening venous ulcer wound (shallow, slow-healing, or chronic [long term] wounds) on Resident 1's right leg and/or initiate in a timely manner a verbal order on [DATE] from the Medical Director (MD) to arrange a consultation with a vascular surgeon (a highly trained specialist who diagnoses and manages diseases affecting arteries and veins); the expectation of the WD was the recommendation would have been initiated on [DATE] and the MD's expectation was that the verbal order would be initiated within 24 hours.2.The facility did not monitor Resident 1's vital signs and pain level score from [DATE] through [DATE], every shift for 72 hours, after a deterioration of Resident 1's right leg venous ulcer wound was identified on [DATE] (numerical pain scale 0-10; 0=no pain, 1 through 4 [mild pain], 5 through 6 [moderate pain], 7 through 10 [severe pain]). 3. The facility did not provide wound treatment for Resident 1's right leg venous ulcer as directed by the physician.The cumulative effects of these failures have resulted in Resident 1 experiencing poor quality of care (medical care that falls below the reasonable level of competence) and a delay in a higher level of care from [DATE] through [DATE] (6 days) and resulted in Resident 1's death on [DATE] due to cardio-pulmonary arrest (heart and lungs stop working), septic shock (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection), and necrotizing fasciitis of the right leg (a serious infection that kills the body's tissue).Vital signs - measurement of the body's most basic functions such as body temperature, heart rate per minute, respiration rate per minute, and blood pressure.Findings:A review of Resident 1's clinical record titled, admission Record, (a document that contains the resident's demographic information) indicated Resident 1 was admitted to the facility on [DATE] and Resident 1's diagnosis included a non-pressure chronic ulcer of the right lower leg, cellulitis (potentially serious bacterial skin infection), and type 2 diabetes (the body cannot regulate blood sugar and places the resident at a higher risk for infection). The record further indicated Resident 1 did not have the capacity to make her own decisions and had a Responsible Party ([RP]- usually a family member who assists with decision making when a resident cannot make decisions for oneself]). The record indicated Resident 1's code status was full code (the resident requests that all lifesaving measures be implemented in the case of extreme illness).A review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool), dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status score of 4 reflecting severe cognition impairment.(BIMS - 0 through 15-point standardized assessment used to evaluate cognitive function; 0 through 15 = [intact cognition], 8 through 12 [moderate impairment], and 0 through 4 [severe impairment]).A review of Resident 1's clinical record titled, Order Summary, dated [DATE], indicated, Wound evaluation and treatment by [Wound Care Company Name]. The order did not indicate the frequency of the evaluation.A review of Resident 1's clinical record titled, Weekly Skin Integrity Assessment for Non-Pressure Sore, date of observation was [DATE], signed by the WN on [DATE], indicated, . right lower leg (front), Venous Ulcer - Wound is larger with significant drainage [fluid leaks out of the wound]; measures about 15cm [centimeters, unit of measurement (L=length)] x [by] 5cm [W=width] x 0.4cm [D=depth] post debridement [the medical removal of dead tissue to promote the growth a healthy tissue]. Wound bed [surface of the wound] 50% [percent, amount for every hundred] S [Slough (a yellow, tan, or white, stringy layer of dead tissue)], 50% G [granulation tissue, new vascular tissue - healing surface of the wound], significant drainage, no odor, no s/sx [signs and symptoms] of infection. wound showing improvement . The clinical record does not describe the type of drainage.A review of Resident 1's clinical record titled, Weekly Skin Integrity Assessment for Non-Pressure Sore, date of observation was [DATE], signed by the WN on [DATE], indicated, .Right lower leg (front) Venous Ulcer - wound shows slow improvement and appears healthier; measures about 15cm[L] x5cm[W] x 0.4cm[D] post debridement. Wound bed 30% S,70% G, significant drainage, no odor, no s/sx of infection. wound showing improvement. The clinical record does not describe the type of drainage.A review of Resident 1's clinical record titled, Weekly Skin Integrity Assessment for Non-Pressure Sore, date of observation was [DATE], signed by the WN on [DATE], indicated, . Right lower leg (front) Venous Ulcer - wound is worse. measures [sic] about 15cm[L]x 5cm[W] x 0.4cm[D] post debridement. 100% slough/necrotic [dead, non-viable tissue resulting in lack of blood flow and/or infection] tissue. heavy [sic], drainage, no odor, no s/sx of infection. WOUND MD recommends hospital admission for operative debridement above and below leg amputation [the surgical removal of a limb (arms) or extremity (legs)] . The clinical record does not describe the type of drainage.During an interview on [DATE] at 12:47 PM with the WN, the WN stated as a Registered Nurse (RN) and Wound Care Nurse, her job duties included weekly rounds (a structured process where a medical team [doctors and nurses] assesses the residents' condition, care plans [a document that indicates the resident's problems, goals, and interventions] are updated on the day the condition or event occurred, and the team coordinates their care with other providers) with the Wound Doctor (WD). The WN stated before rounds, the WN updated the WD with any changes to Resident 1's wound. The WN stated after rounds were conducted with the WD, the facility process included the WN updated the Medical Director (MD - Resident 1's primary doctor) about Resident 1's current health status. The WN stated if the WD suggested a new treatment or provided recommendations, the facility process included the WN carried out the order (to execute, fulfill, or perform a command, instruction, or task) given by the WD.During a follow-up concurrent interview and record review on [DATE] at 12:53 PM with the WN, Resident 1's clinical record titled, Progress Notes, dated [DATE], by the WN, was reviewed for the condition of Resident 1's right lower leg wound. The WN stated although Resident 1's Progress Note was entered on [DATE], it was written to reflect the rounds made by the WD and the WN on [DATE]. The Progress Notes, dated [DATE], indicated, Resident was seen and evaluated by [Wound Care Company Name] MD [Medical Doctor, here refer to the WD] for R [right] lower leg ulcer this week. Wound is Worsening. Wound has 100% slough/necrotic tissue .Wound has heavy drainage.Noted resident in excruciating pain.Pain medication was given prior.Resident still appears in very much pain. Wound MD recommends hospital admission for operative debridement above and below R leg amputation . The WN stated the WD assessed Resident 1's wound on [DATE] and recommended Resident 1 to be admitted to the hospital for an operative debridement because her wound was getting worse. The WN stated the Progress Note, dated [DATE] was a note that should have been documented on [DATE]. The WN stated she had not added the phrase, late entry note, because she did not want the documentation to be flagged as a late entry.During an interview on [DATE] at 12:48 PM with the WD, the WD stated he treated Resident 1's right lower leg wound once a week, and he noticed there was little to no improvement, and eventually the wound worsened. The WD stated he spoke with the MD and the WN on [DATE] and the WD informed the MD that the bedside treatment (wound care) was not effective, Resident 1 was getting worse, and needed to go to the hospital to have a surgical wound debridement or amputation of the right leg. The WD stated he expressed urgency and serious concern for Resident 1 with the MD and the MD stated he agreed with his recommendation and (MD) would take care of it and he (MD) walked into Resident 1's room. The WD stated after he spoke with the MD and the WN about his concerns he expected Resident 1 would be transferred to the hospital no later than the end of that day on [DATE]. The WD stated he knew if Resident 1 was not sent out to the hospital for a higher level of care, she would develop sepsis.A review of Resident 1's clinical record titled, Care Plan Report, for Resident 1's skin integrity, initiated on [DATE], indicated, . Recommends hospital admission for operative debridement above/lower leg amputation.During an interview on [DATE] at 3:46 PM with the MD, the MD stated on [DATE] the WD notified him of the serious concern he had for the condition of Resident 1's right lower leg venous stasis ulcer (a shallow, slow-healing open sore that develops from long term insufficient blood supply). The MD stated the WD informed him Resident 1's wound was not healing and that he was concerned that the right lower leg might need to be amputated. The MD stated the WD relayed to him that Resident 1's wound had significant vascular compromise, (lack of blood flow) Resident 1 needed to be seen by a vascular surgeon and required hospitalization. The MD stated after speaking with the WD, he (MD) gave a verbal order to the WN on [DATE] for Resident 1 to be seen by a vascular surgeon. The MD stated after he gave the verbal order to the WN he expected that order to be carried out no later than the following day ([DATE]). A review of Resident 1's clinical record titled, Order Summary Report, indicated, . refer to Vascular Surgeon for worsening R [right] lower leg venous ulcer . was entered into Resident 1's clinical record on [DATE].During a telephone interview on [DATE] at 12:20 PM with the RP, the RP stated Resident 1's baseline level was Resident 1 was aware of her surroundings, communicated, and recognized the family upon arrival. The RP stated on [DATE] he noticed Resident 1 was a little more confused than usual and within the week Resident 1's cognition quickly declined. The RP stated when the family visited Resident 1 on [DATE], Resident 1 could not identify the family. The RP stated he never refused to send Resident 1 to the hospital or complained about cost.A review of Resident 1's clinical record titled, Progress Notes, dated [DATE] at 9:50 AM, by the WN indicated, . 79/42 [blood pressure, low],100 [Oxygen saturation percentage, normal], 30 [respirations per minute, high] .99.6 [temperature, high] Resident not responding per baseline [Resident 1's normal status]. Nonverbal to questions. Refused medications. Refused breakfast. Not taking in any fluids. Facial grimacing with moaning. Refused pain medication.A review of Resident 1's clinical record titled, Care Plan Report, dated [DATE], indicated, .Send to [Hospital] for evaluation and treatment. Resident will transfer via emergency services .During a review of Resident 1's [Hospital] record titled, Discharge Summary, dated [DATE] through [DATE], indicated Resident 1 presented to the Emergency Department (ED) on [DATE] at 10:18 AM with confusion, increased heart rate, and low blood pressure due to septic shock related to cellulitis of the right lower extremity. Resident 1's [NAME] Blood Cell Count (WBC-high count indicates infection) was 25 (high, normal range 5-10), lactic acidosis (high production of lactic acid in the blood indicates sepsis, normal range 0.5 to 1.0) was 2.7. A Computed Tomography (CT- diagnostic test) indicated a large soft tissue defect (a significant loss or injury of skin, fat, muscle, or tendon, that cannot be closed simply) on the lateral (side) of the leg with an underlying fluid collection that opened to the skin's surface and extended to the lateral ankle and forefoot (front of the foot) muscles. Resident 1 was admitted to the Intensive Care Unit (ICU- specialized department in the hospital for critically ill patients) and required vasopressor medications (medications to increase blood pressure and sustain life). Resident 1's blood culture (a laboratory test to detect bacteria in the blood) results were positive for multiple bacteria. On [DATE], Resident 1 was placed on comfort measures only (physician orders to keep the resident comfortable through medications and treatments, but no life saving measures are preformed). Resident 1 died on [DATE] related to cardio-pulmonary arrest, septic shock, and necrotizing fasciitis.A review of the facility's Job Description titled, Treatment Nurse, dated 2/2020, indicated, .As Treatment Nurse (LVN [Licensed Vocational Nurse] or RN [Registered Nurse]) you would be responsible for . implementing orders and treatments, . The Treatment Nurse . participates in weekly wound team rounds, documents status, insures [sic] notification of physician and family of changes. which will ensure that patient's needs are met in accordance with professional standards of practice through physician orders, center policies and procedures, and federal, state and local guidelines. Major Duties. Initiate requests for consultation or referral. Respond to requests from the resident, physician, or nursing staff.During a concurrent interview and record review on [DATE] at 4:02 PM with the Director of Nurse (DON), the facility's Policy and Procedure (P&P) titled, Medication and Treatment Orders, dated 1/2025, was reviewed. The P&P indicated, . Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last, credentials, the date and the time of the order. The DON stated the WN did not follow this policy because the verbal order that was given by the MD for the vascular surgeon consultation on [DATE] was written on [DATE] (the vascular surgeon consultation was not carried out before Resident 1's transfer to the hospital on [DATE]).2.During an interview on [DATE] at 12:47 PM with the Wound Nurse (WN), the WN stated the job duties of the WN included weekly rounds with the Wound Doctor (WD). The WN stated if there was a change in condition (COC- an acute change in health status which warrants a formal, documented review of the plan of care) with any of the residents, the WN contacted the MD to obtain an order for treatment, if needed.A review of Resident 1's clinical record titled, Weekly Skin Integrity Assessment for Non-Pressure Sore, observation date [DATE], signed by the WN on [DATE], indicated, . Right lower leg (front) Venous Ulcer - wound is worse. measures [sic] about 15cm [L] x5cm [W] x0.4cm [D] post debridement. 100% slough/necrotic tissue. Heavy drainage, no odor, no s/sx of infection. WOUND MD recommends hospital admission for operative debridement above and below leg amputation .During a follow-up concurrent interview and record review on [DATE] at 12:47 PM with the WN, Resident 1's clinical record titled, Progress Notes, dated [DATE], by the WN, was reviewed for the condition of Resident 1's right lower leg venous wound; and Resident 1's Progress Notes, dated [DATE], [DATE], [DATE], and [DATE], were reviewed for the documentation of vital signs and pain level. The WN stated although Resident 1's Progress Note was entered on [DATE], it was written to reflect the rounds made by the WD and the WN on [DATE]. The Progress Notes, dated [DATE] indicated, Resident was seen and evaluated by [Wound Care Company Name] MD [Medical Doctor, in this case the MD was the WD] for R [right] lower leg ulcer this week. Wound is Worsening. Wound has 100% slough/necrotic tissue .Wound has heavy drainage.Noted resident in excruciating pain.Pain medication was given prior. Wound MD [WD] recommends hospital admission for operative debridement above and below R leg amputation . The WN stated on [DATE] Resident 1 had a COC and should have been monitored for this change starting on [DATE]. The WN stated the facility's process for monitoring a COC included obtaining and documenting the affected Resident's vital signs and pain level every shift (a designated work period [duty hours] within a 24-hour cycle, commonly structured as 8, 10, or 12 hours) for 72 hours. The WN reviewed and verified that on [DATE], [DATE], [DATE], and [DATE] there were no progress notes that indicated Resident 1's pain level and the vital signs were monitored each shift. The WN stated this failure placed Resident 1 at risk for further decline in her health status and increased pain.A review of Resident 1's clinical record titled, Progress Notes, dated [DATE] at 9:50 AM, by the WN, indicated, . 79/42 [blood pressure, low],100 [Oxygen saturation percentage, normal], 30 [respirations per minute, high] .99.6 [temperature, high] Resident not responding per baseline [Resident 1's normal status]. Nonverbal to questions. Refused medications. Refused breakfast. Not taking in any fluids. Facial grimacing with moaning. Refused pain medication.During a concurrent interview and record review on [DATE] at 4:12 PM with the DON, Resident 1's record titled, SBAR, [Situation Background Assessment Recommendation- a communication tool used for information exchange during urgent changes in condition] Communication Form, dated [DATE] (date of incident was [DATE]) and Resident 1's Progress Notes, from [DATE] through [DATE], by the WN, were reviewed for 72-hour monitoring of Resident 1's vital signs and pain rating. The SBAR Communication Form, indicated Resident 1's right leg venous ulcer wound measured 15.0 centimeters x 5.0 cm x 0.4 cm. The wound had heavy drainage and was worsening. The wound had 100% slough and necrotic tissue. The document further indicated Resident 1 was in excruciating pain and rated the pain 10 out of 10 (using the numerical pain scale). The DON stated the SBAR Communication Form was dated [DATE], but the COC occurred on [DATE]. The DON stated the late documentation was without proper labeling as a late entry and could have caused confusion to the reader of the progress notes and was not an acceptable practice. The DON stated the WN received the verbal order (an oral directive given by a physician to another health care professional either face to face or via telephone) from the MD on [DATE] for the vascular surgeon consultation but the order was not generated until [DATE]. The DON stated Resident 1 should have been on 72-hour monitoring (vital signs and pain level assessed once per shift for three days) after the COC was identified on [DATE] and they were not. The DON confirmed Resident 1's progress notes did not indicate her vital signs had been taken and/or pain level assessed and documented every shift for three (3) days after the COC was identified on [DATE]. The DON further stated due to Resident 1's complaint of severe pain, the DON's expectations of her staff was the staff should have reached out to the MD or the WD for possible new treatment orders.During a telephone interview on [DATE] at 12:20 PM with the RP, the RP stated Resident 1's baseline level was Resident 1 was aware of her surroundings, communicated and recognized the family upon arrival. The RP stated on [DATE] he noticed Resident 1 was a little more confused than usual and as the week progressed, Resident 1's cognition declined quickly. The RP stated when the family visited Resident 1 on [DATE], Resident 1 could not identify the family. The RP stated Resident 1's wound on her right leg was bleeding from her knee to her ankle and she was in severe pain.During an interview on [DATE] at 12:48 PM with the WD, the WD stated he treated Resident 1's right lower leg venous wound once a week and he noticed there was little to no improvement, and eventually the wound worsened. The WD stated he spoke with the MD and the WN on [DATE] and the WD informed the MD that the bedside treatment (wound care) was not effective, Resident 1 was getting worse and needed to go to the hospital and have a surgical wound debridement or amputation. The WD stated on [DATE], the MD agreed with his strong recommendation that Resident 1 needed a higher level of care to treat the worsening right leg venous ulcer.During an interview on [DATE] at 3:46 PM with the MD, the MD stated on [DATE] the WD notified him of the serious concern he had for the condition of Resident 1's lower leg venous stasis ulcer. The MD stated the WD informed him that Resident 1's wound was not healing and that he was concerned that the right lower leg may need to be amputated. The MD stated he gave a verbal order to the WN on [DATE] for Resident 1 to be seen by a Vascular Surgeon and the WN stated she would initiate the order. The WD stated his expectation was for the verbal order to be entered into Resident 1's medical record on [DATE] or [DATE].During a follow-up interview on [DATE] at 1:40 PM with the DON, the DON stated the WN waited five days to put in the verbal order from the MD for Resident 1 to have a vascular surgeon consultation. The DON stated there were only two attempts made by the facility to get consent from Resident 1's RP for Resident 1 to be seen by a vascular surgeon ([DATE] and on [DATE]). The DON stated the facility should have attempted to get consent from Resident 1's RP daily and the attempts should have all been documented in Resident 1's medical record. The DON stated it was the licensed nurses' responsibility to obtain consent for the vascular surgeon consultation on [DATE].During a follow-up phone interview on [DATE] at 3:02 PM with the WD, the WD stated on [DATE] he spoke with the MD regarding Resident 1's decline in wound healing of the right leg venous ulcer and the need for transfer to a higher level of care. The WD stated his recommendation for Resident 1's transfer to a higher level of care was proactive because he saw the negative direction the wound was heading toward. The WD stated the MD was overall in charge of Resident 1's care, and he provided recommendations regarding the wound. The WD stated his recommendation was strong and clear and the MD agreed with his recommendation. The WD stated Resident 1's chances of survival would have been better if she had been transferred to the hospital when recommended on [DATE].During a follow-up phone interview on [DATE] at 3:14 PM with the MD, the MD stated on [DATE] the WD debriefed him on Resident 1's condition and he (MD) agreed with the WD's recommendation that Resident 1 needed to be transferred to a hospital for surgical intervention for the right venous leg ulcer. The MD stated consent for the vascular surgeon consolation should have been obtained by the RP as soon as possible (ASAP).During a phone interview on [DATE] at 4:28 PM, the MD stated he had not assessed Resident 1's right leg venous wound on [DATE] and could not recall the last time he assessed the wound.During a concurrent interview and record review on [DATE] at 4:02 PM with the DON, the facility's P&Ps titled, Change of Condition, dated 1/2025 and the P&P titled, POLICY AND PROCEDURES ON DOCUMENTATIONS, dated 1/2025 were reviewed. The Change of Condition P&P indicated, .All nursing actions/interventions will be documented in the licensed progress notes as soon as possible after resident needs have been met . The licensed nurse responsible for the resident will continue assessment and documentation every shift for seventy-two (72) hours until the condition has stable [sic] . The DON stated the WN did not follow the facility's P&P of COC because the nurse had not initiated a COC when the WD identified Resident 1's wound was getting worse on [DATE]. The DON stated when alert charting (a systematic process of identifying, documenting, and acting upon specific resident safety risks) was initiated on [DATE], the licensed nurses had not completed the alert charting every shift for 72 hours. The DON stated this practice did not meet her expectations and these actions presented the risk of Resident 1's right leg wound and overall health was not monitored properly. The facility's P&P titled, POLICYAND PROCEDURES ON DOCUMENTATIONS, indicated, POLICY it is the policy of the facility to document all pertinent data and information of each resident in their respective medical record.Any change of condition such as incidents, medical problems and the like, shall be reflected with all necessary approaches/interventions appropriate for such problems. It should also include the medications, treatments . The DON stated her staff did not follow this policy and acknowledged there was not an initiation of a COC on [DATE] in Resident 1's clinical record for the change of her right leg venous wound, no diagnostic tests ordered, and no changes in medications. The DON stated the WN did not follow with policy when the documentation for [DATE] was submitted on [DATE] without a label that indicated it was a late entry for [DATE] as well as inconsistencies such as within the note indicating as if the events documented occurred on [DATE] instead of [DATE]. The DON stated this type of documentation caused confusion and could be misleading. The DON stated she expected her staff to accurately document care as was provided.3. A review of Resident 1's clinical record titled, Order Summary Report, dated [DATE], indicated, .TX [treat]: Right lower leg - cleanse with nss [normal saline solution - salt water], pat dry, apply Santyl [ointment used to help the healing of skin ulcers], wrap with soaked Kerlix [gauze bandage used to dress wounds] in Dakins solution [a solution used to clean wounds] .then cover with dry dressing and ACE wrap [a bandage]. Monitor for any change . as needed for chronic ulcer. A review of Resident 1's clinical record titled, Order Summary, dated [DATE], indicated, .Dakins . External [apply to skin] Solution . Apply to R lower leg [for treatment of the right venous ulcer] topically [apply to the skin] Everyday for chronic [long term] ulcer Wound measures: L [length] 15.0cm x W [width] 5.0cm x D [depth] 0.4cm .A review of Resident 1's clinical record titled, Order Summary, dated [DATE], indicated, .Santyl [a prescription medication used to remove dead tissue] for chronic skin ulcers External Ointment . Apply to Right Lower Leg [right leg venous ulcer] topically for chronic ulcer L15cm x W 5cm x D 0.4cm wraped [sic] with soaked Kerlix with Dakins solution . The Order did not indicate the frequency of applying the ointment.During an interview on [DATE] at 12:48 PM with the WD, the WD stated after he treated Resident 1's right lower leg wound every week he noticed there was little to no improvement and eventually the wound worsened. The WD stated a couple weeks prior to Resident 1's transfer to the hospital on [DATE], the WD spoke with the DON that he was concerned the WN was not changing Resident 1's right leg venous ulcer dressing daily. The WD stated he had also spoken with the DON and nursing supervisor three to four weeks prior to [DATE] and questioned the quality of wound care Resident 1 received. The WD stated the wound care was not done well as evidenced by when he removed the dressing weekly and assessed the wound, the dressing was dry and hard to remove and stuck to the wound.During a concurrent interview and record review on [DATE] at 4:12 PM with the DON, Resident 1's record titled, SBAR Communication Form, dated [DATE] (date of incident was [DATE]) and Resident 1's Progress Notes, by the WN, from [DATE] through [DATE] were reviewed for 72-hour monitoring of Resident 1's vital signs and pain level. The SBAR Communication Form, indicated Resident 1's right leg venous ulcer wound had 100% slough and necrotic tissue. The document further indicated Resident 1 was in excruciating pain and rated the pain 10 out of 10 (worst pain possible using the 0 through 10 numerical pain scale). The DON stated due to Resident 1's complaint of severe pain, the DON's expectations of her staff were to reach out to the MD or the WD for possible new treatment orders.During a follow up concurrent interview and record review on [DATE] at 4:02 PM with the DON, Resident 1's Treatment Administration Record, (TAR- a document where nursing staff document completed physician treatment orders) dated 2/2026 through 3/2026 and the facility's P&P titled, Wound Care, dated 1/2025 were reviewed. Resident 1's Treatment Administration Record, indicated Resident 1 had not received Dakin Solution treatment to her right lower leg venous statis ulcer on [DATE], [DATE], [DATE], and [DATE]. The DON verified the missing treatments and stated the risk for Resident 1 not receiving the ordered wound care was a deterioration in the wound and overall health for Resident 1. The DON stated she expected her staff to accurately document care as was provided.The P&P titled, Wound Care, dated 1/2025, indicated, .The following information should be recorded in the resident's medical record: 1. The type of wound care given, 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any changes in the resident's condition.6. All assessment data (i.e. [example], wound bed color, size, drainage, odor, pain, etc. [and the rest]) Obtained when inspecting the wound. Weekly by the wound nurse/designee. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. The DON stated the WN did not follow this policy because none of the required documentation listed on the P&P were documented in Resident 1's clinical record when the COC was first noticed on [DATE]. The DON stated Resident 1 was at risk for not receiving continuity of care (the process by which patients receive ongoing, coordinated, and comprehensive care from a consistent healthcare team over time), which could have contributed to the condition of Resident 1's right leg venous ulcer worsening.

Based on observation, interview, and record review the facility failed to notify the physician of a significant change in condition for one of four sampled residents (Resident 1) when,1.The facility did not notify Resident 1's physician after Resident 1 had consistent moderate to severe hip pain and decreased mobility following a fall on 1/31/26. This failure resulted in Resident 1's left hip fracture (break) going undiagnosed for six days resulting in Resident 1 experiencing pain and a decline in the ability to move in bed, transfer (move from one location to another) from the bed to a wheelchair, (a wheeled mobility device, designed as a chair for individuals with limited mobility due to illness, injury, or disability) maintain a standing position, and ambulate (walk) over 50 feet (unit of measurement) while using a front wheeled walker (FWW - a lightweight, four-legged metal frame designed to help people walk with better balance and stability). Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis that included bilateral primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left hip and vascular dementia (a progressive state of decline in mental abilities).A review of Resident 1's clinical document titled, Nurses Note, dated 1/31/26, indicated, Resident 1 had an unwitnessed fall at around 7:30 AM. Resident was found on the floor in his room lying on his left side right next to his bed.Upon assessment, resident reported pain scale of 5/10 [a 1 through 10 numerical pain scale that measures the intensity and impact of pain on daily life: 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 9 = severe pain, and 10 = the worst pain imaginable] on the left site [sic] of the hip . Painful to touch. Pain was sharp.Notified . the Medical Doctor [MD]. Order received as following: Norco [a strong pain medication only available with a prescription] . for moderate to severe pain 4-10/10 [pain medication ordered for pain of 4 out of 10 through 10 out of 10 using the numerical pain scale] PRN [as needed] Q [every] 6hrs [hours] .A review of Resident 1's clinical document titled, Order Summary Report, dated 1/1/26 through 1/31/26, indicated Resident 1 had a physician's order dated 1/10/26 for acetaminophen 325 MG (milligrams, unit of measurement) 2 tablets by mouth every 6 hours as needed for a pain score of 1 through 3 (mild pain) and a physician's order dated 1/31/26 for hydrocodone-acetaminophen 5-325 MG (Norco) give 1 tablet orally every 6 hours as needed for a pain score of 4 through 10 (moderate to severe pain) on a 1-10 numerical pain scale.A review of Resident 1's clinical document titled, MEDICAL NECESSITY-PHYSICIAN FOLLOW-UP VISIT NOTE, dated 2/1/26, indicated, .Seen and examined today for change of condition related to.recent unwitnessed fall with reported pain . New order: Hydrocodone-Acetaminophen [Norco] 5/325 mg. give [sic] 1 tablet PO [by mouth] every 6 hours as needed for moderate to severe pain (4-10/10) for 14 days. New Order: X-ray [a diagnostic test that uses electromagnetic waves to indicate the condition of bones] of bilateral [both] hips and pelvis . Therapy to reassess as indicated.A review of Resident 1's clinical document titled, Order Summary, dated 2/1/26 by the MD, indicated, . Communication Method: Phone . Order Summary: may have follow up appointment with Radiology department to get an x-ray of both hips and pelvis . A review of Resident 1's clinical document titled, Nurses Note, dated 2/2/26, indicated, .Pain scale of 4/10 [four out of 10] reported when the resident is being changed or being transferred [moved] to wheelchair.A review of Resident 1's clinical document titled, Physical Therapy Treatment Encounter Note(s), dated 2/2/26, indicated, .Pt [patient] c/o [complained of] pain 10/10 [the worst pain imaginable] upon movement of LLE [left lower leg]. Pt had a reported fall 1/31/26. Pt assisted x 2 [2 person assist] bed mobility [movement in bed] and proper positioning to prevent skin breakdown [skin tear injuries] and contractures [structural changes to the soft and connective tissues that cause them to stiffen, tighten and contract] .Pain at Rest Intensity = 0/10 [no pain] Pain with Movement Intensity=10/10 [the worst pain imaginable].A review of Resident 1's clinical document titled, Physical Therapy Treatment Encounter Note(s), dated 2/3/26, indicated, .Pt still unable to move LLE without significant pain. Pt able to tolerate sitting in chair with minimal to no movement of LLE.Pain at Rest Intensity=2/10 [mild pain] Pain with Movement Pain Intensity=9/10 [severe pain] .A review of Resident 1's clinical document titled, Physical Therapy Treatment Encounter Note(s), dated 2/4/26, indicated, .Pt unable to ambulate. Any movement of LLE increased pain to 9/10 or 10/10. no [sic] exercises done on LLE.Pain at Rest Intensity=2/10 Pain with Movement Pain Intensity =10/10.A review of Resident 1's clinical document titled, Physical Therapy Treatment Encounter Note(s), dated 2/5/26, indicated, .Pt still having pain on LLE upon gentle ROM [range of motion -the full, maximum distance and direction a joint or body part can normally move]. NWB [non weight bearing- the injured leg must not bear any weight] observed at this time until further examination done. Pain at Rest Intensity 2/10 [mild pain], Pain with Movement Paint intensity = 10/10 [the worst pain imaginable] .During a review of Resident 1's clinical record from the [ACUTE CARE HOSPITAL] titled, XR [x-ray] HIP 2 TWO 3 VIEWS LEFT WO [without] PELVIS, dated 2/6/26, indicated Resident 1 had a new left hip fracture.A review of Resident 1's clinical document titled, Physical Therapy Discharge Summary, dated 1/12/26 through 2/6/26, indicated the following assessment dates and functional level of Resident 1 from the start of physical therapy on 1/12/26 to Resident 1's discharge to [ACUTE CARE HOSPITAL] on 2/6/26, .Bed Mobility: 1/12/2026 Baseline Minimum Assistance Min (A) [patient can perform 75% of the mobility task while the one therapist assists with 25%] required with verbal cues [verbal cues to a resident to help them complete a task] 35% of the time, 2/1/2026 Stand by Assistance (SBA) [assistance of one therapist within arm's reach to ensure safety during the tasks, without touching or helping the patient] required with occasional verbal cues, 2/6/2026 Maximum Assistance (Max A) [assistance of one therapist required to perform approximately 75% of the work of a mobility task while the patient performs 25% of the work] with 75% verbal cueing.Transfers: 1/12/2026 Baseline Moderate Assistance Mod (A) [a person can do about 50%-75% of a task (like bathing, dressing, or walking) on their own but requires significant, hands-on help from a caregiver or therapist for the other 25%-50%] with 35% verbal cueing, 2/1/2026 Contact Guard Assist (CGA) [assistance of one therapist who has one or two hands on the patient's body but provides no other assistance to perform the functional mobility task. The contact is made to help steady the patient's body or help with balance] with 10% verbal cueing, 2/6/2026 Max A x 2 with 75% verbal cueing.Ambulation Distance on Level Surfaces: 1/12/2026 Baseline 20 feet Mod (A), 50% verbal cueing, 2/1/2026 50 feet Min (A) 75% verbal cueing, 2/6/2026 NA [not applicable], DNT [did not attempt due to safety concern] .Patient was discharged from PT when discharged to the acute on 2/6/2026.A review of Resident 1's clinical document titled, Occupational Therapy Treatment Encounter Note(s), dated 2/2/26, indicated .Patient approached for scheduled OT [Occupational Therapy, a form of therapy that focuses on dressing, eating, and grooming] session patient reported 10/10 [severe] pain and refused to get out of bed. OT attempted to initiate bed mobility tasks to assess functional tolerance and promote participation; however, patient stated, 'please No' and declined all therapeutic activity due to pain. Nursing staff confirmed patient experienced a fall over the weekend, which may be contributing to increased pain and decreased activity tolerance. OT assisted CNA with brief [adult diapers that collects urine and stool] change to ensure patients safety, hygiene, and skin integrity. Patient remained verbally expressive of pain throughout encounter and was unable to safely participation skilled OT services at this time due to medical limitations.A review of Resident 1's clinical document titled, Occupational Therapy Treatment Encounter Note(s), dated 2/3/26, indicated, .Patient reported [NAME] [lower extremity - leg] pain and declined any weight bearing activities. [NAME] pain is impacting ability to safely perform transfers and is limiting OT sessions.A review of Resident 1's clinical document titled, Occupational Therapy Treatment Encounter Note(s), dated 2/4/26, indicated, .LLE [left lower extremity] pain is impacting ability to safely perform transfers, patient states, '10/10 pain' this is limiting OT sessions to in chair adls [activities of daily living- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves] and UE [upper extremity] strengthing [sic].A review of Resident 1's clinical document titled, Occupational Therapy Treatment Encounter Note(s), dated 2/5/26, indicated, .LLE pain continues to impact patients [sic] ability to safely perform transfers, toileting [using the bathroom to void or stool] and [NAME] exercises. patient [sic] states, '10/10 pain' with rolling and transfers this is limiting OT sessions to in chair adls and UE strengthing [sic].A review of Resident 1's clinical document titled, Occupational Therapy Discharge Summary, dated 1/12/26 through 2/5/26, indicated the following assessment dates and functional level of Resident 1 from the start of occupational therapy on 1/12/26 to Resident 1's discharge to [ACUTE CARE HOSPITAL] on 2/6/26, .Functional Mobility during ADLS: 1/12/2026 Baseline Mod (A) [patient does 50-75% of the work, and the Occupational Therapist (OT) assists with the remainder] with 35% verbal cueing, 2/1/2026 Min (A) [patient does 75% if the work, and OT does 25% or less of the work] with 20% verbal cueing, 2/5/2026 Max (A) [patient can perform 25-50% of the task and the remainder is completed by OT] with 20% verbal cueing.Dynamic Standing Balance [the ability to maintain an upright, stable posture while moving or shifting one's center of gravity outside the base of support]: 1/12/2026 Baseline Poor + Mod A [resident has significant, but not total, impairment requiring moderate physical assistance to maintain balance and perform tasks safely] and UE [upper extremity] support to stand and reach ipsilaterally [same side] w/o [without] LOB [loss of balance]; unable to weight shift, 2/1/2026 Fair - Min (A) or UE support to stand w/o LOB & to reach ipsilaterally; unable to weight shift, 2/5/2026 Poor (Max (A) & UE support to maintain standing balance and reach ipsilaterally; unable to weight shift.Patient was discharged from OT when sent to the [ACUTE CARE HOSPITAL] on 2/6/2026.A review of Resident 1's clinical documents, titled MEDICATION ADMINISTRATION RECORD (MAR- a document that indicates medications ordered, held, or discontinued along with pertinent lab values that are used for discernment in medication administration), dated 1/1/26 through 1/31/26, indicated Resident 1 received acetaminophen 325 mg 2 tablets on the following dates for the corresponding pain level:1/13/26 pain level 2 out of 101/16/26 pain level 0 out of 101/20/26 pain level 0 out of 101/21/26 pain level 3 out of 101/23/26 pain level 3 out of 101/24/26 pain level 4 out of 101/31/26 pain level 8 out of 10The report indicated that the pain level reported on 1/31/26 and rated as an 8 out 10, corresponded to Resident 1's pain level after the unwitnessed fall that occurred on 1/31/26, and the order for hydrocodone 5/325 mg (Norco) was obtained by Resident 1's physician.A review of Resident 1's clinical document titled, MEDICATION ADMINISTRATION RECORD, dated 2/1/26 through 2/6/26, indicated after the unwitnessed fall on 1/31/26, Resident 1's pain level significantly increased and Resident 1 received hydrocodone-acetaminophen (Norco) 5/325mg 1 tab on the following dates and times with the corresponding reported pain level:2/2/26 at 7:25 AM pain level 7 out of 102/2/26 at 2:48 PM pain level 7 out of 102/2/26 at 11:45 PM pain level 8 out of 102/3/26 at 7:56 AM pain level 5 out of 102/4/26 at 7:55 AM pain level 7 out of 102/4/26 at 2:22 PM pain level 6 out of 102/4/26 at 8:22 PM pain level 7 out of 102/5/26 at 3:14 AM pain level 8 out of 102/5/26 at 9:29 AM pain level 5 out of 102/6/26 at 4:28 AM pain level 8 out of 10A review of Resident 1's clinical documents titled, Progress Notes, dated 1/31/26 through 2/6/26, indicated that at no time was Resident 1's physician made aware of Resident 1's significant pain increase and the declines in Resident 1's inability to move in bed, stand to transfer, bear weight while sitting up in a wheelchair, or walk.During an interview on 2/20/26, at 2:23 PM, with CNA (Certified Nursing Assistant) 1, CNA 1 stated that on 1/31/26 Resident 1 was assisted back to bed after the unwitnessed fall, but Resident 1 was in quite a bit of pain and Resident 1 had difficulty rolling from side to side in the bed as he had been able to do prior to the fall. CNA 1 stated after the unwitnessed fall on 1/31/26, it took two CNAs to help him move in bed, unlike before when it had only taken one CNA. CNA 1 stated that Resident 1 was unable to fully extend his left leg.During an interview on 2/20/26, at 4:23 PM, with CNA 3, CNA 3 stated that on 2/1/26 CNA 3 and another CNA attempted to provide incontinent care (the management of involuntary bladder or bowel leakage) to Resident 1 while he was in bed, Resident 1 was not able to turn in bed using the handrail (a device attached to the bed to assist with repositioning in bed) to pull himself to the side of the bed as he had been able to do prior to the fall on 1/31/26. CNA 3 stated that Resident 1 cried out in pain and stated, 'please, no' repeatedly. CNA 3 stated that Resident 1's pain level and inability to turn in bed was reported to Licensed Nurse (LN) 1.During a concurrent interview and record review on 2/19/26 at 1:30 PM with LN 1, Resident 1's clinical document titled, Nurse Note, dated 1/31/26, which contained information regarding Resident 1's pain level, mobility level, and physician notification of a change of condition was reviewed. LN 1 stated a change of condition in a resident, whether it was an improvement or decline should have been reported to the resident's physician. LN 1 confirmed the Nurse Notes, dated 1/31/26 indicated that on 1/31/26 Resident 1 complained of pain rated at 5/10 when the left hip was touched and there was some decrease in Resident 1's ability to fully move the left leg. LN 1 stated he notified Resident 1's physician of the unwitnessed fall (1/31/26) and resulting pain and the MD gave an order for hydrocodone/acetaminophen (Norco). LN 1 stated that Resident 1's physician came to the facility on 2/1/26 and gave a routine order for an x-ray to both hips and pelvis. LN 1 stated the order request was given to social services (a department in the facility that sets up resident's appointments) to schedule the x-ray to be completed at the acute hospital on 2/6/26.During a concurrent interview and record review on 2/20/26 at 8:10 AM with PT (Physical Therapist), Resident 1's Physical Therapy Treatment Encounter Note(s), Occupational Therapy Treatment Note(s), both dated 1/12/26 through 2/6/26, and Resident 1's record was examined for any Stop and Watch forms [a checklist used by caregivers to identify early signs of a resident's change in condition] were reviewed. PT stated Resident 1 was able to fully straighten the left leg without pain and had full range of motion (ROM), walked between 50 and 60 feet with the use of a FWW and contact guard prior to the fall on 1/31/26. PT stated that after the unwitnessed fall on 1/31/26, Resident 1 was not able to walk at all, could not bear weight on the left leg, was not able to extend or move the left leg, and could not roll from side to side in bed without severe pain. PT confirmed that this information was not documented as being communicated to the licensed nurses or to Resident 1's physician so further assessment and treatment could have been provided.During a follow up concurrent interview and record review on 2/24/26 at 11:03 AM with LN 1, Resident 1's clinical record for physician notifications from the dates of 1/31/26 through 2/6/26 were reviewed. LN 1 stated that following Resident 1's unwitnessed fall, LN 1 suspected that Resident 1 had a possible dislocation or fracture of the left hip because of Resident 1's increased pain level and inability to fully straighten the left leg. LN 1 was unable to confirm that he had documented reporting this information to the physician. LN 1 stated that from 1/31/26 through 2/6/26 therapy had reported that Resident 1 experienced moderate to severe pain of the left hip and a decrease in mobility. LN 1 stated he did not report it to the physician because the hydrocodone/acetaminophen (Norco) was effective in reducing Resident 1's pain and there was an x-ray scheduled to be completed on 2/6/26. LN 1 stated that the CNAs had reported that Resident 1 was having pain during incontinent changes, bed mobility and transfers and that prior to the unwitnessed fall on 1/31/26 pain was never reported as a concern during these ADL tasks.During an interview on 2/24/26 at 12:32 PM with Resident 1's physician (MD), the MD stated that he expected the licensed nurses, physical and occupational therapists to have reported changes of condition in any resident they were treating. The MD stated that when the LN reported Resident 1's unwitnessed fall on 1/31/26, the report did not include that Resident 1 had any change in Resident 1's ability to bear weight on the left leg or fully extend or flex the left leg. The MD stated he ordered the x-ray to be done as routine instead of STAT (no delay) based on his assessment on 2/1/26 and the report he received from LN 1. The MD stated that from 2/1/26 through 2/6/26 he was not contacted by a licensed nurse or a therapist regarding any decline in Resident 1's ability to bear weight on the left leg, transfer from a sitting to standing position, roll side to side in bed, or walk. The MD stated had the facility reported those issues, he would have sent Resident 1 to [ACUTE CARE HOSPITAL] for further evaluation sooner than 2/6/26.During a concurrent interview and record review on 2/24/26 at 3:16 PM with the Director of Nurses (DON), Resident 1's Progress Notes, dated 1/31/26 through 2/6/26 that contained information regarding Resident 1's fall, pain, mobility decline, and physician notification were reviewed. The DON stated assessments of a possible change of condition should have been coordinated between a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN). The DON stated that therapy staff should have also discussed Resident 1's change of condition with a licensed nurse or the MD for further evaluation and treatment. The DON confirmed that there was no documentation that indicated Resident 1's mobility declines and Resident 1's prolonged moderate to severe pain concerns were communicated to Resident 1's physician by a LN, PT, or OT. The DON stated that not reporting these declines and ongoing pain concerns to Resident 1's physician, delayed the diagnosis of Resident 1's left hip fracture and resulting treatment and caused Resident 1 to have continued declines in his mobility as well as unneeded pain and suffering.During a concurrent interview and review on 2/25/26 at 2:24 PM with the DON of the facility's policy and procedure (P&P) titled, Assessing Falls and Their Causes, dated 1/25, was reviewed. The P&P indicated, .Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility. The DON stated that any of these signs or symptoms would be considered a change of condition and as such should have been reported to Resident 1's physician for further assessment and treatment.A review of the facility's P&P titled, Acute Condition Changes-Clinical Protocol, dated 1/25, indicated, . Treatment and Management . The physician will help identify and authorize appropriate treatments .If it is decided after sufficient review, that care of observation cannot reasonably be provided in the facility, the physician will authorize transfer to an acute hospital . Monitoring and Follow-Up The staff will monitor and document the resident/patient's progress and response to treatment, and the physician will adjust treatment accordingly. The physician will help the staff monitor a resident/patient with a recent acute change of condition until the problem or condition has resolved .

Based on interview and record review the facility failed to use appropriate and safe transfer methods according to resident's care needs for one of three sampled residents (Resident 2) when, Certified Nursing Assistant (CNA) 2 transferred Resident 2 from the shower chair (a waterproof chair on wheels used to transport residents to and from the shower room) to her bed using a bear-hug (a transfer technique where a caregiver wraps their arms around the individual under the armpits, like a bear hug, to assist in standing and moving them) and one person assist. This failure resulted in a fracture of Resident 2's right seventh rib, and had the potential to cause increased pain, decreased mobility, skin breakdown, and other negative health outcomes for Resident 2. Findings: A review of Resident 2's ADMISSION RECORD, indicated Resident 2 was admitted to the facility in November of 2019, with diagnoses which included, age-related osteoporosis (condition that decreases bone density and strength, causing bones to be more fragile and susceptible to fractures) and muscle weakness. During a concurrent interview and record review on 3/28/25, at 11:03 AM, Licensed Nurse (LN) 1 confirmed she could not find any documentation in Resident 2's orders or active care plans to indicate how Resident 2 should be transferred. LN 1 stated the only transfer information she could find in the HER (Electronic Health Record) was in Resident 2's baseline care plan (document developed within 48 hours of admission to outline the initial care instructions needed to ensure effective and person-centered care) dated 2019, which indicated Resident 2 required a two-person assist for Bed Mobility (ability to move oneself in bed) and Transfer. LN 1 stated a two-person transfer was correct for Resident 2. A review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) with a target date of 5/23/24, indicated, .Section GG_ Functional Abilities and Goals .GG0170.Mobility . Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed .E. Chair/bed to chair transfer: The ability to transfer to and from a bed to chair (or wheelchair) . Both areas were coded 02. The legend indicated, .Coding .02. Substantial/maximal assistance- Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort . A review of Resident 2's clinical document titled, Care Plan Report, initiated 3/6/21, revision on 9/12/24, indicated, .Focus .[Resident 2] is at risk for spontaneous pathological fractures related to skeletal fragility and loss of bone mass secondary to AGE RELATED OSTEOPOROSIS .Interventions .Handle gently during care giving .Protect resident from sudden movement or bumps during care . A review of Resident 2's clinical document titled, Progress Notes, dated 1/26/25, at 7:33 AM, indicated, .Nurses Notes .Reported by CNA [Certified Nurse Assistant] in charge that after showering resident yesterday at 0745 [7:45 AM], and transferring resident back to bed, while pivoting back to bed hugging her to prevent resident from falling, resident shouted Ow my rib! CNA reported the incident to charge nurse right away Nursing assessment done along with charge -RN from NOC [night] shift, no noted skin discoloration at the complaint area at RT [right] upper quadrant of abdomen [area of the abdomen located above the waistline and below the ribs] just under the right breast .Pain scale 5/10 [a scale from 0-10 used to measure pain, 4-6 is considered moderate pain] .New order to send to .ER for further evaluation andtreatment [sic] . A review of Resident 2's clinical document titled, EMERGENCY DEPARTMENT PHYSICIAN NOTE, dated, 1/26/25, indicated, .CHIEF COMPLAINT .Rib pain .RADIOLOGY INTERPRETATION .Acute [ sudden or traumatic] anterolateral [in front and to the side] right seventh rib fracture . During a concurrent interview and record review on 3/28/25, at 10:35 AM, CNA 1 stated Resident 2 required two staff during transfers. CNA 1 further stated when Resident 2 was transferred she was placed in a seated position with a CNA on each side of her. CNA 1 stated the information on how to transfer residents was in the facility's electronic charting system. CNA 1 reviewed Resident 2's chart and confirmed she could not find any information to indicate how Resident 2 should be transferred. CNA 1 stated the nurse could access transfer information in the resident's electronic health record (EHR) and inform the CNA. A review of Resident 2's clinical document titled, Care Plan Report, initiated 1/26/25, indicated, Focus .At risk for recurrent pain secondary to witnessed transferring back to bed from shower wheelchair, and complaint of RT [right] rib pain .Goal .Resident will have less to no episodes of pain daily x 90 days if possible . A review of Resident 2's clinical document titled, Progress Notes, dated 1/25/25, at 11:12 AM, indicated, .Resident unable to stand up and hold weight on feet . signed by restorative nursing assistant (RNA, a CNA who specializes in helping patients regain or maintain physical function). A review of Resident 2's clinical document titled, Progress Notes, dated 1/25/25, at 12:55 PM, indicated, .Nurses Notes .pain 7/10 .resident on monitoring for pain under the right breast, res. [resident] was shouting it hurts under there, when attempting to assess/palpate [examine by touch] the area resident removed my hand and began to shield the area .after further assessment the area under the breast is slightly red, but skin tear present . A review of Resident 2's clinical document titled, Progress Notes, dated 1/26/25, at 6:15 AM, indicated, .Nurses Notes .Resident under monitoring for right breast redness. Noted redness, and resident refused touch on the area due to pain .0605 [6:05 AM] RN [registered nurse] supervisor requested undersigned to assess resident's right-lateral abdomen. Upon palpation by the RN Supervisor, the resident exhibited pain through her facial expression/withdraws to pain .RN supervisor will seek advise [sic] if resident will be sent out to [hospital] for further evaluation . During an interview on 3/28/25, at 12:38 PM, LN 1 stated on the morning of 1/25/25, she informed CNA 2 she would help transfer Resident 2 back to bed after her shower. LN 1 further stated when she went to Resident 2's room to help assist CNA 2 place Resident 2 back into the bed, Resident 2 was already in bed. LN 1 stated CNA 2 reported she may have hurt Resident 2. LN 1 further stated CNA 2 told her she heard a crack when she moved Resident 2. During an interview on 3/28/25, at 3:42 PM, Occupational Therapist 1 (OT, healthcare provider who helps residents regain or maintain skills needed for daily living, like dressing and bathing) stated OT staff helped to train CNAs on transfer techniques. OT 1 further stated when transferring a resident, a hug technique was not recommended. OT 1 stated a resident would require a two person assist to transfer, with a gait belt, if they could not stand and pivot. During an interview on 3/28/25, at 4:50 PM, CNA 2 stated she gave Resident 2 a shower on 1/25/25. CNA 2 further stated Resident 2 transferred from her bed to the shower chair with the assistance of two CNA's. CNA 2 stated Resident 2 was usually more awake after her shower and could transfer back to bed with one assist. CNA 2 further stated when she transferred Resident 2 back to bed from the shower chair on 1/25/25, she hugged her for support. CNA 2 stated when she sat Resident 2 on the bed, she did not sit her back far enough. CNA 2 further stated she had to stand up straighter to move Resident 2 further back on the bed. CNA 2 stated when she straightened up, she heard a crack from Resident 2, and it was very disturbing. CNA 2 stated after she finished getting Resident 2 back in bed, she explained to the nurse what had happened. CNA 2 stated she told the nurse she had held Resident 2 under her arms like she was giving her a hug, then she lifted her up more. CNA 2 stated she knew Resident 2 had fragile bones. CNA 2 further stated she was trained to transfer residents with two-person assistance if they needed more support and to use a gait belt. CNA 2 stated she was not taught to hug a resident to perform a resident transfer. During an interview on 4/1/25, at 12:50 PM, the Director of Staff Development (DSD) stated the DSD and the rehab staff (rehabilitation staff who work with residents to restore their function and mobility and improve overall physical health) trained the CNAs to perform transfers. The DSD further stated the CNAs were taught to always use a gait belt when they transferred a resident. The DSD stated to perform a two person transfer staff members stood on each side of the resident and grasped the gait belt. The DSD stated to transfer with one assist staff stood on one side of the resident and held the gait belt. The DSD stated a hug was never the appropriate way to transfer a resident. The DSD further stated transferring a resident using a hug could result in an injury to the resident and/or the staff. During a telephone interview on 4/4/25, at 10:27 AM, RNA 1 stated Resident 2 began to have difficulty standing in November 2024. RNA 1 stated Resident 2 required a two person transfer since then because she would not stand, and her feet would slide out from under her. During an interview on 4/4/25, at 11:38 AM, the Physician's Assistant (PA) stated Resident 2 had a history of osteoporosis and had fractured ribs in the past. The PA further stated osteoporosis made Resident 2's bones fragile, therefore it was possible that the method of transfer contributed to Resident 2's fractured rib. The PA stated the facility needed to have a protocol to ensure residents were transferred safely. A review of a facility policy and procedure (P&P) titled, Transfer/Gait Belt, dated, 6/12, indicated, . It is the policy of this facility to provide safety [sic] transfer by using gait belt for the dependent resident, to aid in transfer and to prevent injuries to employees and resident (i.e., back strain or potential for chronic disability, resident falls or fractures), and to allow the resident and aide to feel more secure during a transfer .TRANSFER FROM BED TO CHAIR, COMMODE, OR WHEELCHAIR ( One Person Transfer, Resident Able to Bear Weight) .Place gait belt around resident's waist; snug but not tight. Avoid ribs, hipbone, or breasts .Straighten your knees and, with spine straight, aid resident to lead with the strong leg and stand close to you with both feet flat on the floor .The residents hands may help to push on the bed or may be placed on your arms or shoulders but not around your neck .Using the gait belt to angle and lift residents buttocks, lower resident into chair while flexing your knees and pushing them against the residents to help position buttocks into chair . A review of an undated facility document titled, Nursing Supervisor (RN), indicated, .The primary purpose of your job position is to .ensure that the highest degree of quality care is maintained at all times .Ensure that all Nursing Service personnel follow established facility policies and procedures including .the use of proper body mechanics in lifting or moving residents or supplies, including the use of a gait belt .

Based on observation, interview, and record review, the facility failed to provide a safe environment and the supervision needed to ensure one of 24 sampled residents (Resident 39) was protected from physical abuse when another resident (Resident 79), who had a history of severe mental illness and violent behaviors, entered Resident 39's room and struck him in the face multiple times. This failure resulted in Resident 39 sustaining facial bruising and redness, a cut lower lip, overall head pain, and feelings of fearfulness. Findings: A review of Resident 39's clinical record titled. Admission Record (a document that contained the resident's demographic information), indicated Resident 39's diagnoses included Multiple Sclerosis (a disease that blocks messages between the brain and body, causing a variety of symptoms, including muscle weakness). During a concurrent observation and interview on [DATE], at 11:14 a.m., with Resident 39, in his room, Resident 39 was observed to have a cut on his left lower lip, and his face was red with bruising around his eyes and nose. Resident 39's left hand and arm were observed to have contractures (permanent shortening of muscles that limit movement and causes stiffness), and his legs were unable to move. Resident 39 stated that Resident 79 came into his room and hit him in the face 15 times. Resident 39 stated if the nurses hadn't come to his room when they did, Resident 79 could have killed him. Resident 39 stated he still had pain in his head. A review of Resident 79's clinical record titled, Admission Record, indicated Resident 79's diagnoses included schizophrenia (a serious mental health condition that affects how people think, feel and behave) and bipolar disorder (a mental illness that causes extreme mood swings). A review of Resident 79's clinical record titled, Progress Notes, dated [DATE], at 6:08 a.m., by Licensed Nurse (LN) 10, indicated a loud sound was heard at Nurses' Station 1. The progress note revealed that Resident 79 attacked a licensed nurse and pushed him against the door and had both hands around the nurse's neck. A female nurse tried to help the nurse when Resident 79 slammed her on the desk and to the floor. Resident 79 kept saying, he has a gun. A review of Resident 79's clinical record, titled Progress Notes, dated [DATE], at 6:48 p.m., by the Minimum Data Set Nurse (MDS nurse - nurse who assessed and monitored the health of patients in long-term care facilities), indicated Resident 79 shouted at a Certified Nursing Assistant (CNA), pulled his hair, and hit him on the head. A review of Resident 79's clinical record titled, Physician's Progress Notes/Psychological Evaluation, dated [DATE], by Medical Doctor (MD) 1, indicated Resident 79 had become more paranoid (suspiciousness, distrust, and feelings of persecution) over the past few days and his Schizophrenia and dementia (a decline in mental abilities that could affect a person's ability to perform everyday activities) was uncontrolled. A review of Resident 39's clinical record titled, Progress Notes, dated [DATE], at 2:09 a.m., indicated Resident 39 was hit repeatedly on his face by Resident 79. Resident 39's face was red and bruised along the nasal bridge (top of the nose) and under the eyes, and his eyes were blood shot (red/irritated). A review of Resident 39's clinical record titled, Progress Notes, dated [DATE], at 2:48 a.m., by LN 8, indicated that at around 12:58 a.m., Resident 79 was heard by staff stating, I'm going to kill him and went into Resident 39's room and beat him by slapping him in the face. Resident 39 stated he was hit in the face 15 times. A CNA ran over to the room and pulled Resident 79 off of Resident 39 by pulling him by the back of his pants. Resident 79 grabbed the CNA by the right arm and knocked her down. The police were called and arrived at the facility. The progress note indicated other residents in the facility were afraid. A review of Resident 79's clinical record titled, Progress Notes, dated [DATE], at 2:58 a.m., indicated Resident 79 had tried to bend a LN's hand backward. Resident 79 said there were people in his room with guns. A review of Resident 79's clinical record titled, Progress Notes, dated [DATE] at 8:59 a.m., by LN 1, indicated Resident 79 yelled, she's in there and he has her. A review of Resident 79's clinical record titled Progress Notes, dated [DATE], at 9:00 a.m., by LN 9, indicated Resident 79 was banging on the office doors stating there was an [AGE] year old lady trapped inside the office. A review of Resident 39's clinical record titled, Progress Notes, dated [DATE], at 2:34 p.m., by Social Services (SS), indicated, Resident 39 stated, 'He was yelling in the hallway saying stuff angry and I told him hey man calm down. He then came to my door still yelling and I told him man calm down. After I said that he came into my room all angry towards me and slammed my computer to the floor and he started to punch me. He punched me like 15 times .I was scared for my life. It took you guys a long time to come and save me . If they didn't stop him, he would have killed me' . Resident proceeded to express, 'Look at my face I was beat up . I could have died ' . During a interview on [DATE], at 2:03 p.m., with LN 4, LN 4 stated after Resident 79 attacked Resident 39, Resident 39 was very afraid for his safety. LN 4 stated Resident 79 hit Resident 39 in the face approximately 15 times. LN 4 stated Resident 39 was a vulnerable resident who could not defend himself. LN 4 stated, Resident 39 was emotional and upset after the incident. During an interview on [DATE], at 8:55 a.m., with Resident 46, Resident 46 stated she did not feel safe when Resident 79 lived at the facility. During a concurrent interview and record review on [DATE], at 3:36 p.m., with the Administrator (ADM), the facility's Policy and Procedure (P&P) titled, [FACILITY NAME] Abuse Prohibition Policy and Procedure, dated 2021, was reviewed. The P&P indicated, . Abuse is defined as the willful infliction of injury . resulting physical harm, pain, injury, or mental anguish . physical abuse includes hitting, slapping, pinching, kicking, etc. Purpose - to ensure that [FACILITY NAME] staff are doing all that is within their control to prevent occurrences of abuse ( . physical) . for all patients . The ADM stated she did not deny that Resident 39 was attacked by Resident 79, but stated it was not abuse. A review of the facility's P&P titled Safety and Supervision of Residents, dated ,d+[DATE], indicated, . The care team shall target interventions to reduce individual's risks . including adequate supervision . A review of the facility's P&P titled, Resident Rights, dated ,d+[DATE], indicated, . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . be free from abuse .

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 2) from physical abuse when Resident 2 and Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Resident 2 being pushed to the ground and caused an injury to Resident 2's forehead, and a [CONDITION(S)]. Findings: Resident 2 was admitted to the facility in late 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3 was admitted to the facility in late 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's plan of care, dated 3/4/21, indicated Resident 3 had socially inappropriate and disruptive behaviors. These behaviors included cursing, threatening, and hitting staff. Interventions for these behaviors included assessing whether the behavior endangered other residents, and if so, intervene when necessary. The plan of care read to avoid over-stimulation and included examples which were listed as noise, crowding, and other physically aggressive residents. A review of two nurse progress notes regarding Resident 2, both dated 11/9/21, indicated, .Due to resident's episodes of behavior outburst (thinking roommate is in her own house). IP [Infection Preventionist] and administrator ok to move resident to own room .Also while trying to redirect resident and letting her know that her roommate also lives there, resident started swinging her cane and cane hit CNA's [Certified Nurse Assistant] on the back .IP and Admin [Administrator] aware and for possible room change due to physical aggression and safety of roommate . A review of a nurse progress note, dated 11/10/21, indicated approximately one hour after breakfast Resident 3 became Irate and verbally explicit. The note read Resident 3, .stormed out of her room carrying a bin of her belongings and attempted to elope the facility. The front door alarm sounded and staff members who were outside convinced Resident 3 to go back inside, and staff heard yelling from Resident 3's room a few minutes later. The nurse documented Resident 2 and Resident 3 now shared a bathroom located between their two rooms and were both yelling at each other to get out of the bathroom. The nurse intervened and escorted Resident 2 out of the bathroom. The nurse realized the bathroom door handle was broken on Resident 2's side of the room and called maintenance to fix it. Both residents were left alone and several minutes later banging was heard. When maintenance arrived with parts to fix the door handle Resident 2 was witnessed seated on the floor. The note indicated Resident 3 was standing over Resident 2 and when asked, Resident 2 stated Resident 3 had pushed her. Resident 2 complained of right elbow and knee pain and was noted to have a lump on the forehead. Resident 2's physician was notified of the incident and ordered Resident 2 be sent to the hospital for further evaluation. A review of another nurse's progress note, dated 11/10/21, revealed the police department was notified of Resident 3's verbal and physical aggression and the facility explained to them Resident 3's behavior was unmanageable. The police department was unable to assist the facility with Resident 3's behavioral health due to Resident 3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a nurse progress note, dated 11/10/21, indicated the nurse called the hospital late in the evening and was told Resident 2 was being admitted for a right [CONDITION(S)]. A review of a Social Services (SS) note, dated 11/11/21, indicated SS had witnessed Resident 3 attempting to leave the facility on 11/10/21. During the attempt, SS documented Resident 3 had grabbed a visitors bag out of her hands and proceeded to also push the visitor. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/29/21, at 10:11 a.m., the Director of Nursing (DON) stated Resident 3 was restless and irritated on 11/10/21, and attempted to leave the facility. The DON explained a visitor tried to stop Resident 3 from leaving and Resident 3 proceeded to hit the visitor on the back. A short while later the DON was informed of the incident between Resident 2 and Resident 3 and upon arrival to the room, Resident 2 was on the floor and stated Resident 3 had hit Resident 2. During an interview on 11/29/21, at 10:51 a.m., Resident 3 could not recall the incident with Resident 2. When asked if anyone ever tried to use her bathroom Resident 3 stated, Yeah, that [OBSCENITY] behind that door and pointed at the bathroom door. During a concurrent observation and interview on 11/29/21, at 11:59 a.m., Resident 2 was observed seated in a wheelchair and complained of right hip pain. Licensed Nurse (LN) 1 was also in the room and was observed holding a cup with medication and indicated it was Resident 2's pain medication. Two additional staff members were in the room and asked LN 1 to look at Resident 2's hip. LN 2 pulled Resident 2's pants down on the right side where bruising and swelling were observed to the right hip area. LN 2 stated the incision looked good but the site was not as swollen or tender the previous week. When asked, Resident 2 could not remember the incident with Resident 3 and stated, I guess I fell going to the bathroom or something. Do you know how I fell ? During an interview on 11/29/21, at 1:50 p.m., LN 2 stated she was Resident 2 and Resident 3's nurse the day of the incident. LN 2 confirmed Resident 3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LN 2 further stated Resident 2 was moved from the previous room the day before because Resident 2 thought the roommate was in her house and yelled, Get out of my house! LN 2 voiced Resident 2 and Resident 3 should not have been placed close together due to their history of behaviors. During an interview on 11/29/21, at 3:32 p.m., the Maintenance Supervisor (MS) stated prior to returning to fix the bathroom door handle yelling between Resident 2 and Resident 3 could be heard but the MS was not able to decipher what was being said. The MS entered Resident 3's room and found Resident 2 seated on the ground between the bathroom and Resident 3's side of the room. The MS went on to say Resident 3 was often witnessed yelling and screaming in the hallways. During an interview on 11/29/21, at 3:50 p.m., the DON was unaware why Resident 2 was moved to that particular room and stated ideally the two should not be next to each other. The DON went on to say it may have been missed there was a shared bathroom between the two rooms. A review of the facility census dated 11/9/21, indicated Station 1 (an area where residents reside), where Resident 2 was moved next to Resident 3, had 30 empty rooms. A review of the facility's policy and procedure titled, Abuse and Neglect Prevention Management, revised 12/2104, indicated, .It is the policy of the facility to ensure our residents safe and free from abuse .our residents have the right to be free from abuse .by anyone, including .other residents .the following .components comprise the protocol .in the abuse .prevention .guide .identification: of occurrences and patterns of potential abuse .implementing changes to prevent future occurrences of abuse .abuse: is the willful infliction of injury .with resulting physical harm .prevention .assessment, care planning .monitoring of residents with .behaviors that might lead to conflict .such as history of aggressive behaviors .enter other resident's rooms .

Based on interview and record review, the facility failed to prevent a fall for one of three sampled residents (Resident 1) when staff supervison and assistance during transfer and toileting was not provided, a new fall risk assessment was not conducted when Resident 1 had a change of condition (C[NAME]) and the care plan was not followed or updated to identify new interventions to prevent a fall, based on Resident 1's C[NAME]. This deficient practice resulted in Resident 1's fall, in which she sustained a broken hip. Findings: A review of Resident 1's Face Sheet indicated she was admitted in (YEAR) with [DIAGNOSES REDACTED]. A review of the clinical record for Resident 1 included the following documents: A Minimum Data Set (MDS, an assessment tool) dated [DATE], which described Resident 1 as having severe cognitive impairment, scoring 7 out of 15 possible points (scoring range is ,[DATE], with 15 reflecting no memory impairment) on the Brief Interview for Mental Status (BIMS). The MDS also described Resident 1 as requiring supervision or oversight and encouragement or cueing for transfer and limited assistance, in which staff provided guided maneuvering of limbs or other non-weight-bearing assistance, for toileting. A Fall Risk Assessment (FRA), completed on [DATE], categorized Resident 1 as being at high risk for falls. A physician's progress note, dated [DATE], indicated Resident 1 was weak and confused. An Order Summary Report, dated [DATE], reflected, Resident 1 is incapable of giving informed consent and/or able to participate in treatment plan. A nursing progress note, dated [DATE] and written at 12:33 p.m., indicated Resident 1 was, Noted with C[NAME] (change of condition), more confusion than per norm, generalized weakness, inability to stand, stuttering, staring at ceiling singing, answering questions inappropriately and episodes of incontinence with urine. A Resident Transfer Record, dated [DATE], indicated Resident 1 was sent to a General Acute Care Hospital (GACH) due to an altered level of consciousness and weakness upon standing. A nursing progress note, dated [DATE] and written at 8:36 p.m. by Licensed Nurse 2 (LN 2), reflected Resident 1 returned to the facility from the GACH at 5:30 p.m. with a [DIAGNOSES REDACTED]. There was no documented evidence of a resident assessment upon return from the GACH. A nursing progress note, dated [DATE] and written at 4:02 a.m. by LN 3, indicated Resident 1 was noted with increased confusion and was slow to respond. A nursing progress note, dated [DATE] and written at 6:55 p.m. by LN 4, indicated Resident 1 was alert with confusion and short term memory loss, and appeared more confused. A nursing progress note, dated [DATE] and written at 12:45 p.m. by LN 5, indicated Resident 1 was found sitting on the floor in front of the toilet with her wheelchair in the bathroom doorway. Resident 1's left leg was bent and under her right leg, which was outstretched in front of her. Resident 1 reported, Terrible pain and was unable to move the left leg without pain. Resident 1 was transferred to a GACH for further evaluation. The GACH Emergency Department Physician notes, dated [DATE], indicated Resident 1's admitting [DIAGNOSES REDACTED]. The GACH Discharge Summary, dated [DATE], reflected Resident 1's condition worsened, and Resident 1 died on [DATE]. Resident 1's certified Death Certificate listed the cause of death as cardiopulmonary arrest (a sudden loss of blood flow resulting from the heart failing to effectively pump) secondary to [MEDICAL CONDITION] (impaired lung function that leads to inadequate delivery of oxygen to the body's tissues), [MEDICAL CONDITION] and acute [MEDICAL CONDITION] (sudden failure of the kidneys to filter waste products from the blood). A Risk For Injury Care Plan, initiated on [DATE], indicated the goal of preventing or minimizing falls for Resident 1. Interventions initiated on [DATE] included; assisting the resident as needed, resident assessment, constant safety reminders daily and as needed, providing a safe environment, encouraging the resident to use her call light and a non-skid wheelchair pad. The care plan was last updated on [DATE] and reflected no additional interventions were taken to address Resident 1's change of condition on [DATE]. In an interview on [DATE] at 1:15 p.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 required supervision for toileting and she stated supervision meant, You stand by and keep an eye on them. CNA 1 stated she was aware of Resident 1 frequently taking herself to the bathroom without staff supervison. CNA 1 stated she noticed Resident 1 was having a hard time standing. In an interview on [DATE] at 1:34 p.m., CNA 2 stated supervision meant the CNA watched the resident transfer when going to the bathroom and then stood by. CNA 2 stated Resident 1 was supposed to be supervised, but often used her wheelchair to go to the bathroom and transferred herself to the toilet. CNA 2 stated Resident 1 was, A lot more weaker, and recently more incontinent than before. CNA 2 stated Resident 1 had recently, Started forgetting faces she always knew. In an interview on [DATE] at 1:50 p.m., LN 1 stated supervision for transfer meant staff were to stand by, survey for safety, lock the wheelchair, and verbally direct the resident. Supervision and assistance of 1 staff member meant the CNA explained the process and verbally directed the resident. If the resident asked for privacy, the CNA closed the door but must stay on the other side of the door unless the resident was fully alert and oriented. LN 1 confirmed Resident 1 required supervision, but was aware she often took herself to the bathroom. LN 1 stated Resident 1 was starting to forget things a lot recently. In an interview on [DATE] at 2:25 p.m., the MDS Coordinator stated transfer supervision meant staff were to stand by, and limited assistance toileting meant staff verbally directed the resident, took them by the elbow, but no weight bearing on staff's part, We don't want (residents) to do it alone. The MDS Coordinator stated toileting assistance meant the CNA was in the room or outside the room in the hall. The MDS Coordinator also confirmed she interviewed the residents when completing the MDS assessment, and had assessed Resident 1 to be supervision for transfer and limited assistance for toileting. In an interview on [DATE] at 9:10 a.m., CNA 3 stated Resident 1 had become very incontinent prior to the fall and Resident 1 required supervision to transfer. CNA 3 stated at the time of the fall, [DATE] at 12:45 p.m., she was assigned to care for Resident 1. CNA 3 stated she was getting ready to shower another resident when she heard Resident 1's screams for help and ran to Resident 1's room. CNA 3 confirmed Resident 1 was found in the bathroom and was unsupervised. In an interview on [DATE] at 9:40 a.m., LN 5 stated at the time of Resident 1's fall, Resident 1 was being treated for [REDACTED]. LN 5 stated she was not Resident 1's nurse on [DATE], but CNAs called her to Resident 1's room. LN 5 stated she was standing at Nursing Station 2 and ran down the hallway to Resident 1's room. LN 5 stated Resident 1 was taking herself to the bathroom without staff supervison or assistance. In a telephone interview on [DATE] at 11:10 a.m., CNA 5 stated she was standing at Nursing Station 2 and heard Resident 1's yelling down the hallway. CNA 5 stated she ran to the room with CNA 4 and found Resident 1 sitting on the floor facing the toilet with her left leg folded under her outstretched right leg. CNA 5 stated she saw Resident 1's wheelchair pushed back against the sink and believed Resident 1 did not lock her wheelchair before attempting to transfer herself to the toilet without staff supervision. CNA 5 stated Resident 1 required supervision. A review of the facility's Accident/Fall Risk/Injury Assessment and Prevention Policy stipulated, It is the responsibility of nursing to complete an accident/fall risk/injury assessment within 7 days upon admissions, quarterly, annually, and as often as needed and with any significant change of condition. The policy also stipulated, Check and assess resident's safety awareness since poor judgement, confusion and inability to comprehend could cause fall. In an interview on [DATE] at 11:30 a.m., the DON verified Resident 1 did not have the capacity to make decisions. The DON verified there was no documented evidence of an RN assessment when Resident 1 returned from the GACH, and between [DATE] and Resident 1's unwitnessed fall on [DATE]. The DON confirmed no new FRA was completed on [DATE] for Resident 1 when she returned from the GACH with the UTI diagnosis. The DON also verified Resident 1 had some [MEDICAL CONDITION] (sudden, severe confusion due to physical or mental illness) with her UTI, and she was weaker when she returned from the GACH. The DON agreed Resident 1 was less safe to ambulate due to the UTI and it was the responsibility of staff to check on Resident 1. The DON stated staff should have performed frequent visual checks, every 30 minutes or every hour, on Resident 1 to assure supervision. The DON stated she could not provide evidence that a staff member was supervising or assisting Resident 1 with toileting at the time of the fall. The DON confirmed Resident 1's care plans were not updated to address Resident 1's [MEDICAL CONDITION], increased incontinence, confusion, weakness or how staff would keep Resident 1 safe with the change of condition.

Based on staff interview, clinical record review, and policy and procedure review, the facility failed to ensure prompt physician notification when Resident A experienced pain of the left knee with swelling and decreased ability to move or reposition after she sustained a fall. This failure resulted in Resident A experiencing, at times, severe pain which was unrelieved by the ordered pain medication for a period of 36 hours. Findings: Resident A was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Assessment (MDS-assessment tool), dated 9/18/11, indicated Resident A had severely impaired cognition. She was able to transfer, walk in her room and the corridors with supervision. Documentation indicated Resident A used a front wheel walker for mobilization. Resident A was frequently incontinent of her bowel and bladder function. A Pain Assessment, dated 9/6/11, indicated Resident A had no complaints of pain. Resident A had prior left knee replacement surgery. A Resident Care Plan, dated 9/6/11, documented Resident A was at risk for fall or injury related to confusion, incontinence, an unsteady gait even with her walker, and getting out of bed without assistance. Care plan interventions included bilateral upper side rails (1/2 rails), timed toileting, and a bed alarm (alarm that sounds if resident rises from the bed). Nurse's Notes, dated 11/2/11 at 4:45 a.m., documented Resident A was discovered on the floor outside the bathroom door in her room. Documentation in the note indicated water was noted spilled on the floor and the resident did not have her slippers on. The documentation indicated, "No apparent injury. Assisted to stand but took about 2 steps (and) knees/ankles buckled and she could not remain standing." Documentation indicated Resident A was assisted to bed and instructed not to get up. A "Nonemergent Communication" fax, dated 11/2/11, was sent to Resident A's Physician with the following information. "Found sitting on floor in room- no apparent injury- unable to stand on feet (with) assessment- knees and ankles buckle. Lower legs with 2+ [MEDICAL CONDITION] (swelling)." Documentation in the Nurse's Notes indicated the fax was sent at 5 a.m. Resident A's Physician responded to the faxed information on 11/2/11 at approximately 9:30 a.m. with the following. 1. "Please always include some evaluation especially complete vital signs including BP (blood pressure) P (pulse) & Temp. 2. UA (urinalysis) C&S if indicated (culture and sensitivity of bacteria found in the urine with a list of antibiotics the organism is sensitive to)." A "Nonemergent Communication" fax, dated 11/2/11, was sent to Resident A's physician at 9:15 p.m. and contained the following information. "(status [REDACTED]. Resident (complaint of) L (left) knee pain. [MEDICAL CONDITION] (swelling) noted to L knee. Pain (increased) with weight bearing. Medicated (twice) with Tylenol as ordered for pain." A Nurse's Note, dated 11/3/11 at 9:00 a.m., revealed a new order was received from Resident A's physician to obtain a PT/INR in one month (laboratory blood test to monitor the residents blood thinning medication.) The order was in response to the results of a recent laboratory test. There was no documentation which indicated nursing staff discussed or reported Resident A's complaints of left knee pain and swelling with Resident A's physician. Review of Resident A's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident A's Pain Assessment Flowsheet for November 2011 was reviewed. Pain was to be assessed every shift and rated on a scale of 1-10. 0 being no pain, 1, 2, 3 being mild pain, 4, 5, 6 being moderate pain and 7, 8, 9, 10 being severe pain. Documentation on the Pain Assessment Flowsheet indicated on 11/2/11 at 7:30 a.m. Resident A's pain was rated at 7/10 (severe pain). At 4 p.m. Resident A's pain was rated at 5/10 (moderate pain). Resident A was medicated with Tylenol 2 tablets for her left knee pain. A "Physician Notification of Change in Condition" form, dated 11/3/11 at 11:05 a.m., and faxed to Resident A's physician documented, "(Resident's) L knee swollen and painful to touch. Refuses to get out of bed or bare any weight. Medicated (with) Tylenol 325 mg (2) tablets (with) ineffective results. Can you (please) advise?" There was no documented response from Resident A's physician to the faxed information. Nurse's Notes, dated 11/3/11 at 9:40 p.m., documented Resident A continued to complain of left knee pain. She was medicated with Tylenol with "slight relief." "Awaiting response from MD." Nurse's Notes, dated 11/4/11 at 3:25 a.m., documented Resident A's pain was rated at 6/10 and she was medicated with Tylenol with "poor effect." Documentation indicated Resident A "appeared to be awake most of the night." Resident A was described as being unable to ambulate and she had persistent [MEDICAL CONDITION] of her leg despite her legs being elevated. Nurse's Notes, dated 11/4/11 at 11:30 a.m., documented Resident A sustained three skin tears while staff was attempting to transfer her from the bed to the wheelchair. The note indicated Resident A's physician was notified of the skin tears. There was no information in the fax regarding Resident A's continued complaints of left knee pain, swelling, or inability to ambulate. Nurse's Notes, dated 11/4/11 at 12:45 p.m., documented Resident A continued to complain of pain in her left knee and Tylenol was given for the pain which was ineffective at 8 a.m. Documentation indicated Resident A refused to be repositioned in bed and her left knee was swollen with decreased range of motion. The note indicated, "Continue to await (new orders) from (doctor). Nurse's Notes, dated 11/4/11 at 10:45 p.m., a period of 36 hours since staff had last attempted to contact Resident A's physician regarding her left knee injury, indicated Resident A's physician came to the facility and evaluated her left knee. The physician ordered bedrest and to elevate her left leg. There were no orders obtained to address the pain Resident A was experiencing in her left knee. Nurse's Notes, dated 11/7/11 at 5 a.m., documented Resident A was complaining of severe pain with movement or touching her left leg. At 12 p.m. the physician ordered an x-ray of the left knee. At 9 p.m. the x-ray result revealed Resident A had a left distal femoral periprosthetic fracture with overlying soft tissue swelling ([MEDICAL CONDITION] bone just above the prosthetic knee replacement.) On 11/8/11 at 2 p.m. a left knee immobilizer was ordered to treat Resident A's fracture. The facility's policy titled Change of Condition, revised 8/2010, was reviewed. The policy included, in part, the following: It is the policy of this facility that all changes in resident condition will be communicated to the physician. Acute Medical Changes: 1. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit immediately and/or acute care evaluation. The licensed nurse in charge will notify the physician. 2. If unable to contact attending physician or alternate physician timely. Notify Medical Director for follow-up to change in resident condition. An interview was conducted with the Assistant Director of Nurses (ADON) on 2/14/13 at 2 p.m. The ADON stated nursing staff should have been more aggressive in calling and contacting Resident A's physician when she displayed symptoms of injury and severe pain to her left knee after sustaining a fall. The ADON acknowledged the physician would not be available to respond to the faxes that had been sent after regular business hours. The ADON stated Resident A was more susceptible to fracture because of the prosthetic knee and nursing staff should have contacted the Medical Director when Resident A's physician did not respond. An MDS, dated [DATE], approximately four months after Resident A fractured her femur, indicated Resident A was dependent on staff to transfer from her bed to wheelchair and back and she could no longer ambulate.