Every finding on record at Laurel Ridge Center for Health & Rehabilitation

Based on clinical record reviews, review of facility documentation, facility policies, and interviews for two (2) of two (2) sampled residents (Residents #1 and #2) who were reviewed for dignity and respect, the facility failed to ensure a staff member refrained from making a disrespectful comment to Resident #1 and Resident #2 while the residents were viewing a movie in Resident #1's room. The findings include: *Resident #2's diagnosis included autistic disorder, depression, attention deficit hyperactivity disorder, history of a traumatic brain injury, and unspecified intellectual disabilities. The annual Minimum Data Set assessment dated [DATE] identified Resident #2 had some orientation and memory recall deficits. The Resident Care Plan dated 5/7/26 identified Resident #2 had psychosocial well-being problems related to adjustment to placement in the facility, behavior concerns and mental health needs. Interventions directed to allow the resident time to answer questions and to verbalize feelings, perceptions and fears, and consult with psychiatric/psychological services as needed. **Resident #1's diagnoses included hemiplegia and hemiparesis following a cerebrovascular accident, depression, anxiety, and unspecified mood disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, and time. The Resident Care Plan dated 7/17/26 identified Resident #1 had depression related to adjustment disorder. Interventions directed to arrange for psychiatric consult as needed, assist the resident in developing a program of activities that is meaningful and of interest, discuss any concerns, fears, issues regarding health or other subjects, and monitor for nonverbal signs of increased depression. The nurse's note dated 8/3/26 identified the Assistant Director of Nursing (ADON) and the social worker (SW #1) met with Resident #1 at 11:30 AM and Resident #1 reported he/she was missing $10.00 after ordering food the previous week. The note indicated after SW #1 asked Resident #1 if he/she had any further concerns, Resident #1 reported that a nurse aide, Nurse Aide (NA) #1, on multiple different occasions, had engaged in sexually inappropriate conduct both verbally and physically towards him/her. The note identified NA #1 was removed from the schedule immediately and an investigation was initiated. The Facility Reported Incident form dated 8/3/26 at 2:30 PM identified Resident #2 was watching videos with Resident #1 and Resident #1 noted Resident #2 had fluid on his/her face. The report indicated a staff member entered the room and made a crude sexual joke referring to both residents regarding the fluid on Resident #2s face. The report identified both residents confirmed the comment NA #1 made. Review of NA #1's written statement dated 8/3/26 identified he denied the allegations made against him. NA #1 indicated that the previous night (8/2/26) when he entered Resident #1's room, he observed Resident #2 with fluid on his/her mouth, and he informed Resident #2 of this. NA #1 denied that the comment was sexual in nature. The Summary Report dated 8/6/26 identified NA #1 was suspended pending the outcome and would be terminated for violating customer service in regards to dignity. Interview with Resident #1 on 8/31/26 at 11:06 AM identified on 8/2/26 Resident #2 was in his/her room and they were watching a movie when NA #1 entered the room and made a crude sexual comment to him/her and Resident #2 regarding some fluid on Resident #2's mouth. Resident #1 reported that NA #1 had made similar sexual comments and advances in the past but never reported any of those occurrences. Interview with SW #1 on 8/31/26 at 12:48 PM identified on 8/3/26, Resident #1 reported that NA #1 made some inappropriate comments to both Resident #1 and Resident #2 the previous evening, 8/2/26, while they were watching a movie. SW #1 identified neither resident had any ill effects after the incident. Interview the Assistant Director of Nursing (ADON) on 8/31/26 at 1:20 PM identified Resident #1 had reported to the administrator that $10.00 was missing from his/her drawer. The ADON identified when she went up to investigate the missing money, Resident #1 reported that NA #1 had made some inappropriate sexual comments to him/her and Resident #2. The ADON identified that neither Resident #1 nor Resident #2 had any previous history of accusatory behaviors. The ADON identified at the conclusion of the investigation, although it was determined NA #1 had not maintained professional boundaries with Resident #1 and Resident #2, the facility could not substantiate sexual abuse had occurred. The ADON identified the facility policy for resident rights directed that every resident is to be treated with dignity and respect and it was the responsibility of all staff members to ensure the policy is followed. Interview with the administrator on 8/31/26 at 1:31 PM identified on 8/3/26, Resident #1 initially reported that he/she was missing $10.00. The administrator identified the ADON went to investigate the missing money and at that time Resident #1 reported NA #1 had made inappropriate comments to Resident #1 and Resident #2. The administrator explained the outcome of the investigation, they could not substantiate the egregious allegations of sexual abuse, however they were able to substantiate the allegation that NA #1 made inappropriate comments to Resident #1 and Resident #2 and NA #1 was terminated. Although attempted, an interview with NA #1 was unable to be obtained. Review of the facility policy titled Residents' [NAME] of Rights, revised 9/2017, directed, in part it is the policy of the facility to adhere, inform and educate residents and staff of the residents' bill of rights. The policy further directed, in part, each resident has the right to be treated with consideration, respect and full recognition of their dignity and individuality.

Based on review of clinical records, interviews, and review of facility documentation and policy for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a change of condition was reported to the provider on two occasions in accordance with facility policy. The findings included: Resident #1 was admitted to the facility in December of 2024 with diagnoses that included unspecified dementia, Type 2 diabetes mellitus, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and was dependent with eating, oral and personal hygiene, and independent with ambulation. Review of the Resident Care Plan (RCP) dated 2/26/25 identified Resident #1 wandered related to dementia with behaviors and had the potential for falls due to poor safety awareness. Interventions directed to ensure Resident #1's room and the surrounding environment were safe and free from hazards that could cause harm and to monitor for changes in mental status such as new onset confusion, sleepiness, behavioral and neurological changes. 1. A nurse's note by LPN #1 dated 3/31/25 at 3:50 PM identified Resident #1 was alert, confused, and lethargic, had care provided with the assist of one (1) person, ate 0% of breakfast, 50% of lunch, fluid intake was encouraged, and APRN #1 was informed. Interview with APRN #1 on 5/2/25 at 1:47 PM identified LPN #1 failed to inform him/her that Resident #1 was lethargic (sleepy) on 3/31/25, but that LPN #1 informed him/her of Resident #1's decreased meal consumption and that Resident #1 was otherwise at his/her baseline. APRN #1 further identified that she was at the facility on 3/31/25 and, had he/she been made aware of lethargy (sleepiness), he/she would have formally seen Resident #1 to further evaluate him/her. Interview with LPN #1 (first shift charge nurse from 7:00 AM to 3:30 PM) on 5/6/25 at 9:47 AM identified Resident #1 was still ambulating on and off throughout the day on 3/31/25 but appeared lethargic (sleepy). LPN #1 indicated he/she updated the provider with Resident #1's status, however was unable to recall exactly what he/she reported. 2. A nurses note by LPN #1 dated 4/1/25 at 2:31 PM identified Resident #1 was observed wandering next to the nurse's station, tripped and lost balance after bumping into another resident's walker, and was able to hold onto the bench as he/she lowered himself/herself onto the floor. The 4/1/25 Change of Condition Evaluation completed by RN #1 identified Resident #1 sustained a fall that morning (4/1/25), was awake and responded to name when called, was not in pain, did not grimace or moan, range of motion to both upper and lower extremities was unlimited and moving well without pain, bilateral lower extremities were equal in length, and no mental status changes were observed. RN #1 further indicated the provider was notified and recommended to monitor Resident #1. Resident #1 was immediately assisted to his/her wheelchair and transferred back to bed. Review of RN #1's note dated 4/2/25 at 1:59 PM identified Resident #1 911 was called due to a change in Resident #1's level of consciousness. Review of the hospital Discharge summary dated [DATE] identified Resident #1 was admitted to the hospital with diagnoses that included hyperosmolar hyperglycemic state, hypernatremia, acute metabolic encephalopathy, and right clavicle fracture. Interview with SW #1 on 5/2/25 at 9:58 AM identified he/she returned a call from Person #1 on 4/2/25 who voiced concerns regarding Resident #1's health status, indicating he/she did not appear well and that Person #1 thought something was wrong. SW #1 indicated he/she informed both the Administrator and Director of Nurses following the phone call and Resident #1 was sent to the hospital shortly thereafter. Interview with LPN #1 (7:00 AM to 3:00 PM charge nurse) on 5/2/25 at 11:47 AM identified Resident #1 would constantly walk on the unit, however after he/she fell on 4/1/25, Resident #1 remained in bed the remainder of the afternoon until LPN #1's shift ended at 3:00 PM. LPN #1 further identified it was unusual for Resident #1 to stay in bed but the provider was not notified of the change in Resident #1's activity level during his/her shift. Interview with LPN #2 (3:00 PM to 11:00 PM charge nurse on 4/1/25) on 5/2/25 at 12:27 PM identified Resident #1 would walk up and down the hallways of the facility all the time, however after his/her fall on 4/1/25, remained in bed. LPN #2 further identified that was unusual for Resident #1 as he/she normally walked unless he/she was being fed or assisted to bed, and would normally attempt to get out of bed after being assisted to bed. LPN #2 identified that because Resident #2 had sustained a fall earlier that day, he/she did not expect Resident #1 to get out of bed. LPN #2 indicated he/she did not inform the provider of Resident #1's change of condition. Interview with APRN #1 on 5/6/25 at 12:50 PM identified labs were ordered following Resident #1's fall on 4/1/25 and that he/she was not aware Resident #1 remained in bed following his/her fall the remainder of the day (4/1/25). APRN #1 further identified that Resident #1's lack of activity and remaining in bed was a change in condition as he/she was normally very active, and that a provider should have been informed. Interview with the Director of Nurses on 5/7/25 at 12:15 PM identified the standard of practice for a change of condition was to perform a change of condition evaluation, and to notify the provider and family/patient representative of the concern. Review of the Change of Condition policy directed the facility would inform the resident, resident's healthcare provider, and the resident's family/legal representative when there was a significant change in the resident's physical, mental, or psychosocial status, and to ensure a resident's change of condition was evaluated and documented properly.

Based on staff interview and review of Payroll Based Journal (PBJ) the facility failed provide appropriate number of staff for Quarter 2 (January 1, 2024 through March 31, 2024 ). The findings include: PBJ submissions for Quarter 2, 2024 (January 1, 2024 to March 31, 2024) indicated excessively low weekend staffing. An interview on 4/8/25 at 11:41 AM with the Administrator identified for Quarter 2 in 2024 (January 1, 2024 to March 31, 2024), the previous owner would not allow the facility to use agency staff or to have licensed staff work as Nursing Assistants, which would assist with having adequate nursing staff. Further identifying that the facility did have low weekend staffing during Quarter 2 of 2024. Review of the Mandatory submission of staffing information based on payroll data in a uniform format. The facility must electronically submit to CMS complete and accurate direct care staffing information.

Based on staff interview and review of Payroll Based Journal (PBJ) submissions for Quarter 1, 2025 (October 1, 2024 through December 31, 2024) the facility failed to ensure the PBJ data was submitted accurately. Also, it was identified through the PBJ report that the facility failed provide appropriate number of staff for Quarter 2 (January 1, 2024 through March 31, 2024 ). The findings include: PBJ submissions for Quarter 1 of 2025 identified the facility was had 1-star rating, Registered Nurse (RN) Hours and Licensed Nursing Coverage for 24 hours/day for 10/1/24, 10/2/24, 10/3/24, 10/4/24, 10/5/24, 10/6/24, 10/7/24, 10/8/24, and 10/9/24 identified no RN hours and failed to have licensed nursing coverage 24 hours/day. Also, identified on the PBJ report for Quarter 2, 2024 (January 1, 2024 to March 31, 2024) indicated excessively low weekend staffing. An interview on 4/8/25 at 11:41 AM with the Administrator identified that the No Registered Nurse hours along and a licensed nursing coverage for 24 hours in a day was triggered (coded) incorrectly by the previous owner of the facility. Also, identified was that Quarter 2 in 2024, the previous owner would not allow the facility to use agency staff or to have licensed staff work as Nursing Assistants, which would assist with having adequate nursing staff. Further identifying that the facility did have low weekend staffing during Quarter 2 of 2024. Review of the Mandatory submission of staffing information based on payroll data in a uniform format. The facility must electronically submit to CMS complete and accurate direct care staffing information.

Based on record review, facility documentation, and staff interviews for 1 of 1 residents (Resident #9) reviewed for an injury of unknown origin, for 2 of 4 residents involved in resident to resident altercations (Resident #59 and Resident #81), and for four of eight residents (Resident #27, #40, #62 and #99) reviewed for abuse, the facility failed to report the injury of unknown origin (Resident #9) and the resident to resident altercations to the Stage Agency. Additionally, for Resident #27, #40, #62 and #99, the facility failed to ensure staff reported an allegation of abuse immediately. The findings include: 1. Resident #9 was admitted to the facility in October of 2024 with diagnoses that included hemiplegia (one sided muscle paralysis) affecting the right dominant side, hypertension, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was cognitively intact, was dependent on staff for toileting and required maximum assistance for personal hygiene and bed mobility and transfers. The MDS further identified Resident #9 had an impairment on one side of his/her upper extremity and lower extremities and used a walker and wheelchair for ambulation. The Resident Care Plan (RCP) dated 10/24/24, identified Resident #9 required extensive assistance of 1 staff member for self-care tasks due to weakness, impaired sitting balance and strength. Interventions included assisting Resident #9 with self-care tasks and referral to occupational therapy when applicable. A facility Reportable Event (RE) form dated 11/29/24 at 12:00 PM written by LPN #3 identified Resident #9 with a discoloration to the left eye with no complaints of pain or discomfort. The RE further identified Resident #9 was alert and oriented, the responsible party was notified of the injury on 11/29/24 at 3:00 PM and APRN #2 was notified of the left eye discoloration on 11/29/24 at 3:05 PM. A nursing note dated 11/29/24 at 3:17 PM written by LPN #3 identified that she was notified by NA #7 of Resident #9's discoloration to the left eye. LPN #3 notified APRN #2 who directed a complete blood count with differential test (group of blood cells that measure the number and size of the different cells in blood), cold compresses every 15 to 20 minutes for 24 hours and neuro assessments according to the facility's protocol. The nursing note further directed staff to notify the APRN with worsening symptoms such as swelling to the left eye, blurred or double vision, headache, nausea or vomiting. LPN #3 indicated that Resident #9's responsible party was also notified. Interview with LPN #3 on 4/3/24 at 2:40 PM identified that she was notified of Resident #9's discoloration to left eye on 11/29/24 by NA #7. LPN #3 identified that she assessed Resident #9 and noted a bluish color/discoloration around the entire left eye. LPN #3 further identified that she notified the Nursing Supervisor (RN#2) and the provider APRN #2 of the injury through a phone call. LPN #3 identified that APRN #2 directed a blood test and cold compress to the left eye. LPN #3 identified that the RN Supervisor was responsible for assessing and ensuring that accidents and incidents were reported to the appropriate state agencies according to the facility's policy. Interview and record review with RN #2 on 4/3/25 at 3:00 PM, identified that she was the Nursing Supervisor for the 7:00 AM to 3:00 PM shift on 11/29/24 when Resident #9's injury was identified. RN #2 identified that notification of Resident#9's injury to the state agency was not done since she did not complete an assessment of Resident #9's left eye. RN #2 identified that such an injury would be classified as an injury of unknown origin and should have been reported to the overseeing state agency after the injury was identified. (Please cross reference F 658) Interview with the DNS on 4/5/25 at 12:00 PM identified that Resident #9's injury was not reported to the overseeing state agency. The DNS identified that an injury of unknown origin should have been investigated and reported to the overseeing state agency. Subsequent to document request, the facility provided a statement completed by LPN #3 dated 4/11/24 that identified that the discoloration to Resident#9's left eye was approximately pea size even though she had identified in an interview with the surveyor that she noted a bluish color/discoloration around Resident #9's entire left eye. Review of facility policy titled, Accident/Incident Reporting Policies and Procedures, identified in part, that all incident all occurrences are reported and thoroughly investigated as per state and federal regulations. 2a. Resident #59 was admitted to the facility in September of 2022 with diagnoses that included dementia, anxiety, and dysphagia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 was severely cognitively impaired, had verbal behavioral symptoms directed towards others, had the behavior of wandering, and was independent with eating, bed mobility and transfers. The Resident Care Plan (RCP) dated 4/29/24 identified Resident #59 had a history of anxiety and depression. Interventions included observing periods of anxiety, provide a calm, quiet environment and encourage Resident #59 to verbalize thoughts and feelings related to anxiety. A nursing note written by Licensed Practical Nurse (LPN) #2 on 5/13/24 at 5:45 PM (referring to an event that occurred on 5/12/24 per the facility Reportable Event form) identified Resident #59 was in the dining room waiting for dinner when another resident (Resident #81) approached him/her asking questions and Resident #59 responded, I don't understand you., after which Resident #81 punched Resident #59 in the face. The nursing note identified that LPN #2 assessed Resident #59, performed neuros, and did not identify bleeding, pain or discomfort. The nursing note further identified LPN #2 redirected Resident #81 to his/her room, and the APRN and responsible party were notified. b. Resident #81 was admitted to the facility in June of 2023 with diagnoses that included Alzheimer's disease, anxiety disorder, and delusional disorders. The Resident Care Plan (RCP) dated 2/27/24 identified Resident #81 had potential for agitation manifested by hitting other residents and Resident #81 was physical and combative at times as evidenced by hitting and aggression on 10/20/23 and aggression/altercation on 4/29/24. Interventions included offering fluids/snacks and have Resident #81 stay next to the nursing station sitting on the bench, ensure Resident #81 was the first resident to get ready for bed after dinner, and provide one on one with Resident #81 to manage agitation. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #81 was severely cognitively impaired, had several days of the mood symptom of being short-tempered and easily annoyed, had verbal behavioral symptoms directed towards others, had the behavior of wandering, required supervision or touching assistance with eating, and was independent with transfers and walking. A nursing note written by LPN #2 dated 5/12/24 at 10:18 PM identified Resident #81 was anxious, crying and aggressive with another resident (Resident #59), and Resident #81 was redirected to his/her room, was offered crackers and apple juice without positive results, and was given Lorazepam (antianxiety medication) 0.25 milligrams (mg) with positive results. A facility Reportable Event form dated 5/13/24 identified on 5/12/24 at 4:30 PM Resident #81 walked up to Resident #59 and punched Resident #59 in the face. The event was witnessed by a visitor who reported it to Licensed Practical Nurse (LPN) #2. Review of the State Agency reportable event website identified the facility didn't report the resident to resident altercation until 5/13/24 at 10:00 AM (17 hours and 30 minutes after the event). Interview with Director of Nursing Services (DNS) on 4/8/2025 at 9:50 AM identified she had not reported the resident to resident altercation to the State Agency timely due to she was not aware of the incident until the following day. On 5/13/25 when she became aware of the incident she immediately reported it to the State Agency. Review of the Clinical Services Abuse Policy and Procedure directed, in part, when any allegations of abuse or mistreatment are observed by any employee the following steps will be implemented: immediately protect the resident from alleged abuse; immediately notify the nursing supervisor; the nursing supervisor/charge nurse will immediately report abuse allegations to the Administrator and DNS; and the facility will notify the Department of Public Health immediately but no later than 2 hours after the allegation is made if the event involves abuse. 3a. Resident #27 had a diagnosis of obstructive and reflux uropathy (impaired urine flow). The admission MDS dated [DATE] identified Resident #27 had a BIMS of 14 indicating an intact cognition and was always incontinent of bladder and bowel. The RCP dated 1/6/2025 identified a self-care deficit, and incontinent of bladder and bowel. Interventions directed to assist with ADLs and provide incontinent care. b. Resident #40 had a diagnosis of hemiplegia/ hemiparesis (weakness/paralysis) of the right dominant side, and aphasia. The annual MDS dated [DATE] identified severely impaired cognitive skills, required assistance with ADLs, and was always incontinent of bladder and bowel. The Resident Care Plan (RCP) dated 2/3/2025 identified alteration in ADLs, and incontinence. Interviews directed to assist with ADLs and provide incontinent care. c. Resident #62 had a diagnosis of cerebral infarction (stroke) with hemiplegia affecting the left side, and a cognitive communication deficit. The annual MDS dated [DATE] identified Resident #1 had a BIMS of 14 indicating intact cognition and was frequently incontinent of bladder, and always incontinent of bowel. The RCP dated 2/3/2025 identified incontinent of bowel and bladder, and a self-care deficit. Interventions directed to assist with ADLs and to provide incontinent care approximately every 2 hours and as needed. d. Resident #99 had a diagnosis of dementia. The quarterly MDS assessment dated [DATE] identified Resident #99 had a Brief Interview of Mental Status (BIMS) score of 8 indicating moderately impaired cognition, was dependent for ADLs, and was always incontinent of bladder and bowel. The RCP dated 1/23/2025 identified an ADL deficit and incontinent of bowel and bladder. Interventions directed to assist with ADLs, and to provide incontinent care every two (2) hours and as needed. A facility incident report dated 3/10/2025 at 12 noon identified on 3/8/2025 at approximately 1:30 PM, LPN #1 identified when LPN #1 was providing treatments he identified Resident #40 was in need of incontinent care. LPN #1 and a NA provided the care. Further, LPN #1 identified Residents #27, #62 and #99 were in need of incontinent care, and care was provided. Facility summary dated 3/14/2025 identified although morning care was provided for Residents #27, # 40, #62 (Resident #99 refused morning care), incontinent care was not provided until 2 PM for Residents #27, 40, #62 and #90 when it was provided by LPN #1. Please cross reference F 600. Review of the State Agency reportable event website identified the State Agency was notified of the allegation of neglect on 3/10/2025 at 12 PM. Review of the reportable event identified the incident occurred on 3/8/2025 at 1:30 PM; the State Agency was notified (1 day, 22 hours and 30 minutes after the facility was aware). Facility undated written statement from RN #1 identified on 3/8/2025 LPN #1 notified her that NA #1 did not change the residents she was assigned to during the afternoon. Although attempted, an interview with RN #1 was not obtained during the survey. Interview and record review with the DNS on 3/28/2025 at 9:32 AM identified Residents #27, 40, 62 and 99 did not receive care on 3/8/2025. The DNS stated although RN #1 (supervisor working 7 AM to 3 PM) was aware of the allegation, RN #1 did not notify her until the end of RN #1's shift (shift ended at 3 PM). The DNS stated RN #1 should have notified her immediately when the neglect was identified, and the State Agency should have been notified within two (2) hours. Interview failed to identify why the State Agency was not notified until 3/10/2025. Review of facility Abuse Policy directed in part, abuse allegations require immediate action, report immediately to the supervisor and a two (2) hour requirement to report to the State Agency. Facility documentation review identified staff education was initiated on 2/28/2025 and included directing staff to report allegations immediately, and allegations are required to be reported to the State Agency within two (2) hours. A QAPI meeting was held on 3/10/2025, and audits were initiated on 3/14/2025. Based on review of facility documentation, past non-compliance was identified. 50250 51183

Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #104) reviewed for recreational activities, the facility failed to provide activities that met Resident #104's interests and preferences. The findings include: Resident #104 was admitted to the facility in October 2024 with diagnoses that included chronic kidney disease, diabetes, combined forms of age-related bilateral cataracts, and hypertension. An activities admission assessment dated [DATE] indicated Resident #104's past interests included drawing/painting, fishing, traveling, sports, movies, concerts, cooking, and listening to music. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #104 had a severe cognitive impairment, highly impaired vision, adequate hearing, and supervision or touching assistance with activities of daily living. The MDS (daily preferences) further identified that Resident #104 indicated that it was very important for him/her to choose clothes to wear, have snacks available between meals and have family or close friend involved in discussion about his/her care. Activity preferences identified that it was very important for him/her to listen to music that he/she liked, go outside and to get fresh air when the weather permitted and be around animals such as pets. The Resident Care Plan dated 11/24/24 identified Resident #104 had impaired visual function related to visual loss in left eye from previous stroke and bilateral cataracts. Interventions included one-on-one visits from staff. (The RCP failed to include a recreational activities care plan. Please cross reference F 656). Review of the activities calendar for the month of March and April 2025 identified that pet therapy was provided 3 times per week by the facility. Interview and observation with Resident #104 on 3/31/25 at 11:46 AM identified Resident #104 was lying in bed with the head of the bed elevated with the television on. Observations of the room identified a recreation calendar on the bathroom door but failed to identify any means for Resident #104 to listen to music as was identified an the preference assessment. Interview with Resident #104 at that time indicated that he/she was unaware about recreational activities that were offered at the facility. Resident #104 further identified he/she was blind, was not involved in activities or taken out for fresh air. Interview with the Assistant Director of Recreation (ADR) on 4/7/25 at 2:30 PM indicated that he provided 1:1 activity for Resident #104 in the resident's room twice a week which entail; socializing, listening to TV, and passing snacks. The ADR further indicated that socializing entails about 1 minute of 1:1 interaction with Resident #104 whereby he asks the resident how he/she was doing and nothing else in specific while for the television therapy he would pass by/peek inside the room and if the television was on, without necessarily entering the room, he would chart/document that television therapy was administered. The ADR identified that Resident #104 liked music and hockey sports but had not looked into that or engaged him/her in those activities. Re-interview with the ADR on 4/8/25 at 10:30 AM identified that even though Resident #104 liked music, pets and fresh air, he/she had not been out of his/her room for fresh air breaks since he was admitted to the facility due to bad weather, does not have a radio/cd player in his/her room for music therapy and pet therapy had not been attempted (despite pet therapy occurring in resident rooms). The ADR further indicated Resident #104 had visual impairment and did not seem like he/she wanted to go to groups. The ADR further identified that he would start Resident #104 on daily therapy to include dog therapy, fresh air breaks and start music therapy. The ADR indicated that engaging Resident #104 in activities of his/her interests was his responsibility and indicated that it was an oversight on his part for not having done it. Interview with the Recreational Director (RD) on 4/8/25 at 11:01 AM, identified that Resident #104 had vision impairment, refused to come out of his/her room, and was not inclined to engaging in group activities. The RD indicated that Resident #104 received 1:1 activity in his/her room which were provided by the ADR. The RD identified that since the initial admission recreational activity assessment was done in November of 2024, no further assessments had been done. The RD indicated that she would reassess Resident #104 and engage him/her in activities of his/her interests to include music therapy, fresh air breaks and dog therapy. Review of facility policy titled, Therapeutic Recreation, identified in part, that therapeutic recreation will provide recreational activities that will contribute to resident's level of function and well-being by stimulating increased physical, emotional and social interactions. The therapeutic recreation department will provide activities centered around individual interest, needs as well as expressed requests. Activities are resident centered based on residents' age, physical and cognitive limitations.

Based on observations, facility documentation, facility policy and interviews, the facility failed to ensure food temperatures were palatable. The findings include: A Resident council meeting was completed on 4/2/25 at 1:44 PM and residents verbalized concerns regarding food palatability, specifically cold food. The residents identified that they had raised the issue with the Food Service Director (FSD) during Monthly Food Committee meetings but food continued to be cold. Review of Food Committee Meeting minutes from 4/10/24 through 3/12/25 identified residents' concerns about cold food. On 4/10/24 residents expressed concerns about cold coffee, cold soup and cold dinner. On 8/14/24 a resident raised concern about cold soup. On 2/12/25 the FSD informed residents that if they get cold food, they could call the kitchen or ask the Nurse Aides (NA's) to warm the food since thermometers were available at the nursing stations to measure food temperatures. On 3/13/25 the issue about cold soup and cold meals was mentioned once again and the FSD encouraged residents to ask staff for food to be reheated or ask for the meal to be replaced. Observation of the tray line on 4/3/25 at 11:45 AM identified meal plates being placed on trays then covered by clear plastic lids. Each plastic lid contained a large hole/opening at the top/upper section. The trays were placed in enclosed/insulated meal delivery carts and delivered on the first-floor unit (dementia unit). No hot plates or insulated lids were used on the first-floor meal delivery cart. Interview with the FSD identified that residents who reside on first floor were served meals using plates that were covered by plastic lids. The FSD further identified that hot plates and insulated lids were not used for residents who reside on first floor due to risk of burns related to dementia but indicated that insulated lids and hot plates were used for residents who reside on second floor and third floor. The FSD further indicated that first floor residents were always served before all other residents to avoid issues with food temperatures. FSD was not able to give a reason the clear lids had holes/openings on top or explain if the hole/opening would affect food temperature. Observation of tray line on 4/3/25 identified second floor food carts were served at 12:00 PM and third floor food carts were served at 12:25 PM. Even though FSD had indicated that insulated lids and hot plates were used for second and third floor residents, about half of the meals loaded in the delivery carts had plates that were covered by plastic lids that had openings/holes at the top. Interview with the FSD identified that they did not have enough hot plates and insulated lids for residents on second and third floor. The FSD indicated that sometimes not all dishes were collected from previous meals. The FSD further indicated that she had placed an order for more insulated lids and hot plates to be supplied. A test tray was conducted on the third-floor meal delivery cart at 12:38 PM on 4/3/25 with the FSD and the cart was brought through the elevator to the third-floor nursing unit. All meal trays were delivered to the residents by nursing staff on the unit. The test tray was the last tray served on the nursing unit, was brought to the nursing unit kitchenette at 12:45 PM and the following temperatures were obtained: Cheezy potatoes: surveyor obtained a temperature of 136 degrees Fahrenheit, the FSD obtained a temperature of 140 degrees Fahrenheit. The pork lion: surveyor obtained a temperature of 127 degrees Fahrenheit and the FSD obtained a temperature of 130 degrees Fahrenheit. The brussel sprout: surveyor obtained a temperature of 124 degrees Fahrenheit and the FSD obtained a temperature of 124 degrees Fahrenheit. Interview with the FSD on 4/6/25 at 12:16 PM identified the food temperatures were low for the pork lion and sprout. The FSD further indicated that food temperature should be maintained above 140 degrees Fahrenheit with use of insulated covers and hot plates. Review of the Food Temperatures policy identified that hot foods would be maintained at 140 degrees Fahrenheit or more.

Based on resident and staff interviews, initial tours and review of the facility policy, the facility failed to ensure snacks were passed out after dinner/before bed. The findings include: 1. Resident #14 's diagnosis included cerebral palsy, chronic kidney disease, and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact, and dependent assist for showering, dressing, personal hygiene, and repositioning. The MDS further identified Resident #14 required a set up for eating. The Resident Care Plan (RCP) dated 1/6/25 identified Resident #14 had an activities of daily living risk related to paralysis and cerebral palsy with intervention that included to provide a mechanical lift for transfers with assistance of 2, Resident #14 was non ambulatory and was to be provided set up assistance for meals. On 4/1/25 at 10:22 AM during initial tour Resident #14 identified that she/he was not always offered a snack and at times Resident #14 would want a snack. On 4/1/25 at 11:00 AM an observation during the initial tour of the facility identified signage for snacks was posted for 10:00 AM, 3:00 PM and 8:00 PM, containing a large list of snacks that was available. 2. On 4/2/25 at 1:44 PM a Resident Council meeting was conducted with numerous residents who were in attendance that identified that residents were not offered snacks from staff, but had to request a snack. On 4/2/25 at 3:00 PM an interview with the Dietary Director identified that snacks were provided at 10:00 AM, 3:00 PM, and 8:00 PM. Also, identified that the dietary staff delivered the snacks to the residents in the facility and a list was provided by the Dietician and/or nursing for the residents that were provided with a snack. Resident #14 was not on the list provided. Further identifying, that if a resident was bedbound the resident needed to ask for a snack. On 4/3/25 at 1:53 PM an interview with Nurse Aide (NA) #4 identified that the Dietary staff brings the snacks to the unit and the NAs were responsible for passing the snacks, that there was a list provided for Residents wanting a snack and that a resident was care planned for snacks with this information being found in the Electronic Health Record. Further, identifying that a resident needs to request a snack and that NA #4 was not sure of the policy regarding snacks. On 4/3/25 at 1:58 PM an interview with Registered Nurse (RN) #2 identified that NAs were responsible for asking residents if they would like a snack between 10:00 AM, 3:00 PM and 8:00 PM. On 4/ 3/25 at 2:04 PM an interview with NA #5 identified that she does not go to each room and offer residents snacks and that if a resident requested a snack she would check with the nurse to see if the snack was acceptable for the individual resident before providing one. On 4/3/25 at 2:32 PM an interview with the Administrator identified that the staff was responsible for offering snacks and that a resident needed to ask for one. Further, identified that the signage regarding snacks posted by the nurse's station was new and that she had never seen it before. Also, she identified that snacks were not provided at 10:00 AM, 3:00 PM, and 8:00 PM, the NAs were responsible for passing out snacks to residents on all shifts when a resident requested a snack, and education would be provided to the staff regarding the signage posted on all the units regarding snacks. Review of the policy for Meal Frequency identified that the meal service schedule was planned such that there are no more than 14 hours between the evening meal and breakfast the following day. Up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a nourishing snack was provided for all residents. Also, identified snacks are offered to residents at bedtime and per their request.

Based on record review, facility documentation, and staff interviews for one of six residents (Resident #40) reviewed for abuse, the facility failed to ensure the medical record was complete and accurate to include timely documentation of an APRN visit. The findings include: Resident #40 had a diagnosis of hemiplegia/ hemiparesis (weakness/paralysis) of the right dominant side, and aphasia. The annual MDS dated [DATE] identified severely impaired cognitive skills, required assistance with ADLs, and was always incontinent of bladder and bowel. The Resident Care Plan (RCP) dated 2/3/2025 identified alteration in ADLs, and incontinence. Interviews directed to assist with ADLs and provide incontinent care. A facility incident report dated 3/10/2025 at 12 noon identified on 3/8/2025 at approximately 1:30 PM, LPN #1 identified when LPN #1 was providing treatments when he identified Resident #40 had not received timely incontinent care. Interview and record review with the DNS on 3/28/2025 at 9:32 AM identified care was not provided timely during the shift, and the DNS indicated an RN assessment was not completed after the delay in care was identified; from 1:30 PM through 11 PM no assessment was performed. Subsequent to surveyor inquiry, the facility provided an APRN late entry note, dated 3/27/2025 at 11:58 AM. The note indicated that the APRN saw Resident #40 on 3/10/2025 (1 day, 18 hours and 30 minutes after the omitted care was identified) at 8 AM to evaluate Resident #40's skin on his/her buttocks that was identified as bleeding during routine care. Although the APRN note identified she saw Resident #40 on 3/10/2025 at 8 AM, and the omitted care occurred on 3/8/2025 at 1:30 PM (1 day, 18 hours and 30 minutes before the APRN visit occurred). Record review failed to identify the APRN note was entered in the clinical record timely. The late entry note was written 17 days after the APRN visit occurred. Interview and record review with APRN #1 on 3/28/2025 at 11:07 AM identified she saw Resident #40 on 3/10/2025 when she was asked to see the resident, but she did not write a note until 3/27/2025 (17 days later) because she forgot to write the note on 3/10/2025. APRN #1 stated she should have written the note on 3/10/2025 after she saw the resident. Interview and record review with the DNS on 3/28/2025 at 9:32 AM identified the APRN note should have been written on 3/10/2025 when Resident #40 was seen, and the DNS did not know why it was not entered until 3/27/2025 (17 days after the visit occurred). Review of facility charting and documentation policy dated 1/2025 directed in part, to complete documentation at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on review of clinical records, facility documentation, facility policy and interviews for four sampled residents (Resident #59, Resident #81, Resident #90 and Resident #100) reviewed for mistreatment, the facility failed to prevent resident to resident altercations between Resident #59 and Resident #81, and between Resident #90 and Resident #100. Additionally, for four of eight residents (Residents #27, #40, #62 and #99) reviewed for abuse, the facility failed to ensure the residents were free from neglect and that care was provided in a timely manner on 3/8/2025 during the 7 AM to 3 PM shift. The findings include: 1a. Resident #59 was admitted to the facility in September of 2022 with diagnoses that included dementia, anxiety, and dysphagia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 was severely cognitively impaired, had verbal behavioral symptoms directed towards others, had the behavior of wandering, and was independent with eating, bed mobility and transfers. The Resident Care Plan (RCP) dated 4/29/24 identified Resident #59 had a history of anxiety and depression. Interventions included observing for periods of anxiety, provide a calm, quiet environment and encourage Resident #59 to verbalize thoughts and feelings related to anxiety. A nursing note written by the Nursing Supervisor (the current Director of Nursing (DNS)) dated 5/13/24 at 12:45 PM identified she assessed Resident #59 who had been punched in the face by another resident (Resident #81). The nursing note identified Resident #59 was seated in the dining room with other residents when Resident #81 approached Resident #59 and asked some questions, Resident #59 responded saying, I don't understand you., and Resident #81 then punched Resident #59 in the face. The nursing note identified Resident #59 was taken to his/her room for further assessment and neuro checks, Resident #59 denied pain, and had intact skin with no redness or scratches to the face. The nursing note further identified the responsible party and attending APRN had been notified, and the attending APRN came to the facility to evaluate Resident #59. The progress note failed to identify Resident #59 had been punched in the face the previous evening on 5/12/24 (when the actual event occurred). A nursing note written by Licensed Practical Nurse (LPN) #2 on 5/13/24 at 5:45 PM (1 day after the resident to resident altercation occurred) identified Resident #59 was in the dining room waiting for dinner when another resident (Resident #81) approached him/her asking questions and Resident #59 responded, I don't understand you, after which Resident #81 punched Resident #59 in the face. The nursing note identified that LPN #2 assessed Resident #59, performed neuros, and did not identify bleeding, pain or discomfort. The nursing note further identified LPN #2 redirected Resident #81 to his/her room, and the APRN and responsible party were notified. b. Resident #81 was admitted to the facility in June of 2023 with diagnoses that included Alzheimer's disease, anxiety disorder, and delusional disorders. The Resident Care Plan (RCP) dated 2/27/24 identified Resident #81 had potential for agitation manifested by hitting other residents and Resident #81 was physical and combative at times as evidenced by hitting and aggression on 10/20/23 and aggression/altercation on 4/29/24. Interventions included offering fluids and snacks and have Resident #81 stay next to the nursing station sitting on the bench, ensure Resident #81 was the first resident to get ready for bed after dinner, and provide one on one with Resident #81 to manage agitation. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #81 was severely cognitively impaired, had several days mood symptoms of being short-tempered and easily annoyed, had verbal behavioral symptoms directed towards others, had the behavior of wandering, required supervision or touching assistance with eating, and was independent with transfers and walking. A nursing note by LPN #2 dated 5/12/24 at 10:18 PM identified Resident #81 was anxious, crying and aggressive with another resident (Resident #59), and Resident #81 was redirected to his/her room, was offered crackers and apple juice without positive results, and was given Lorazepam (an antianxiety medication) 0.25 milligrams (mg) with positive results. A facility Reportable Event form dated 5/13/24 identified on 5/12/24 at 4:30 PM Resident #81 walked up to Resident #59 and punched Resident #59 in the face. The event was witnessed by a visitor who reported it to Licensed Practical Nurse (LPN) #2. A nursing progress note written by the Nursing Supervisor (the current Director of Nursing (DNS)) dated 5/13/24 at 7:44 PM identified Resident #81 had been evaluated by the APRN who issued a Physician's Emergency Certificate (PEC) (authorization for temporary involuntary psychiatric treatment) sending Resident #81 to the Emergency Department (ED) for crisis intervention. Interview with LPN #2 on 4/8/25 at 11:00 AM identified she had been outside the dining room when she heard yelling and she went into the dining room to see what was happening. Upon entering the dining room LPN #2 identified she had observed Resident #81 standing next to Resident #59 and a visitor sitting near them told her Resident #81 had hit Resident #59. LPN #2 identified she had removed Resident #81 from the dining room and brought him/her to his/her room to sit with a Nurse Aide. LPN #2 identified she had evaluated Resident #81 but that she cannot recall what she had done after that. Review of the Clinical Services Abuse Policy and Procedure directed, in part, the facility will provide individualized care plans that identify risk factors of residents as well as plans for protecting their rights and when any allegations of abuse or mistreatment are observed by any employee the facility will immediately protect the resident from alleged abuse. 2a. Resident #90's diagnoses included Alzheimer's disease, delusional disorder, and psychosis. The Resident Care Plan (RCP) dated 2/28/25 identified Resident #90 had the potential for negative behaviors with interventions to approach and speak to Resident #90 in a calm manner. Also, for the staff to anticipate/meet Resident #90's needs, and to explain all procedures to the resident before starting care. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #90 was severely cognitively impaired, required substantial/maximal assistance for toileting, showering, dressing and personal hygiene. Also, identified that Resident #90 was independent with ambulation/transfers, and required set up for eating. b. Resident #100's diagnoses included dementia, anorexia, and chronic heart disease. The quarterly MDS assessment dated [DATE] identified Resident #100 was severely cognitively impaired, requiring substantial assistance for dressing, and personal hygiene. Also, identified Resident #100 required assistance for eating, and oral hygiene, was totally dependent on showering, and toileting. Further, identified that Resident #100 required supervision assistance with transfers, and ambulation. The Resident Care Plan dated 1/27/25 identified Resident #100 had a deficit in functional mobility with interventions to encourage Resident #100 to engage in physical activities such as walking along with supervise/touching assist for transfers. Resident #100 was also at risk for falls with interventions for Resident #100 to ask for assistance prior to transfers or ambulation as needed, and to orient Resident #100 to his/her surroundings. A facility Reportable Event form dated 3/26/25 identified at 10:26 AM Nurse Aide (NA) #6 was trying to provide morning care to Resident #90 but he/she was visibly agitated even though an attempt was made by NA #6 to redirect Resident #90. Resident #90 pushed NA #6 away and then proceeded to push Resident #100 who fell to the ground. The Psychiatric Evaluation and Consultation dated 3/26/25 noted Resident #90 was evaluated after increased behavioral disturbances. Resident #90 was identified with becoming more impulsive/combatively recently and has been more difficult to redirect. Resident #90 was anxious and pacing throughout the interview. Resident #90 had become combative with care with increased impulsive behavior and tended to be intrusive and wander throughout the facility. An interview on 4/3/25 at 12:05 PM with Licensed Practical Nurse (LPN) #2 identified that Resident #90 was resistive to care on 3/26/25 while NA #6 was with him/her. Further, identifying that Resident #100 was walking the hallway by Resident #90's room that morning when the incident occurred but her vision was obstructed, and she did not see the pushing. An interview on 4/7/25 at 10:16 AM with NA #6 identified that she was attempting to provide morning care for Resident #90, but the resident was agitated, angry and pacing in his/her room. NA #6 further identified that she attempted to redirect Resident #90 to go in the opposite direction in the hallway. Further, identifying Resident #90 then tried to push her and then as Resident #100 was walking by, Resident #90 pushed Resident #100 onto the floor. Review of the facility's Resident Abuse policy dated 1/23 identified that each resident has the right to be free from abuse, neglect, and misappropriation of resident's property and exploitation. Also, identified was the facility to encourage an environment that recognizes the special qualities of the residents and provides them with a safe environment. Further, identified was Resident to Resident altercation is defined as physical or verbal act between two residents with or without resulting an injury. 3a. Resident #27 had a diagnosis of obstructive and reflux uropathy (impaired urine flow). The admission MDS dated [DATE] identified Resident #27 had a BIMS of 14 indicating an intact cognition and was always incontinent of bladder and bowel. The RCP dated 1/6/2025 identified a self-care deficit, and incontinent of bladder and bowel. Interventions directed to assist with ADLs and provide incontinent care. b. Resident #40 had a diagnosis of hemiplegia/ hemiparesis (weakness/paralysis) of the right dominant side, and aphasia. The annual MDS dated [DATE] identified severely impaired cognitive skills, required assistance with ADLs, and was always incontinent of bladder and bowel. The Resident Care Plan (RCP) dated 2/3/2025 identified alteration in ADLs, and incontinence. Interviews directed to assist with ADLs and provide incontinent care. c. Resident #62 had a diagnosis of cerebral infarction (stroke) with hemiplegia affecting the left side, and a cognitive communication deficit. The annual MDS dated [DATE] identified Resident #1 had a BIMS of 14 indicating intact cognition and was frequently incontinent of bladder, and always incontinent of bowel. The RCP dated 2/3/2025 identified incontinent of bowel and bladder, and a self-care deficit. Interventions directed to assist with ADLs and to provide incontinent care approximately every 2 hours and as needed. d. Resident #99 had a diagnosis of dementia. The quarterly MDS assessment dated [DATE] identified Resident #99 had a Brief Interview of Mental Status (BIMS) score of 8 indicating moderately impaired cognition, was dependent for ADLs, and was always incontinent of bladder and bowel. The RCP dated 1/23/2025 identified an ADL deficit and incontinent of bowel and bladder. Interventions directed to assist with ADLs, and to provide incontinent care every two (2) hours and as needed. A facility incident report dated 3/10/2025 at 12 noon identified on 3/8/2025 at approximately 1:30 PM, LPN #1 identified when LPN #1 was providing treatments he identified Resident #40 was in need of incontinent care. LPN #1 and a NA provided the care. Further, LPN #1 identified Residents #27, #62 and #99 were in need of incontinent care, and care was provided. Facility summary dated 3/14/2025 identified although morning care was provided for Residents #27, #40, #62 (Resident #99 refused morning care), incontinent care was not provided until 2 PM for Residents #27, 40, #62 and #90 when it was provided by LPN #1. Record review of NA care card on 3/8/2025 identified Resident #27 received or provided incontinent care at 4:08 AM and did not receive incontinent care again until 2:31 PM (10 hours and 23 minutes after last received). Record review of NA care card on 3/8/2025 identified Resident #40 received incontinent care at 6:47 AM on 3/8/2025 and did not receive incontinent care again until 1:44 PM on 3/8/2025 (6 hours and 57 minutes after last received). Record review of NA care card on 3/8/2025 identified Resident #62 received incontinent care at 3:49 AM and did not receive incontinent care again until 2:34 PM (10 hours and 45 minutes after last received). Record review of NA care card on 3/8/2025 identified Resident #99 received incontinent care at 4:40 AM and did not receive incontinent care again until 11:53 AM (7 hours and 13 minutes after last received). Facility written statement from LPN #1 on 3/9/2025 identified he took a NA with him to perform resident treatments and when performing treatments on Resident #40, LPN #1 identified the resident's brief was fully soiled with a bowel movement and urine. The statement further identified that all the residents he provided treatments for, required incontinent care. RN #1 (day shift supervisor) was notified the residents had not received care. Facility undated written statement from RN #1 identified on 3/8/2025 LPN #1 notified her that NA #1 did not change the residents she was assigned to during the afternoon. RN #1 questioned NA #1 about her assigned residents that were not changed and indicated all assigned residents need to be toileted and changed in the afternoon after lunch. Although attempted, interviews with LPN #1 and RN #1 were not obtained during the survey. Interview with NA #1 on 3/28/2025 at 1:26 PM identified NA #1 gave incontinent care to Resident #27 at 8:30 AM and then did not check on Resident #27 again until 1:30 PM (5 hours later), and she gave no additional incontinent care after 8:30 AM because Resident #27 said he/she did not need it. NA #1 stated Resident #40 required assist of two (2) staff, and on 3/8/2025 about 9:30 AM she tried asking other NAs to wash and change Resident #40, but they never came to help her. NA #1 stated she tried to change Resident #40 but he/she said no, and then when she checked, Resident #40 was not incontinent. The next care provided was about 2:30 PM by LPN #1 and another NA; NA #1 stated she gave no care to Resident #40 during the shift because she did not have a second staff to assist. For Resident #62, NA #1 stated she saw Resident #62 at 9:30 AM and washed only his/her upper body. NA #1 did not change Resident #62's brief or wash the lower body, and stated Resident #62 was not incontinent at 9:30 AM. NA #1 indicated she wanted to change Resident #62 but no other staff would help her. NA #1 stated she then checked on Resident #62 at 2:30 PM (5 hours later) and another NA saw Resident #62 was incontinent and she said she was going to report NA #1. NA #1 stated she told the other NA that she had asked for help during the shift, but the other NA did not help her. NA #1 stated she washed Resident #99's upper body at 9:30 AM and Resident #99 was not incontinent at that time. NA #1 gave no care to the lower body because Resident #99 required two (2) staff for care and no other staff would help her. NA #1 did not check on Resident #99 again until 2:30 PM (5 hours later) and then provided care to the resident at that time. NA #1 stated she only must check on residents two (2) times a shift - once in the morning and then again right before her shift ends. NA #1 further stated that she did not ask the charge nurse or RN supervisor for help but stated that she should have asked them and she should have checked on her residents more often. Interview and record review with the DNS on 3/28/2025 at 9:32 AM identified the 4 residents that did not receive care on 3/8/2025 were Resident #27, #40, #62 and #99. The DNS stated she did not know why the residents did not receive care. The DNS indicated NA #1 had asked other staff for assistance, but did not notify LPN #1/charge nurse or RN #1/supervisor that she required assistance. The DNS stated the facility investigation identified the last time incontinent care was provided was a follows: Resident #27 at 8:30 AM, next provided at 1:30 PM (care was next provided 5 hours later). Resident #40 at 4:16 AM, next provided at 2:30 PM (care was next provided 10 hours and 14 minutes without care). Resident #62 at 3:49 AM and then next provided at 2:36 PM (care was next provided 10 hours and 47 minutes without care). Resident #99 at 4:41 AM and then next received care at 2:30 PM (care was next provided 9 hours and 49 minutes without care). The DNS stated residents are supposed to be checked every two (2) hours to see if they need incontinent care and as needed. The DNS stated based on her investigation, NA #1 failed to check on her residents every two (2) hours to see if care needed to be provided. The DNS concluded based upon the investigation that was conducted the allegation of neglect was substantiated. Review of facility Abuse Policy dated 12/2023 directed in part, neglect means the failure of the facility/employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 50094 51183

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #9) reviewed for accidents, the facility failed to conduct a complete investigation for a resident with an injury of unknown origin. The findings include: Resident #9 was admitted to the facility in October of 2024 with diagnoses that included hemiplegia (one sided muscle paralysis) affecting the right dominant side, hypertension, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was cognitively intact, was dependent on staff for toileting and required maximum assistance for personal hygiene and bed mobility and transfers. The MDS further identified Resident #9 with an impairment on one side of his/her upper extremity and lower extremities and used a walker and wheelchair for ambulation. The Resident Care Plan (RCP) dated 10/24/24, identified Resident #9 required extensive assistance of 1 staff member for self-care tasks due to weakness, impaired sitting balance and strength. Interventions included assisting Resident #9 with self-care tasks and referral to occupational therapy when applicable. A facility Reportable Event (RE) form dated 11/29/24 at 12:00 PM written by LPN #3 identified Resident #9 with a discoloration to the left eye with no complaints of pain or discomfort. The RE further identified Resident #9 was alert/oriented, the responsible party was notified of the injury on 11/29/24 at 3: 00 PM and APRN #2 was notified on 11/29/24 at 3:05 PM. A nursing note dated 11/29/24 at 3:17 PM written by LPN #3 identified that she was notified by NA #7 of Resident #9's discoloration to the left eye. LPN #3 notified APRN #2 who directed a complete blood count with differential test (group of blood cells that measure the number and size of the different cells in blood), cold compresses every 15 to 20 minutes for 24 hours and neuro assessments according to the facility's protocol. The nursing note further directed staff to notify the APRN with worsening symptoms such as swelling to the left eye, blurred or double vision, headache, nausea or vomiting. LPN#3 indicated that Resident #9's responsible party was also notified. Interview with LPN #3 on 4/3/24 at 2:40 PM identified that she was notified by NA #7 of the discoloration to Resident #9's left eye on 11/29/24. LPN#3 identified that she assessed Resident #9 and noted a bluish color/discoloration around the entire eye. LPN #3 further identified that she notified the Nursing Supervisor (RN #2) and the APRN #2 of the injury through a phone call. LPN #3 identified that APRN #2 directed a blood test and cold compress to the left eye. LPN #3 identified that the RN Supervisor was responsible for ensuring that investigative statements were obtained from all staff members who worked on the unit for the last 72 hours to try and determine the cause of injury, but review of the clinical record and facility RE form failed to identify an investigation was completed for an injury of unknown origin. Interview and record review with RN #2 on 4/3/25 at 3:00 PM, identified she was the Nursing Supervisor for the 7:00 AM to 3:00 PM shift on 11/29/24 when Resident #9's injury of unknown origin to the left eye was identified. RN #2 identified that investigative statements were not obtained from staff members who worked on the unit for the previous 72 hours due to her failure to assess Resident #9. RN #2 indicated that had she assessed Resident #9, she would have obtained statement from Resident #9 and staff members to try and determine the cause of injury. (Please cross reference F 658). Interview with the DNS on 4/5/25 at 12:00 PM identified that investigative statements should have been obtained from all staff who worked on the unit for the previous 72 hours of Resident #9 developing a left eye discoloration and from Resident #9 him/herself to identify the cause of the injury so that preventive measures could be initiated. The DNS was unable to give a reason an investigation was not done. Subsequent to document request, the facility provided a statement completed by LPN #3 dated 4/11/24 that identified that the discoloration to Resident#9's left eye was approximately pea size even though she had identified in an interview with the surveyor that she noted a bluish color/discoloration around Resident #9's entire left eye. Review of facility policy titled, Accident/Incident Reporting Policies and Procedures, identified in part, that occurrences will be investigated in a timely manner and preventive measures initiated. If the occurrence is an injury of unknown origin, i.e., skin tear or a bruise, statements from staff members on the unit will be taken to try and determine the cause of injury. Statements may need to continue for the previous 24-72 hours or more if needed and cease once cause is identified.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #104) reviewed for recreational activities, the facility failed to develop a comprehensive care plan regarding Resident #104's activity needs and preferences. The findings include: Resident #104 was admitted to the facility in October 2024 with diagnoses that included chronic kidney disease, diabetes, combined forms of age-related bilateral cataracts, and hypertension. An activities admission assessment dated [DATE] indicated Resident #104's past interests included drawing/painting, fishing, traveling, sports, movies, concerts, cooking, and listening to music. The Resident Care Plan dated 11/24/24 identified Resident #104 had impaired visual function related to visual loss in left eye from previous stroke and bilateral cataracts. Interventions included one-on-one visits from staff. An admission Minimum Data Set assessment dated [DATE] identified Resident #104 with a severe cognitive impairment, highly impaired vision, adequate hearing and supervision or touching assistance with activities of daily living. The MDS (daily preferences) further identified that Resident #104 indicated that it was very important for him/her to choose clothes to wear, have snacks available between meals and have family or close friends involved in discussion about his/her care. Additionally, activity preferences identified that it was very important to listen to music that he/she liked, go outside and to get fresh air when the weather permitted and be around animals such as pets. Interview and observation with Resident#104 on 3/31/25 at 11:46 AM identified Resident #104 was lying in bed with the head of the bed elevated with the television on. Observations of the room identified a recreation calendar but failed to identify a radio/CD player was in the room to provide music as was identified as being very important to him/her. Interview with Resident #104 at that time indicated that he/she was unaware about recreational activities that were offered at the facility. Resident #104 further identified he/she was blind and was not involved in activities or taken out for fresh air. Interview and care plan review on 4/8/25 at 10:30 AM with the Assistant Director of Recreation failed to identify a care plan was initiated related to activities therefore there were no interventions to provide activities to Resident #104. Subsequent to the surveyor inquiry, the RCP was updated identifying Resident #104 would benefit from 1 to 1 visitation from staff since he/she was not interested in group activities but accepted 1 to 1 visits. Interventions included providing 1 to 1 visitation, offering refreshment cart treats and offering independent activity material such as music and pet therapy visits. Review of facility policy titled, Baseline/Comprehensive Person-Centered Care Plan (CPCP), identified in part, that the CPCP will be periodically reviewed and revised by a team of qualified persons after each assessment or re-assessment. The CPCP will be reviewed and revised quarterly following MDS completion. The CPCP will be kept by all disciplines on an ongoing basis. Disciplines will be responsible for updating the care plan when there is a new problem that requires that discipline to intervene.

Based on record review, facility documentation, facility policy and staff interviews for 1 of 8 residents (Resident #9) reviewed for accidents, for 1 of 4 residents reviewed for resident to resident altercations (Resident #59 and Resident #81) and for four of eight residents (Residents #27, #40, #62 and #99) reviewed for abuse, the facility failed to ensure Registered Nurse (RN) assessments were completed timely. The findings include: 1. Resident #9 was admitted to the facility in October of 2024 with diagnoses that included hemiplegia (one sided muscle paralysis) affecting the right dominant side, hypertension, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was cognitively intact, was dependent on staff for toileting and required maximum assistance for personal hygiene and bed mobility and transfers. The MDS further identified Resident #9 with an impairment on one side of his/her upper extremity and lower extremities and used a walker and wheelchair for ambulation. The Resident Care Plan (RCP) dated 10/24/24, identified Resident #9 required extensive assistance of 1 staff member for self-care tasks due to weakness, impaired sitting balance and strength. Interventions included assisting Resident#9 with self-care tasks and referral to occupational therapy when applicable. A facility Reportable Event (RE) form dated 11/29/24 at 12:00 PM written by LPN #3 identified Resident #9 with a discoloration to the left eye with no complaints of pain or discomfort. The RE further identified that Resident #9 was alert/oriented, the responsible party was notified of the injury on 10/29/24 at 3: 00 PM and APRN #2 was notified on 10/29/24 at 3:05 PM. A nursing note dated 11/29/24 at 3:17 PM by LPN #3 identified that she was notified by NA #7 of Resident #9's discoloration to the left eye. LPN #3 notified APRN #2 who directed a complete blood count with differential test (group of blood cells that measure the number and size of the different cells in blood), cold compresses every 15 to 20 minutes for 24 hours and neuro assessments according to the facility's protocol. The note further directed staff to notify the APRN with worsening symptoms such as swelling to the left eye, blurred or double vision, headache, nausea or vomiting. LPN #3 indicated that Resident #9's responsible party was also notified. Interview with LPN #3 on 4/3/24 at 2:40 PM identified that she was notified by NA #7 of the discoloration to Resident #9's left eye on 11/29/24. LPN #3 identified that she assessed Resident #9 and noted a bluish color/discoloration around the entire eye. LPN #3 further identified that she notified the Nursing Supervisor (RN#2) and APRN #2 of the injury through a phone call. LPN #3 identified that APRN #2 directed a blood test and cold compress to the left eye. LPN #3 was unable to identify whether Resident #9 was assessed by RN #2 but indicated that the RN Supervisor should have assessed Resident #9 and documented the assessment findings including measurements and description of the bruise. Interview and record review with RN #2 on 4/3/25 at 3:00 PM, identified that she was the Nursing Supervisor for the 7:00 AM to 3:00 PM shift on 11/29/24 when Resident #9's left eye discoloration was identified. RN #2 was unable to identify an RN assessment and documentation related to Resident #9's left eye discoloration on 11/29/24. RN #2 identified that an injury of unknown origin should have been assessed by an RN and investigation into the incident initiated to identify the cause of the injury. RN #2 could not recall if she was notified by LPN #3 but indicated that she was responsible for having completed the RN assessment and documentation of the injury. Interview with the DNS on 4/5/25 at 12:00 PM identified that RN #2 was responsible for completing and documenting an assessment of Resident #9's bruising to the eye. The DNS was unable to identify the reason RN#2 did not assess and/or document her assessment findings in Resident#9's clinical record. Subsequent to document request, the facility provided a statement completed by LPN #3 dated 4/11/24 that identified that the discoloration to Resident#9's left eye was approximately pea size even though she had identified in an interview with the surveyor that she noted a bluish color/discoloration around Resident #9's entire left eye. Review of facility policy titled, Accident/Incident Reporting Policies and Procedures, identified in part, that staff will notify the nursing supervisor/licensed nurse when an incident occurs. The licensed nurse or the nursing supervisor will complete an evaluation of residents' condition. The evaluation is to include, but not limited to vital signs and neuro signs, if applicable, type of injury with location on the body, include measurements if the injury's a skin tear or a bruise. 2a. Resident #59 was admitted to the facility in September of 2022 with diagnoses that included dementia, anxiety, and dysphagia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 was severely cognitively impaired, had verbal behavioral symptoms directed towards others, had the behavior of wandering, and was independent with eating, bed mobility and transfers. The Resident Care Plan (RCP) dated 4/29/24 identified Resident #59 had a history of anxiety and depression. Interventions included to observe for periods of anxiety, provide a calm, quiet environment and encourage Resident #59 to verbalize thoughts and feelings related to anxiety. A facility Reportable Event form dated 5/13/24 identified on 5/12/24 at 4:30 PM another resident (Resident #81) walked up to Resident #59 and punched Resident #59 in the face. The event was witnessed by a visitor who reported it to Licensed Practical Nurse (LPN) #2. A nursing note written by Licensed Practical Nurse (LPN) #2 on 5/13/24 at 5:45 PM (1 day after the actual resident to resident altercation occurred per the facility Reportable Event form) identified Resident #59 was in the dining room waiting for dinner when another resident (Resident #81) approached him/her asking questions and Resident #59 responded, I don't understand you, after which Resident #81 punched Resident #59 in the face. The nursing note identified that LPN #2 assessed Resident #59, performed neuros, and did not identify bleeding, pain or discomfort. The nursing note further identified LPN #2 redirected Resident #81 to his/her room, and the APRN and responsible party were notified. The nursing note failed to identify the nursing supervisor had been notified of the event. Review of the clinical record failed to identify a nursing note or assessment by a Registered Nurse (RN) for Resident #59 on 5/12/24 following a resident to resident altercation on 5/12/24 at 4:30 PM. Interview with Director of Nursing Services (DNS) on 4/8/25 at 9:50 AM identified LPN #2 should have told the Nursing Supervisor immediately when the resident to resident altercation occurred so that the Supervisor could have done an assessment and provided additional directions. b. Resident #81 was admitted to the facility in June of 2023 with diagnoses that included Alzheimer's disease, anxiety disorder, and delusional disorders. The Resident Care Plan (RCP) dated 2/27/24 identified Resident #81 had potential for agitation manifested by hitting other residents and Resident #81 was physical and combative at times as evidenced by hitting and aggression on 10/20/23 and aggression/altercation on 4/29/24. Interventions included offering fluids/snacks and have Resident #81 stay next to the nursing station sitting on the bench, ensure Resident #81 was the first resident to get ready for bed after dinner, and one on one with Resident #81 to manage agitation. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #81 was severely cognitively impaired, had several days of the mood symptom of being short-tempered and easily annoyed, had verbal behavioral symptoms directed towards others, had the behavior of wandering, required supervision or touching assistance with eating, and was independent with transfers and walking. A nursing note written by LPN #2 dated 5/12/24 at 10:18 PM identified Resident #81 was anxious, crying and aggressive with another resident (Resident #59), and Resident #81 was redirected to his/her room, was offered crackers and apple juice without positive results, and was given Lorazepam (an antianxiety medication) 0.25 milligrams (mg) with positive results. The nursing note failed to identify the Nursing Supervisor had been notified of the event. A facility Reportable Event form dated 5/13/24 identified on 5/12/24 at 4:30 PM Resident #81 walked up to Resident #59 and punched Resident #59 in the face. The event was witnessed by a visitor who reported it to Licensed Practical Nurse (LPN) #2. Review of the clinical record failed to identify a nursing note or assessment by a Registered Nurse for Resident #81 on 5/12/24 following a resident to resident altercation on 5/12/24 at 4:30 PM. Interview with Director of Nursing Services (DNS) on 4/8/25 at 9:50 AM identified LPN #2 should have told the Nursing Supervisor immediately when the resident to resident altercation occurred on 5/12/24 so that the Supervisor could have completed an assessment and provided additional directions. Review of the Clinical Services Abuse Policy and Procedure directed, in part, any observation of resident abuse is to be thoroughly investigated and reported. When any allegations of abuse or mistreatment are observed by any employee the nursing supervisor is notified immediately and the nursing supervisor/charge nurse will immediately report abuse allegations to the Administrator and DNS, and notify the provider to conduct a physical and/or mental assessment. Additionally, the facility investigation will be completed within 5 days of the incident and documentation will include all necessary evaluations (skin/body checks, pain evaluation). 3a. Resident #27 had a diagnosis of obstructive and reflux uropathy (impaired urine flow). The admission MDS dated [DATE] identified Resident #27 had a BIMS of 14 indicating an intact cognition and was always incontinent of bladder and bowel. The RCP dated 1/6/2025 identified a self-care deficit, and incontinent of bladder and bowel. Interventions directed to assist with ADLs and provide incontinent care. b. Resident #40 had a diagnosis of hemiplegia/ hemiparesis (weakness/paralysis) of the right dominant side, and aphasia. The annual MDS dated [DATE] identified severely impaired cognitive skills, required assistance with ADLs, and was always incontinent of bladder and bowel. The Resident Care Plan (RCP) dated 2/3/2025 identified alteration in ADLs, and incontinence. Interviews directed to assist with ADLs and provide incontinent care. c. Resident #62 had a diagnosis of cerebral infarction (stroke) with hemiplegia affecting the left side, and a cognitive communication deficit. The annual MDS dated [DATE] identified Resident #1 had a BIMS of 14 indicating intact cognition and was frequently incontinent of bladder, and always incontinent of bowel. The RCP dated 2/3/2025 identified incontinent of bowel and bladder, and a self-care deficit. Interventions directed to assist with ADLs and to provide incontinent care approximately every 2 hours and as needed. d. Resident #99 had a diagnosis of dementia. The quarterly MDS assessment dated [DATE] identified Resident #99 had a Brief Interview of Mental Status (BIMS) score of 8 indicating moderately impaired cognition, was dependent for ADLs, and was always incontinent of bladder and bowel. The RCP dated 1/23/2025 identified an ADL deficit and incontinent of bowel and bladder. Interventions directed to assist with ADLs, and to provide incontinent care every two (2) hours and as needed. A facility incident report dated 3/10/2025 at 12 noon identified on 3/8/2025 at approximately 1:30 PM, LPN #1 identified when LPN #1 was providing treatments he identified Resident #40 was in need of incontinent care. LPN #1 and a NA provided the care. Further, LPN #1 identified Residents #27, #62 and #99 were in need of incontinent care, and care was provided. Facility summary dated 3/14/2025 identified although morning care was provided for Residents #27, #40, #62 (Resident #99 refused morning care), incontinent care was not provided until 2 PM for Residents #27, 40, #62 and #90 when it was provided by LPN #1. Record review of NA care card on 3/8/2025 identified Resident #27 received or provided incontinent care at 4:08 AM and did not receive incontinent care again until 2:31 PM (10 hours and 23 minutes after last received). Record review of NA care card on 3/8/2025 identified Resident #40 received incontinent care at 6:47 AM on 3/8/2025 and did not receive incontinent care again until 1:44 PM on 3/8/2025. Record review of NA care card on 3/8/2025 identified Resident #62 received incontinent care at 3:49 AM and did not receive incontinent care again until 2:34 PM. Record review of NA care card on 3/8/2025 identified Resident #99 received incontinent care at 4:40 AM and did not receive incontinent care again until 11:53 AM. Facility written statement from LPN #1 on 3/9/2025 identified he was performing resident treatments, he identified Residents #28, #40, #62 and #99 did not receive care timely and he notified RN #1. Please cross reference F 600. Facility undated written statement from RN #1 identified on 3/8/2025 LPN #1 notified her that NA #1 did not change the residents she was assigned to during the afternoon. RN #1 questioned NA #1 about her assigned residents that were not changed and indicated all assigned residents needed to be toileted and changed in the afternoon after lunch. Although attempted, interviews with LPN #1 and RN #1 were not obtained during the survey. Record review failed to identify RN assessments were completed for Residents #27, #40, #62, and #99 on 3/8/2025. Subsequent to surveyor inquiry, the facility provided nursing notes for Residents #27, #40, and #62 that were dated 3/27/2025 as late entries for 3/10/2025. The nursing notes were written by LPN #3 and LPN#8, and although the notes indicated resident evaluations were completed on 3/10/2025, no RN assessments were completed. Further, subsequent to surveyor inquiry, the facility provided an APRN late entry note, dated 3/27/2025 at 11:58 AM. The note indicated the APRN saw Resident #40 on 3/10/2025 at 8 AM to evaluation Resident #40's skin on his/her buttocks that was identified as bleeding during routine care. Although the APRN note identified she saw Resident #40 on 3/8/2025, the visit occurred at 8 AM, and the omitted care occurred at 1:30 PM (5 1/2 hours after the APRN visit occurred). Although attempted an interview was not obtained with RN #1 during the survey. Interview and record review with the DNS on 3/28/2025 at 9:32 AM identified Residents #27, #40, #62 and #99 did not receive care on 3/8/2025. The DNS stated the investigation identified the last time incontinent care was provided was a follows: Resident #27 at 8:30 AM, next provided at 1:30 PM (5 hours after last provided). Resident #40 at 4:16 AM, next provided at 2:30 PM (10 hours and 14 minutes without care). Resident #62 at 3:49 AM and then next provided at 2:36 PM (10 hours and 47 minutes without care). Resident #99 at 4:41 AM and then next received care at 2:30 PM (9 hours and 49 minutes without care). The DNS further stated RN #1 and the 3 PM to 11 PM shift RN supervisor did not complete RN assessments/skin assessments for the residents after it was identified they had not received timely care. The DNS stated RN assessments should have been completed immediately following the incident and the DNS did not know why RN #1 did not complete assessments. Review of the facility Procedure for Abuse Investigation dated 12/2023 directed in part, to conduct a physical assessment as appropriate. 50250 51183

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #40) reviewed for pressure ulcers, for 1 of 2 residents (Resident #45) reviewed for positioning and for 1 of 3 residents (Resident #102) reviewed for nutrition, the facility failed to ensure an air mattress was set at the appropriate setting. Additionally, for 1 of 1 resident (Resident #65) reviewed for a non-pressure skin condition, the facility failed to initiate timely treatments. The findings include: 1. Resident #40's diagnosis included cerebrovascular disease, pressure ulcer, and epilepsy. The annual Minimum Date Set (MDS) assessment dated [DATE] identified Resident #40 was severely cognitively impaired, was dependent on bathing, dressings, personal hygiene, and transfer. Also, identified that Resident #40 was a set up for eating and had an unhealed stage 3 pressure ulcer. The Resident Care Plan dated 2/3/25 identified Resident #40 had a facility acquired stage 3 pressure ulcer with interventions that included to monitor for signs and symptoms of infection, update the physician with any changes as needed, and provide treatments as ordered. Review of weights summary dated 2/4/25 identified that Resident #40 weight was 202 pounds (lbs). A physician order dated 3/7/25 directed air mattress monitoring function of mattress/setting must be adjusted to resident's weight every shift for preventative care. Observation on 4/7/25 at 10:50 AM noted Resident #40 lying in bed on an air mattress with the setting of the air mattress on light 7. Additionally, an instruction card was attached to the mattress indicating the light level for Resident #40 with a weight of 212 should be set at level 4 (not level 7). Interview and observation on 4/8/25 at 10:00 AM with Licensed Practical Nurse (LPN)# 6 who was the Infection Preventionist, identified that she was unsure about the setting of Resident #40's air mattress because it was a turn and reposition mattress, but it was set on light 7. Also, identified was the resident had it about a month (2/20/25) and LPN #6 did not think it was set by the resident's weight of 214 pounds, LPN#6 did not think it was set correctly, was attempting to adjust the setting but did not know how. Further, identifying that she needed to refer to the manufacturer's instructions. Interview with Vendor #2 from the Air Mattress company on 4/9/25 at 4:35 PM identified that the type of air mattress that Resident #40 utilizes was the turn and repositioning mattress and should be set by the resident's weight, that every mattress comes with a card attached identifying what light level it should be set at according to weight and width of bed. Interview with Vendor #2 Air Mattress on 4/10/25 at 8:30 AM identified that light #7 was for a heavier individual. Also, identifying that Resident #40 was in a size 36-inch-wide mattress, and one should follow what the attached card indicated for the level the air mattress should be set at. Further, identifying that a good starting point was to go with each resident weight, but the air mattress could be adjusted somewhat for comfort. Also, identified that if it was set too high/firm it could take longer for a pressure ulcer to heal. Review of the Manufactures education identified the pump had a turn/lock dial which can be adjusted to the individual resident's weight to ensure comfort and to aid caregivers. The facility policy for use of support surfaces identified for the correct setting to be set by the nurse based on the resident's current weight. 2. Resident #45 was admitted to the facility in January of 2020 with diagnoses that included dementia, dysphagia, and abnormal weight loss. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 was severely cognitively impaired and was dependent for eating, bed mobility, and transfers. Additionally, the MDS identified Resident #45 was at risk for developing pressure ulcers, had 2 venous/arterial ulcers, had a pressure reducing device for the chair, and had a pressure reducing device for the bed. The MDS further noted that Resident #45 was receiving hospice services. The Resident Care Plan dated 2/25/25 identified Resident #45 had the potential for skin breakdown due to decreased level of consciousness, impaired circulation, and sensory impairment. Interventions included to perform weekly skin evaluations, turn and reposition Resident #45 every 2 to 3 hours and/or as tolerated by Resident #45, and placement of a special mattress (alternating pressure air mattress) set to current weight and check for function and placement every shift. .A physician order dated 3/3/25 directed use of a specialty air mattress and to check setting and function every shift. A Wound Care Specialists Physician (MD) #2 progress note dated 3/31/25 identified Resident #45 was seen for evaluation of his/her wounds. The note identified Resident #45 had a pressure ulcer to the coccyx which was first evaluated on 6/10/24 and an arterial wound to the left foot. Observation on 3/31/25 at 11:35 AM identified Resident #45 was lying supine in bed on top of an air mattress set on alternating pressure with a 15 minute cycle time and with all 5 lights lit up indicating a setting of firm (Resident #45 weighed 114.0 pounds (lbs.)). .Review of the Treatment Administration Record (TAR) dated 3/1/25 through 4/3/25 identified a specialty air mattress was ordered, check setting and function every shift was signed off by the licensed nurse(s) on all 3 shifts (11:00 PM to 7:00 AM, 7:00 AM to 3:00 PM, and 3:00 PM to 11:00 PM). Observation on 4/1/25 at 11:10 AM, 4/2/25 at 11:08 AM, and 4/3/25 at 1:39 PM identified Resident #45 was lying supine in bed on top of an air mattress set on alternating pressure with a 15 minute cycle time and with all 5 lights lit up indicating a setting of firm (Resident #45 weighed 114.0 pounds (lbs.)). Interview and observation of Resident #45's air mattress pump settings with Licensed Practical Nurse (LPN) #2 on 4/3/25 at 1:45 PM identified when following the physician order for an air mattress, LPN #2 would verify that the air mattress was set at the correct weight for the resident, LPN #2 would then check the inflation of the mattress by pushing down on it to make sure that the mattress wasn't flat allowing her to feel the metal frame beneath it. LPN #2 identified that none of the residents on the unit should have an air mattress at a firm setting. When the settings of the air mattress pump were observed with LPN #2 she was unable to identify the reason the setting was on firm with all 5 lights lit up or what the correlating firmness setting on the pump should be for Resident #45's weight of 114 lbs. LPN #2 identified that she would call Maintenance to come check the pump and to determine the correct setting because that air mattress pump was different than what she was used to and she didn't know what the settings should be. Interview and observation of Resident #45's air mattress pump settings with Registered Nurse (RN) #5 on 4/3/25 at 3:30 PM identified that the air mattress settings should be included within the physician orders. When the settings of the air mattress pump were observed with RN #5 she was unable to identify the reason the setting was on firm with all 5 lights lit up or what the correlating firmness setting on the pump should be for Resident #45's weight of 114 lbs. RN #5 further identified a clear see through plastic sleeve on the front of the pump containing a settings card for the air mattress pump that did not have settings filled out (all setting bubbles on the card were blank) and no writing was noted on the plastic sleeve. RN #5 indicated that she would call the company and find out the correct setting, she would then adjust the settings on the air mattress pump and update the provider order for the air mattress with the correct settings. Subsequent to surveyor inquiry, a physician order dated 4/3/25 directed use of a specialty air mattress with settings of alternate pressure, cycle 15 with medium pressure, and to check setting and function every shift. Observation on 4/7/25 at 11:44 AM identified Resident #45 lying supine in bed with the HOB elevated approximately 75 degrees. Resident #45 was lying on top of an air mattress set on alternating pressure with a 15 minute cycle time and on medium pressure with 3 lights lit. The settings card inside the clear plastic sleeve was filled out for medium pressure and cycle of 15. Interview with the DNS on 4/8/25 at 9:50 AM identified the air mattress settings were set according to the resident(s) weight, and the resident's weight would be identified by a sticker on top of the air mattress pump. The DNS identified the settings were verified and checked by nursing every day on all 3 shifts. The DNS identified settings for Resident #45's pump would have needed to be obtained from the company for the air mattress pump, and she was unable to identify what the correlating setting would be for Resident #45's weight. Interview with Customer Service Representative for Resident #45's air mattress on 4/8/25 at 11:32 AM identified Resident #45's air mattress and pump were supplied by his company at the request of hospice and his technicians set up Resident #45's air mattress on the bed for the facility. He identified for Resident #45's height and weight in his records the air mattress pump should be set medium pressure. He further identified that the clear plastic sleeve on the front of the pump should have markings on it superimposed over the card inside to indicate the correct pump pressure and cycle settings. Interview with RN #4 on 4/8/25 at 11:38 AM identified that Resident #45's air mattress was provided through his hospice agency. RN #4 identified that it was his understanding that it was the facility nurse's responsibility to manage the air mattress and pump and it's settings, and if there was a problem with the air mattress or pump they were to call hospice so that the vendor could be sent to evaluate it. RN #4 identified that the air mattress settings were not included within the hospice care plan because the facility nurses managed the air mattress, but that going forward he would ask about having those settings added to the hospice care plan so the hospice nurse could help to monitor and alert the facility nurse if the settings were incorrect. Review of the Guidelines for Use of Support Services policy identified the support surface would be placed on the bed by housekeeping/maintenance and/or the vendor, the correct settings would be set by the nurse based on the resident's current weight and comfort level, and monitoring of the support surface inflation would be done by the nurse every shift and then documented on the TAR. 3. Resident #65 was admitted to the facility in January of 2025 with diagnoses that included metabolic encephalopathy, sepsis, and chronic kidney disease. The Resident Care Plan (RCP) dated 1/27/25 identified Resident #65 had potential for skin breakdown due to fragile skin and Prednisone taper. Interventions included skin checks with care, supplements and/or vitamins as ordered and update provider with changes as needed. The RCP further identified on 2/12/25 Resident #65 had an actual alteration in skin integrity (non-pressure) related to a ruptured blister to the left dorsal foot and blood blister to the left shin. Interventions included treatment as ordered, weekly wound evaluation until resolved, and observe extremities for signs/symptoms of poor tissue perfusion, document changes and report significant findings to the provider. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #65 was severely cognitively impaired, used a walker and wheelchair, was setup or clean-up assistance for eating, and partial/moderate assistance for bed mobility and transfers. Additionally, the MDS identified Resident #65 was at risk for developing pressure ulcers, did not have a pressure ulcer at the time of the assessment and utilized a pressure reducing device to the bed and chair. The Clinical Summary/W10 discharge paperwork dated 2/5/25 (from the hospital) identified Resident #65 was admitted to the hospital on [DATE] and discharged back to the facility on 2/5/25. Further identified was Resident #65 had an abrasion to the anterior left leg which measured 2.0 centimeters (cm) long by 2.0 cm wide by 0.0 cm deep and had a dressing of Xeroform covered by a foam dressing. Also identified was Resident #65 had a ruptured blister to the anterior upper left foot with moderate serous drainage and had a dressing of Xeroform (topical wound dressing) followed by a pad wrapped with a gauze bandage roll. A nursing note written by RN #2 and dated 2/5/25 at 11:19 PM identified Resident #65 had a skin check completed (upon re-admission) and discoloration was observed to the right and left hands, discoloration was observed to the right hip, pitting edema was observed to both feet, a popped blister was observed to the left dorsal foot, and discoloration was observed to the left shin (a discrepancy with the hospital W10 that indicated a left leg abrasion). Additionally, RN #2's nursing note dated 2/5/25 failed to identify measurements, description, assessment of the surrounding skin for the popped blister and did not identify the discrepancy of an abrasion to the left shin versus (hospital W10 documentation) RN #2's documentation of discoloration. A Non-Pressure Wound Evaluation completed by the ADNS on 2/10/25 at 4:39 PM identified a ruptured blister to the left dorsal foot with date of origin of 2/5/25 which measured 6.5 centimeters (cm) long by 5.0 cm wide, with a small amount of drainage, no odor, a wound base of 100% pink or red tissue, and with the periwound intact (there were no previous wound measurements, descriptions documented from re-admission on [DATE] until 2/10/25 to ascertain if the popped blister worsened or was at baseline). A physician's order dated 2/10/25 directed to cleanse the left dorsal foot with Normal Saline and apply Emulsion oil then cover with a dry dressing daily for 14 days (treatment order obtained 5 days after re-admission). A physician's order dated 2/12/25 (treatment order obtained 7 days after re-admission ) directed to cleanse the left shin with wound cleanser followed by Medihoney (topical wound treatment) then cover with a dry clean dressing daily and as needed. A Non-Pressure Wound Evaluation completed by the ADNS on 2/10/25 at 4:39 PM identified a ruptured blister to the left dorsal foot with date of origin of 2/5/25 which measured 6.5 centimeters (cm) long by 5.0 cm wide, with a small amount of drainage, no odor, a wound base of 100% pink or red tissue, and with the periwound intact (there were no previous wound measurements, descriptions documented from re-admission on [DATE] until 2/10/25 to ascertain if the popped blister worsened or was at baseline). A Wound Care Specialist progress note by Medical Doctor (MD) #2 on 2/24/25 identified she was requested for a consult to evaluate a wound to the left foot. The note identified Resident #65 was admitted with a large blister on the left foot, and since admission the blister ruptured and was slow to heal. MD #2 identified the wound measured 5.0 cm long by 5.0 cm wide by 0.1 cm deep, with a moderate amount of seropurulent drainage, no odor, wound base of 75-99% granulation, and with scarring to the periwound. MD #2 further identified a treatment to the wound of cleanse the wound followed by apply Mupirocin (antibiotic) ointment, followed by oil emulsion dressing to the wound base followed by secure with a dry clean dressing and change daily. Interview with RN #2 on 4/3/25 at 2:40 PM identified she had completed the nursing assessment for Resident #65 on readmission on [DATE] and had obtained all the physician orders for that readmission. RN #2 could not identify the reason her documentation of the ruptured blister on Resident #65's left dorsal foot in the nursing assessment did not include measurements or a description of the wound indicating that she had probably missed entering the description. RN #2 identified that she verified treatments and skin issues she observed during her skin check with the documentation of skin issues and treatments included in the hospital paperwork (W10), and she would then verify with the MD and put treatment orders in place. RN #2 did not know the reason she had not put treatment or monitoring orders in place for Resident #65's left dorsal foot or left shin but further identified that Resident #65 had arrived from the hospital with both the left dorsal foot and left shin open to air with no dressings in place. Interview with RN #2 on 4/7/25 at 12:30 PM identified that she had documented on the 2 pages of skin check diagrams on 2/5/25. RN #2 identified she had not obtained physician orders for treatments or monitoring to Resident #65's left dorsal foot and left shin because those areas were uncovered upon arrival from the hospital and both wounds appeared dry. RN #2 further identified that the charge nurses' monitor and chart on all new admission residents for 72 hours after admission, and further identified that the wound nurse followed up on all new admissions during Monday wound rounds even without specific treatment orders in place for monitoring. Interview with the DNS on 4/8/25 at 9:50 AM identified she had instructed the nursing staff to use treatment orders included in the hospital paperwork first and after those orders were in place they could be adjusted as needed. The DNS identified that even though Resident #65 may have arrived to the facility without dressings in place it was her expectation that the treatments in the hospital paperwork would have been put in place. The DNS further identified that the 11:00 PM to 7:00 AM shift audit the new admissions, and she had told the nurses when doing the audits to fix orders that are incorrect or missing. The DNS could not identify the reason treatment orders had not been put in place for Resident #65 on readmission. Review of the Order Review History Report dated 4/8/25 for 2/1/25 through 2/28/25 failed to identify treatment orders initiated for Resident #65's left dorsal foot wound and left shin wound on readmission to the facility on 2/5/25. Review of skin check diagrams in the clinical record identified by RN #2 as completed on 2/5/25 identified bruising to the right hip, bruising above the peri area, bilateral bruising to both arms, bruising to the left shin, an open blister to the left dorsal foot, and pitting edema to both feet. Review of the Admission, Discharge Policy identified the licensed nurse would complete the re-admission Evaluation which encompasses a systematic review of the resident's condition, and orders are reviewed and discrepancies resolved with the attending healthcare provider when validating re-admission orders. 4. Resident #102's diagnoses included unspecified protein calorie malnutrition, primary generalized osteoarthritis, depression and panic disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #102 had intact cognition, required set up assistance for eating and maximum assistance for personal hygiene, bed mobility and transfers. The MDS further identified that Resident #102 experienced pain almost constantly over the last 5 days of the assessment which affected his/her sleep and day to day activities constantly. Additionally, the MDS identified Resident #102 was at risk for the development of pressure ulcers, did not have a pressure ulcer at the time of the assessment and had a pressure reducing device to the bed. The assessment further identified Resident #102 weighed 87 pounds (lbs). Physician's order dated 2/16/25 directed a specialty air mattress to be set at resident's current weight and check setting and function every shift. The Resident Care Plan in effect for the month of March and April 2025 identified Resident #102 was at risk for skin breakdown due to decreased mobility, and incontinence. Interventions included a low air loss mattress, nutrition/hydration assessment, offloading heels, offering turning and repositioning approximately every two hours and as needed, and providing treatments as ordered. Observation and interview with Resident #102 and Person #1 on 3/31/25 at 12:30 PM identified Resident #102 lying in bed with Person #1 in attendance. The alternating pressure mattress (APM) was set at 250 pounds (lbs), and Resident #102 weighed 87 lbs. Interview with Resident#102 identified that the APM felt hard, and Person #1 identified that it felt like a rock. Observation on 4/1/25 at 9:52 AM and 4/1/25 at 3:05 PM identified Resident #102 was lying in bed and the APM was set at 250 pounds. Review of Resident #102's clinical record identified a current weight of 87 pounds. Further review of the clinical record identified that staff signed off the Treatment Administration Record (TAR), that APM was set at Resident #102's current weight (87 Lbs) and were checking APM setting and function every shift even though the APM was set at 250 lbs. Observation and interview with Licensed Practical Nurse (LPN) #4 on 4/1/25 at 3:10 PM identified that the APM was set at 250 pounds instead of 87 pounds, that Resident #102 was on comfort measures and the APM had been placed by hospice for comfort. LPN #4 identified that Resident #102 had not complained that the APM felt hard throughout the 7:00 AM to 3:00 PM shift. LPN #4 identified that she was responsible for checking the APM setting function/placement and had not checked for placement and function on her shift even though she had signed off that she did on the TAR. LPN #4 indicated that Resident #102 or Person #2 may have adjusted the setting since the APM was set at the correct setting when it was initially placed by hospice staff. Subsequent to surveyor inquiry, the APM setting was adjusted by LPN #4 to reflect Resident #102's current weight of 87 pounds. Interview with the Infection Preventionist (LPN #6) on 4/2/25 identified Resident #102's APM was for comfort and assigned nurse was responsible for checking the setting and function of the APM each shift and as needed. Interview with Resident #102 on 4/2/25 at 12:45 PM identified that neither her/him or Person #1 interfered with or reset the APM setting. Interview with the DNS on 4/7/25 at 10:30 AM identified that nurses were responsible for checking APM placement and function and following physician's orders. The DNS identified that LPN #4 would be re-educated regarding APMs. Review of facilities Guidelines for Use of Support Surfaces, identified, in part, that the correct setting will be set by the nurse based on the residents correct weight and comfort level. Monitoring the support surface inflation will be done by the nurse every shift and documented on TAR.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #83) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to refer Resident #83 for a Level II PASRR evaluation after identifying a new mental disorder. The findings include: Resident #83 was admitted to the facility in January 2023 with diagnoses that included a cerebral infarction affecting right dominant side and Parkinson's disease. Upon admission to the facility, there was no mental disorder diagnoses identified. A PASRR Level I screen dated 1/11/23 identified that a Level II PASRR screening was not required because there was no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavior health condition. Additionally, it identified if changes were to occur or new information refuted those findings, a new screening must be submitted. An Advanced Practice Registered Nurse (APRN) note dated 5/26/23 identified Resident #83 with a new diagnosis of psychotic disorder with delusions due to known physiological condition. On 4/7/25 at 12:53 PM, an interview and record review with the Director of Social Services #1 (SW), identified that Resident #83 had a Level I PASRR completed on 1/11/23 and that a Level II PASRR screening was not required at that time because there was no evidence of a an intellectual/developmental disability or a serious behavior health condition. SW #1 indicated a Level II PASRR should have been completed when the APRN diagnosed the resident with a new mental disorder on 5/26/23 and it was Social Services who was responsible to ensure it was done. Additionally, the interview identified that the process for identifying residents with new mental disorders was that after the psychiatry provider assesses the residents' and assigns a new diagnosis, they will report the findings to Social Services, who would then notify the proper agency to conduct a Level II PASRR screening. SW #1 also stated that this was missed due to the new diagnosis not coming from the psychiatry provider but from the medical APRN. Although a policy for PASRR was requested, one was not provided.

Based on clinical record reviews, facility documentation, facility policies, and interviews for one (1) of two (2) sampled residents (Resident #2) who was reviewed for an allegation of resident-to-resident abuse, the facility failed to ensure the resident was free from physical abuse. The findings include: Resident #1's diagnoses included dementia with psychosis, craniotomy for temporal lobe tumor, anxiety disorder, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented and was independent for mobility with an assistive device. The Resident Care Plan dated 9/4/24 identified Resident #1 was currently taking antidepressants, antipsychotic, and psychotropic medications. Interventions directed to monitor and record occurrences for target behavior symptoms of hallucinations and document per facility protocol, administer medications as ordered by the physician and monitor for any adverse reactions, and psychiatric evaluations as needed. Resident #2's diagnoses included chronic congestive heart failure, acute respiratory failure, panic disorder, and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented and was independent for transfers and supervision for mobility with assistive devices. The Resident Care Plan dated 8/7/24 identified Resident #2 had episodes of anxiety. Interventions directed to administer anti-anxiety medications per the physician's order and monitor for effectiveness, encourage participating in activities of interest as a form of diversion to reduce anxiety, and provide resident one to one (1:1) visits with the social worker to establish a relationship and build trust. Record review identified Residents #1 and #2 were roommates. The psychiatric Advanced Practice Registered Nurse (APRN), APRN #1, progress note dated 7/27/24 at 5:15 AM identified on 7/26/24, Resident #1 was seen as a follow-up for medication and behavioral review. The note indicated during the morning visit, resident looked tired but verbalized he/she was sleeping at night, the visual hallucinations decreased and stopped, he/she did not see anything since the last visit on 7/23/24, Resident #1 verbalized baseline symptoms of depression and denied any suicidal/homicidal ideations. The note identified in the afternoon of 7/26/24, she was paged and asked to see Resident #1 urgently. The note indicated Resident #1 was sitting in the Director of Nursing's office, verbalized that he/she was feeling scared, but could not report what he/she was scared of, mentation was noted to be altered, Resident #1 observed to be increasingly confused and does not seem to be at his/her baseline. The note identified Resident #1 was not able to answer questions that he/she had answered earlier in the morning, appeared to be disoriented, the medical APRN, APRN #2, was contacted, and the decision was made to send Resident #1 to the emergency room for further evaluation due to an altered mental status. The behavioral health hospital Discharge summary dated [DATE] identified Resident #1's discharge diagnoses included dementia, confusion, hallucinations, urinary tract infection, and depression, the Risk Assessment identified Resident #1 was not a current danger to self or others and does not meet the criteria for inpatient psychiatric hospitalization at this time. The summary noted Resident #1 verbalized understanding, understood the consequences of reporting versus not reporting destructive thoughts, and had a reasonable plan to get help if needed and Resident #1 to be discharged back to skilled nursing facility on 9/4/24. APRN #2's progress note dated 9/4/24 identified Resident #1 was sent out for crisis evaluation on 7/26/24 due to progressive psychosis and subsequently transferred to a Behavioral Health hospital on 7/29/24 through 9/4/24 for inpatient treatment and has now returned to this facility. The hospital discharge diagnosis was vascular dementia, Resident #1 denied specific complaints though he/she is minimally conversive. The note identified multiple changes had been made to Resident #1's psychiatric medications per review of the Inter-Agency Referral Form (W-10). The Facility Reported Incident form dated 9/5/24 at 10:40 PM identified Resident #2 called the Nursing Supervisor, Registered Nurse (RN) #1, to report that Resident #1 was standing over Resident #2's bed and Resident #1 stated to Resident #2 that he/she wanted to choke Resident #2. The report indicated when RN #1 asked Resident #1 what happened, he/she stated, I want to choke my roommate, and Resident #2 denied any touch from Resident #1. The report identified on the morning of 9/6/24, Resident #2 stated to Social Worker #1 Resident #1 did put his/her hands on Resident #2 and choked him/her. The summary indicated there was no injury and no marks on Resident #2's neck, Resident #1 was sent out to emergency department for evaluation. Resident #2 was seen by social services and psychiatry, with new orders entered for Trazodone (anti-depressant). In a written statement dated 9/5/24 the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, identified she went to Resident #1's room to obtain vital signs at approximately 10:00 PM and Resident #1 verbalized to LPN #1 that he/she went over to Resident #2's bed to choke Resident #2. The statement indicated LPN #1 asked Resident #2 to explain what happened and Resident #2 stated Resident #1 was standing over me, and Resident #1 verbalized that he/she wanted to choke me. Interview with Resident #2 on 10/1/24 at 11:00 AM identified he/she and Resident #1 have been roommates for years with no issues prior to the 9/5/24 incident. Resident #2 identified on 9/5/24 around nighttime, he/she was watching football in bed, when he/she began to fall asleep and at some point, he/she felt two (2) hands around his/her neck area and I immediately woke up, to find Resident #1 standing over me. Resident #2 identified he/she pushed Resident #1's hands away and questioned what Resident #1 was doing, to which Resident #1 responded I don't know what I'm doing. Resident #2 indicated he/she did not call for assistance at that moment, due to processing the overall event, but indicated a nurse came into the room for unrelated care and Resident #1 then admitted to attempting to choke me to the nurse. Interview with the Director of Nursing (DON) on 10/1/24 at 2:05 PM identified she did not substantiate abuse for this event because she thought the incident was behavioral, as Resident #1 is cognitively impaired. The DON indicated the residents were evaluated after the incident, no injuries were noted to either resident, Resident #1 was immediately transferred to the hospital, where he/she was again transferred to another Behavior Health Hospital and was readmitted back to the facility on 9/16/24. The DON stated Resident #1 had multiple medication changes per the hospital discharge summary, Resident #1 was placed in a private room, and every fifteen (15) minute checks for thirty (30) days was initiated. Review of facility Abuse, Neglect and Exploitation Policy dated 2/2023 identified it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. For the definition of abuse, means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. For the definition of physical abuse, it includes, but is not limited to hitting, slapping, punching, biting, and kicking.

Based on clinical record review, facility documentation, facility policy, and interviews for one (1) of four (4) residents reviewed for abuse, (Resident #1) the facility failed to ensure the resident was free from verbal abuse from another resident. The findings include: Resident #1's diagnoses included anxiety disorder, depression, unspecified psychosis, vascular dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment and required supervision for ADL's. A Resident Care Plan dated 10/4/22 identified episodes of anxiety and major depression with interventions that directed to administer medications per order and to monitor for effectiveness, encourage participation in activities of interest, offer support and reassurance to the resident, provide a calm, quiet environment, and psych evaluation, and follow up as needed for counseling. A nurse's note dated 12/16/22 at 11:56 PM identified Resident #1 was upset because Resident #2 lost track of where h/she was going and entered Resident #1's room. The note identified the charge nurse quickly re-directed Resident #2 back to his/her room, Resident #1 was very upset and called the police. The police came to the facility and stated that Resident #2 was confused with a diagnosis of dementia and the police could not investigate due to Resident #2's dementia diagnosis. Resident #1 refused a stop sign to be added to the door to h/her room. The facility incident audit report dated 12/17/22 at 7:02 PM identified Resident #1 screamed at Resident #2 for entering his/her room, the charge nurse immediately intervened and redirected Resident #2 to the correct room and Resident #1 called the police. The report additionally identified Resident #2 was placed on every 15-minute checks for twenty-four hours and would be provided with continuous redirection. Interview with Resident #4 (Resident #1's roommate) on 12/29/22 at 12:01 PM identified on the night in question (12/16/22), Resident #2 wandered into their room, Resident #4 told Resident #2 to get out but Resident #2 did not respond. Resident #1 awoke and asked Resident #2 to leave the room when Resident #2 raised his/her hands to Resident #1. Resident #4 further identified Resident #1 then yelled at Resident #2 get out of her or I will hit you with my walker to which Resident #2 replied if you hit me, I will kill you. Interview with Resident #1 on 12/29/22 at 12:12 PM identified on 12/16/22 Resident #1 identified s/he told Resident #2 to get out, at which time Resident #2 raised his/her hands as if to gesture h/her hands around Resident #1's neck (Resident #2 was not within reaching distance of Resident #1), and said, I'll kill you. Resident #1 identified the nurses came into the room and escorted Resident #2 out of the room and Resident #1 called 911. Additionally, Resident #1 identified s/he is still afraid of Resident #2 who was still on the same unit. Interview with LPN #1 on 12/29/22 at 12:40 PM identified she was the nurse on the unit at the time of the incident when she heard someone yelling get out of my room. LPN #1 indicated she went to Resident #1's room and observed Resident #2 was in the room. LPN #1 further identified she re-directed Resident #2 out of Resident #1's room back to h/her own room, at that time Resident #1 informed LPN #1 that Resident #2 had threatened him/her, and s/he was going to call 911. LPN #1 identified she then put Resident #2 on one-to-one observation and offered a stop sign for Resident #1's door, but Resident #1 refused. Interview with RN #3 (the 3:00 PM to 11:00 PM shift supervisor) on 12/29/22 at 2:24 PM identified while in the nurse's office on the night of the incident, she heard a scream around approximately 6:15 PM from Resident #1. RN #1 indicated she immediately went to Resident #1's room along with LPN #1 and Resident #1 stated get Resident #2 out of my room. RN #3 further identified that Resident #1 had called the police, the police officer came and talked to both residents and to RN #3 who informed the police officer of the events, and the police officer stated Resident #2 is confused so they cannot proceed with an investigation. RN #3 further identified Resident #2 was placed on every 15-minute checks and put up a stop sign on his/her doorway. RN #3 indicated she could not recall if Resident #1 had informed her that Resident #2 had threatened him/her. Interview with the DNS on 1/3/23 at 9:56 AM identified she was informed that on 12/16/22 Resident #2 had walked into Resident #1's room. RN #3 reported that Resident #2 was confused and walked into Resident #1's room looking for the bathroom, when Resident #1 started screaming at Resident #2, and Resident #2 stated he would kill Resident #1 in response. The DNS identified Resident #2 was redirected to the correct room and placed on every 15-minute checks for safety. Review of the facility policy titled Abuse Prohibition dated September 2020 directed, in part, the facility has the responsibility to ensure that each resident has the right to be free from abuse, mistreatment, neglect, exploitation and misappropriate of his or her personal property. The policy further directed it will be the facility's responsibility to identify, correct and intervene in situations where abuse, mistreatment, neglect, exploitation and/or misappropriate of resident property occur. Additionally, the policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability.

Based on clinical record review, facility documentation, facility policy, and interviews for one (1) of four (4) residents reviewed for abuse, the facility failed to ensure the facility reported abuse allegations to the state agency in accordance with facility policy. The findings include: Resident #1 's diagnoses included anxiety disorder, depression, unspecified psychosis, vascular dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment and required supervision for ADL's. A nurse's note dated 12/16/22 at 11:56 PM identified Resident #1 got upset due to a resident (Resident #2) had lost track of his/her room, and entered Resident #1's room. Additionally, the note identified the charge nurse quickly re-directed Resident #2 back to his/her room, Resident #1 was very upset and called the police. The note further identified the police came and realized Resident #2 was confused with a diagnosis of dementia and said they could investigate due to Resident #2's diagnosis of dementia. The facility incident audit report dated 12/17/22 at 7:02 PM identified Resident #1 screamed at Resident #2 for entering his/her room, the charge nurse immediately intervened and redirected Resident #2 to the correct room and Resident #1 called the police. The report additionally identified Resident #2 was placed on every 15-minute checks for twenty-four hours and would be provided with continuous redirection. Interview with Resident #4 (Resident #1's roommate) on 12/29/22 at 12:01 PM identified on the night in question (12/16/22), Resident #2 wandered into their room, Resident #4 told Resident #2 to get out but Resident #2 did not respond. Resident #1 awoke and asked Resident #2 to leave the room when Resident #2 raised his/her hands to Resident #1. Resident #4 further identified Resident #1 then yelled at Resident #2 stating get out of her or I will hit you with my walker to which Resident #2 replied if you hit me, I will kill you. Resident #4 identified there have been no further incidents since that date. Interview with Resident #1 on 12/29/22 at 12:12 PM identified on 12/16/22 Resident #2 entered Resident #1's room and Resident #4 told Resident #2 not to come in. Resident #1 identified s/he told Resident #2 to get out at which time Resident #2 raised his/her hands as if to go around Resident #1's neck and said, I'll kill you. Resident #1 identified the nurses came into the room and escorted Resident #2 out of the room and Resident #1 called 911. Additionally, Resident #1 identified s/he is still afraid of Resident #2 who was still on the same unit. Review of the Department of Health Reportable Event site identified the altercation between Resident #1 and Resident #2 was reported to the state agency on 12/23/22 at 3:20 PM, (seven days after the event occurred). Interview with the DNS on 1/3/22 at 9:56 AM identified she was notified of the incident on 12/16/22 at 10:30 PM. However, she was unaware this incident was a reportable event because it was only verbal with no physical contact, so she did not immediately report it to the State Agency. The DNS further identified when there is an allegation of abuse, it should be reported within 2 hours of knowledge of allegation. Interview and record review with the Administrator on 1/3/22 at 12:08 PM identified that the reportable event to the State Agency was made on 12/23/22, 7 days after the allegation of abuse. Additionally, the Administrator identified the facility policy on abuse directs that an allegation of abuse must be reported timely, within 2 hours for abuse and the DNS is responsible to submit this to the State Agency. The Administrator further identified she could not give a reason why this event was reported seven days after the occurrence and that it should have been reported within 2 hours of knowledge of the event. The facility policy titled Abuse Prohibition Policy dated September 2020, directed, in part, all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the Department of Public Health immediately, but not later than two hours after the allegation is made.

Based on clinical record review, facility documentation, facility policy, and interviews for two (2) of four (4) residents reviewed for abuse, (Resident #1 and Resident #2), the facility failed to ensure the care plan was updated after a resident-to-resident altercation occurred. The findings include: 1) Resident #1's diagnoses included anxiety disorder, depression, unspecified psychosis, vascular dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicative of no cognitive impairment and required supervision for Activities of Daily Living (ADL's). The Resident Care Plan (RCP) dated 10/4/22 identified episodes of anxiety and major depression with interventions that directed to administer medications per order and monitor for effectiveness, encourage resident to verbalize thoughts and feelings related to anxiety, observe for periods of anxiety, offer support and reassurance to the resident, provide a calm, quiet environment, and psych evaluation, and follow up as needed for counseling. 2) Resident #2 diagnoses included Alzheimer's Disease, and other toxic encephalopathy. The admission MDS dated [DATE] identified Resident #2 had a BIMS score of five (5) out of fifteen (15) indicative of severe cognitive impairment and required extensive assistance with ADL's. The RCP dated 12/9/22 identified impaired cognitive function/dementia with interventions that directed to administer medications as ordered, monitor and document for side effects and effectiveness, and provide structured activities that avoid overly demanding tasks and keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. a) nurse's note dated 12/16/22 at 11:56 PM identified Resident #1 got upset due to a male resident (Resident #2) lost track to his/her room and entered Resident #1's room. Additionally, the note identified the charge nurse quickly re-directed Resident #2 back to his/her room, Resident #1 was very upset and called the police. The note further identified the police came and realized Resident #2 was confused with a diagnosis of dementia and said they could not do much due to Resident #2's condition. The note identified the DNS was notified and Resident #1 refused a stop sign to her room. The facility incident audit report dated 12/17/22 at 7:02 PM identified Resident #1 screamed at Resident #2 for entering his/her room, the charge nurse immediately intervened and redirected Resident #2 to the correct room and Resident #1 called the police. The report additionally identified Resident #2 was placed on every 15-minute checks for twenty-four hours and continuous redirection. Review of Resident #1 and Resident #2's care plan failed to identify interventions were added after the incident on 12/17/22. Interview with Resident #1 on 12/29/22 at 12:12 PM identified on 12/16/22 Resident #2 entered Resident #1's room and Resident #4 told Resident #2 not to come in. Resident #1 identified s/he told Resident #2 to get out at which time Resident #2 raised his/her hands as if to go around Resident #1's neck and said, I'll kill you. Resident #1 identified the nurses came into the room and escorted Resident #2 out of the room and Resident #1 called 911. Additionally, Resident #1 identified s/he is still afraid of Resident #2 who was still on the same unit. Interview with RN #3 on 12/29/22 at 2:14 PM identified it is the nurse's or the supervisor's responsibility to update the care plan as well as the social worker. Additionally, RN #3 identified Resident #1, and Resident #2 did not have an update to their care plan after the incident on 12/16/22. RN #3 further identified the care plans for both residents should have been updated after the incident occurred. Interview and record review with the DNS on 1/3/23 at 9:56 AM she would expect the supervisor to pull up the care plan and care plan for the incident and if they were unable, they should let another staff member know, such as the MDS nurse, the DNS, or the oncoming supervisor. The DNS further identified it is the responsibility of nursing to update the care plan. Additionally, the DNS identified that for both Resident #1 and Resident #2 the update was not done after the incident dated 12/16/22, and both of their care plans should have been updated. The DNS could not give a reason the care plan for both Resident #1 and Resident #2 were not updated after the incident. The facility policy titled Abuse Prohibition Policy dated September 2020 directed, in part, interventions to ensure resident well-being will be identified by the Interdisciplinary Team (IDT) and included in the resident's care plan.

Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for one (1) of four (4) residents, reviewed for mental and psycho-social services, (Resident #1), the facility failed to ensure the resident was seen by the mental health provider after the resident was involved in an altercation with another resident. The findings include: Resident #2 diagnoses included Alzheimer's Disease, and other toxic encephalopathy. The admission MDS dated [DATE] identified Resident #2 had a BIMS score of five (5) out of fifteen (15) indicative of severe cognitive impairment and required extensive assistance with ADL's. The care plan dated 12/9/22 identified impaired cognitive function/dementia with interventions that directed to administer medications as ordered, monitor and document for side effects and effectiveness, provide structured activities that avoid overly demanding tasks and keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. The facility incident audit report dated 12/17/22 at 7:02 PM identified Resident #1 screamed at Resident #2 for entering his/her room, the charge nurse immediately intervened and redirected Resident #2 to the correct room and Resident #1 called the police. The report additionally identified Resident #2 was placed on every 15-minute checks for twenty-four hours and would be provided with continuous redirection. Interview with Resident #4 (Resident #1's roommate) on 12/29/22 at 12:01 PM identified on the night in question (12/16/22), Resident #2 wandered into their room, Resident #4 told Resident #2 to get out but Resident #2 did not respond. Resident #1, who had been asleep, awoke and asked Resident #2 to leave the room when Resident #2 raised his/her hands to Resident #1. Resident #4 further identified Resident #1 then yelled at Resident #2 stating get out of her or I will hit you with my walker to which Resident #2 replied if you hit me, I will kill you. Resident #4 identified there have been no further incidents since that date. Interview with Resident #1 on 12/29/22 at 12:12 PM identified on 12/16/22 Resident #2 entered Resident #1's room and Resident #4 told Resident #2 not to come in. Resident #1 identified s/he told Resident #2 to get out, at which time Resident #2 raised his/her hands as if to go around Resident #1's neck and said, I'll kill you. Resident #1 identified the nurses came into the room and escorted Resident #2 out of the room and Resident #1 called 911. Additionally, Resident #1 identified s/he is still afraid of Resident #2 who was still on the same unit. Review of the reportable events documentation identified an interview with the DNS on 12/23/22 at 2:30 PM which indicated Resident #2's behavior was written in the behavior book but was not seen by psych or sent to the hospital. Interview and chart review with the DNS on 1/3/23 at 9:56 AM identified it was her hope that Resident #2 was seen by psych but was unsure if it had been done. Further interview with the DNS at 12:19 PM identified Resident #2 was not seen by psych and was never placed in the psych book to be seen. Additionally, the DNS identified Resident #2 should have been seen by psych after the incident and she is unable to identify why Resident #2 was not placed in the psych book or seen by the psych provider. Review of the facility policy titled Abuse Prohibition Policy dated September 2020 directed, in part, to provide emotional support and reassurance to the resident. Additionally, the policy directed the facility will provide any necessary interventions to insure the resident's safety and wellbeing. the facility failed to ensure the resident was seen by the mental health provider after the resident was involved in an altercation with another resident (Resident #1). The findings include:

Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 of 5 residents (Resident #6, Resident #40, Resident #55, Resident #161, and Resident #262) reviewed for resident to resident altercations, the facility failed to ensure a resident was free from physical mistreatment. The findings include: 1. Resident #6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 was moderately cognitively impaired and required limited 1 person assistance with transfers and ambulation. The Resident Care Plan (RCP) dated 2/17/22 identified Resident #6 had impaired cognition related to dementia. Interventions directed to use simple, direct communication, verbal cues and task segmentation. The RCP also identified Resident #6 required 1 person assistance for transfers related to decreased strength, coordination, balance and impaired safety awareness, and Resident #6 not always wait for assistance. Interventions included out of bed as tolerated, limited 1 person assistance with transfers and gait, no assistive device and limited 1 person assistance with distances as tolerated. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #161's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set, dated dated dated [DATE] identified Resident #161 was severely cognitively impaired and required supervision with ambulation. The Resident Care Plan dated 12/7/21 identified Resident #161 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to explain issues in short, simple steps, to monitor resident's behavior and arrange for psychiatric follow up as needed. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A Reportable Event form (RE) dated 2/13/22 identified at 4:00 PM, Resident #161 was observed approaching Resident #6 and punching him/her in the face, causing him/her to fall backwards onto the floor. Additionally, the RE identified NA #2 and the Recreation Assistant, witnessed the incident which occurred near the Great Room where NA was talking with other residents. A facility statement from NA #2 identified when Resident #6 was pushed by Resident #161, Resident #6 fell backwards, but there was a ball that prevented him/her from hitting the back of his/her head. NA #2 immediately called the Charge Nurse and Nursing Supervisor for assistance. Resident #6 was assessed by an RN which identified no facial swelling or bruising, Resident #6 was able to move all extremities, and denied pain. Resident #161 was immediately placed on 1 to 1 supervision. The physician was contacted and directed to send Resident #161 to the Emergency Department (ED). Resident #6 was alert and confused, able to make needs known and ambulated with assistance of 1 staff member before and after the event. Resident #161 was alert, confused and ambulatory before and after the event. Physician, responsible parties and police were all notified. A nurse's note, written by RN #4 on 2/13/22, after the incident, identified Resident #6 denied pain and had no injury. Per note, Resident #6 stated I didn't do anything to him/her, he/she just punched me in the face. Resident #6 was assisted to a chair in the Great Room and stayed in view of staff for safety. Interview with NA #2 on 8/10/22 at 9:30 AM identified she witnessed the incident between Resident #6 and Resident #161 on 2/13/22. She identified she was talking with residents in the Great Room, which is close to the nurse's station and was the central area on the unit where activities occur. NA #2 indicated both residents were ambulating independently at the time and suddenly Resident #161 walked up to Resident #6 and hit him/her in the face and pushed resident causing Resident #6 to fall backwards onto his/her back/bottom. NA #2 identified there was a ball in the Great Room which was positioned on the floor near Resident #6 and prevented his/her head from hitting the floor. NA #2 identified she immediately called for help, the RN assessed both resident's and put Resident #161 on 1 to 1 observation until sent to the hospital for evaluation. NA #2 indicated Resident #6 kept saying I didn't do anything. After Resident #6 was assessed he/she was assisted upright to a chair and was monitored for safety. b. A Reportable Event form dated 4/1/22 identified a witnessed resident to resident incident at 3:01 PM. Documentation identified while Resident #6 was walking in the hallway, Resident #161, who was also walking, approached and punched Resident #6 in the chest causing him/her to fall onto his/her bottom. RN assessment of Resident #6 identified no injuries were sustained. Documentation identified Resident #161 was placed on 1 to 1 observation pending hospital transfer for evaluation and Resident #6 was assisted and removed from the area for safety. Interview with NA #1 identified she regularly worked the 7:00 AM to 3:00 PM shift on the Dementia Unit and on 8/10/22 at 11:00 AM witnessed Resident #161 push Resident #6 indicating the incident was unprovoked. NA #1 identified both residents were walking past each other in the hallway and were in front of the Great Room, when suddenly, Resident #161 pushed Resident #6 in the chest causing him/her to fall backwards and onto his/her bottom. NA #1 identified Resident #161 was placed on 1 to 1 observation until sent out to the hospital and continued on 1 to 1 observation upon return from the Emergency Department. NA #1 identified staff tried to divert and distract/redirect residents and always were mindful of where Resident #161 was at all times because he/she was unpredictable. NA#1 indicated Resident #161 had once hit her in the face, knocking her glasses off, while she was speaking with another resident who was seated at a table. 2. Resident #55's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified Resident #55 was moderately cognitively impaired with no behaviors and required supervision with ambulation. The Resident Care Plan dated 12/29/21 identified Resident #55 had the potential to be physically aggressive toward staff and others related to anger, dementia, depression and poor impulse control. Interventions included to provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior and encourage seeking out of staff member when upset. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Reportable Event form dated 3/17/22 identified at 5:30 PM, Resident #55, who was seated in a chair across from the nurse's station, was witnessed standing up abruptly, without any confrontation and pushing Resident #6 to the floor while Resident #6 was walking by. Resident #6 fell backwards, hitting the back of his/her head on the floor, sustaining a 5 centimeter (cm) by 5 cm occipital laceration with a moderate amount of bleeding. Resident was assessed by the RN and first aid was provided which included application of a pressure dressing to the occipital area. APRN, responsible party and police were notified. Resident #6 was sent to the emergency room (ER) for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #55 was placed on 1 to 1 supervision and sent to hospital for crisis evaluation. A nurse's note dated 3/17/22 identified while Resident #6 was ambulating in the hallway, he/she passed by Resident #55 who got up and pushed Resident #6 onto the floor hitting back of his/her head, sustaining a 5 cm by 5 cm long laceration to the occipital area with a moderate amount of bleeding. Resident #6 was removed from the area and first aid was provided in resident's room. Staff supervised resident until paramedics and police arrived. APRN and responsible parties were notified. Resident #6 was sent to the ER for further evaluation and treatment. Interview with LPN #6 on 8/10/22 at 10:00 AM identified she witnessed the incident between Resident #6 and Resident #55 on 3/17/22. LPN identified Resident #55 was sitting in a chair right across from the nurse's station and Resident #6 was walking by. LPN #6 identified Resident #6 was saying I can't find my baby, indicating some of the residents have dolls which gives them something to hold and seems to calm them. LPN #6 identified as Resident #6 was approaching the area where Resident #55 was sitting, Resident #55 got up abruptly and pushed Resident #6 backwards. LPN #6 identified Resident #6 sustained a head laceration and was bleeding. After the RN assessed Resident #6, LPN #6 indicated Resident #6 was sent to the ER for evaluation and returned with staples to the back of his/her head. LPN identified Resident #55 did admit he/she had pushed Resident #6 however shortly afterwards asked where the resident was. LPN #6 identified although Resident #55 had been verbally rude and nasty sometimes to both staff and residents, he/she had never been physically aggressive before. LPN identified she was very shocked when this incident occurred and indicated something must have triggered Resident #55 to cause him/her to push Resident #6. Review of the facility's policy entitled Resident's Bill of Rights identified, in part, you have the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. 3. Resident #40 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 was severely cognitively impaired, required extensive assistance of one with bed mobility, transfers, and locomotion on the unit with the use of a walker or wheelchair. A Resident Care Plan (RCP) dated 12/23/22 identified Resident #40 had an activities of daily living (ADL) deficit related to traumatic brain injury and [CONDITION(S)], requiring assistance of one with ADL's. The RCP also noted mood and behavior patterns with verbal expressions of distress and a previous history of an altercation with another resident (Resident #262). Interventions included attempting to identify the source of anxiety, help resolve where appropriate, do not leave alone with Resident #262 and redirect away from Resident #262. Resident #262 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #262 was severely cognitively impaired, required assist with personal care and independent with ambulating on the unit without assistive devices. A Resident Care Plan dated 12/7/21 identified Resident #262 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to monitor resident's behavior and arrange for psychiatric follow up as needed. A Reportable Event form dated 12/26/21 at 12:00 AM noted staff witnessed Resident #262 strike Resident #40 resulting in swelling to the left side of Resident #40's face. Both residents were separated by staff. Resident #40 received an x-ray of the facial bones which was negative for fracture and Resident #262 was placed on 1 to 1 observation until transport to an outside hospital for further evaluation. Nurse's notes dated 12/26/21 at 9:22 PM noted Resident #40 was noted to have been verbally abusive to another resident (Resident #262) with Resident #40 swearing at Resident #262. Resident #262 punched Resident #40 on the left side of the face while staff were attempting to move him/her away causing an immediate bruise and swelling. Ice was applied. Neurological checks were within normal limits and orders were obtained for an x-ray. An interview on 8/10/22 at 7:19 AM with RN #2 identified she had been working as a per diem nurse intermittently at the facility since 2020. RN #2 indicated she was the assigned nurse the evening of the incident when she heard yelling and swearing from Resident #40 coming from the lounge area. RN #2 stated she went to investigate and observed Resident #262 standing over Resident #40 who was sitting in his/her wheelchair. RN #2 attempted to intervene but Resident #262 pulled away from her and was observed to have struck Resident #40 on the left side of the face. RN #2 could not say for sure if Resident #40's yelling was directed at Resident #262 as Resident #40 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #262 was moved off the unit when an altercation between the two happened a second time. RN #2 stated it would have been difficult to keep the two residents separated as Resident #262 wandered around the unit. An interview on 8/11/22 at 9:14 AM with RN #3 (acting DNS) expected residents be free from physical mistreatment. The facility policy for Abuse directs the facility to ensure each resident have the right to be free from abuse including physical abuse (hitting, slapping, pinching, kicking). Following an alleged incident of abuse, residents are to be immediately separated from each other. Provide any necessary interventions to ensure the residents safety and wellbeing.

Based clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1), reviewed for a medication error, the facility failed to ensure the resident was free from a significant medication error. The facility failed to ensure medications were administer in a safe manner to prevent administration of insulin to the wrong resident, and the facility failed to ensure a narcotic was not administered after the physician discontinued the narcotic. The findings include: Resident #1 had diagnoses that included [CONDITION(S)] and Dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment, required extensive assistance with activities of daily living and had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions directed to identify self, speak slowly, clearly and to explain all procedures. Nurse's notes dated 1/31/2022 at 10:42 PM written by RN #1 identified that LPN#1 notified RN #1 that she had administered [MEDICATION(S)] insulin (long-acting insulin to lower blood glucose levels and treat diabetes) to the resident (Resident #1 had no insulin ordered). The note further identified Resident #1 was stable, in no acute distress with no signs or symptoms of [CONDITION(S)] (low blood sugar) and that MD #1 was notified. MD #1 directed to send Resident #1 to the hospital for evaluation. Nurse's note dated 1/31/2022 at 11:14 PM, written by LPN #1, identified that she had administered [MEDICATION(S)] 40 units at approximately 9:00 PM in error to Resident #1. The note identified that the nursing supervisor, physician, and family were notified, and Resident #1 was transferred to the hospital. Hospital discharge summary dated 2/2/2022 at 2:13 PM identified that Resident #1 had received 40 units of [MEDICATION(S)] insulin in error and had no history of diabetes or insulin use. The summary indicated that upon admission to the emergency room , Resident #1 was stable and had a blood glucose of 73 (normal blood glucose for someone who has eaten in the prior 8 hours is 90 to 110). Resident was started on a Dextrose (solution to provide sugar/glucose) intravenous (IV) drip and remained stable with blood glucose range between 90 to 110. The Dextrose IV was discontinued on 2/1/2022 and Resident #1's blood sugar decreased to 68, and additional Dextrose IV was administered for several more hours. The Dextrose IV was discontinued on 2/1/2022 at 10:30 AM. The summary further indicated that at 36 hours-post [MEDICATION(S)] administration, the resident was outside the timeframe for any hypoglycemic (low blood glucose) effect, had not experienced any changes in mental status or other acute complications from the [MEDICATION(S)], and was transferred back to the facility. Nurse's admission progress note dated 2/2/2022 at 10:54 PM identified that Resident #1 was readmitted to the facility at 7:15 PM. Interview with RN #1 on 2/16/2022 at 9:10 AM identified that LPN #1 had notified her on 1/31/2022 that Resident #1 was administered [MEDICATION(S)] insulin in error. RN #1 immediately assessed Resident #1 and identified he/she was stable, notified the physician and transferred Resident #1 to the hospital. Interview with LPN #1 on 2/16/2022 at 9:17 AM she indicated she was an agency nurse and was not familiar with the residents. She further indicated that on 1/31/2022 she entered the wrong resident room with the insulin and because the resident was not wearing an identification wrist band, she gave the insulin to the wrong patient. She did not verify the resident's identity prior to administering the insulin, and she should have verified that she had the correct resident. Interview with the DON on 2/16/2022 at 12:52 PM identified LPN #1 should have verified Resident #1's identity prior to administration of the [MEDICATION(S)] insulin to ensure she had the correct resident. Further she indicated that the Medication Administration Record (MAR) had resident photos to reference for resident identification, and other staff were available to confirm the resident's identity. The DON indicated that subsequent to the medication error, all licensed staff were provided with education related to resident safety to include proper resident identification prior to medication administration, and a review of the five (5) rights of medication administration. Review of facility undated Medication Administration Policy directed in part, that it was the responsibility of the licensed nurse to review physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Policy further directed to verify resident identity by checking the identification band, checking the photograph located in the MAR, asking the resident's name and or asking another staff member to identify the resident. The policy further identified to always check three (3) times prior to administration of medication. a. Resident #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment, had multiple indicators of the presence of pain observed daily and health conditions that included hip replacement. The Resident Care Plan (RCP) dated 8/13/2021 identified a problem related to recent hip surgery. Interventions included to administer medications as ordered. Physician's progress note dated 9/7/2021 identified plan to discontinue [MEDICATION(S)] ([MEDICATION(S)]) due to good pain control utilizing [MEDICATION(S)] (a synthetic opioid pain reliever) 50 mgs and because the [MEDICATION(S)] was utilized only one (1) time in past week. The note further identified the plan included to continue administration of [MEDICATION(S)] 50 mgs every 6 hours as needed for pain. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility reportable event form dated 9/27/2021 at 11:00 AM identified that LPN #2 continued to administer [MEDICATION(S)] ([MEDICATION(S)]) to Resident #1 after the physician discontinued the medication on 9/7/2021. The form indicated that disposition/actions taken directed that discontinued narcotics would be brought to the supervisor at time they were ordered discontinued. Interview and clinical record review with the ADON on 2/15/2022 at 12:28 PM identified the medication administration error was discovered by a review of the [MEDICATION(S)] ([MEDICATION(S)]) controlled substance disposition record. The review identified that the [MEDICATION(S)] had been dispensed by LPN #2 four (4) times after the physician discontinued the medication on 9/7/2021. The ADON indicated LPN #2 signed the [MEDICATION(S)] controlled substance disposition record and administered the [MEDICATION(S)] on 9/11, 09/14, 09/22 and 09/25/2021, and did not sign the Medication Administration Record (MAR) to identify the [MEDICATION(S)] was administered. She indicated the [MEDICATION(S)] should not have been administered after the physician ordered it to be discontinued. Interview with LPN #2 on 2/15/2022 at 2:54 PM identified that he continued to administer the narcotic because the electronic medication record continued to show that medication remained available. Review of facility undated Controlled Substance Handling Policy directed in part, that discontinued controlled drugs are returned to the nursing office, until destroyed.

Based on clinical record review, review of facility documentation, review of facility policy, and interviews Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #14) who was at risk for aspiration, totally dependent on staff with eating, and had a restriction of specific food items, the facility failed to ensure the resident was served the therapeutic diet in accordance with the physician's order to prevent a choking episode which resulted in immediate jeopardy and for 1 of 3 sampled residents reviewed for skin conditions (Resident #472), the facility failed to ensure medication/cream was administered per the physician's orders. The findings include: 1. Resident #14's [DIAGNOSES REDACTED]. The Fiberoptic Endoscopic Evaluation of Swallowing (FEES) dated 6/27/18 identified Resident #14 was seen for worsening cough, increased mucous and expectoration of food particles from the oral cavity. The FEES was ordered to assess the resident's current swallow function, anatomy and physiology and to provide recommendations regarding the least restrictive diet for the highest level of safety and compensatory strategies. The recommendations for feeding: upright during and after meals, alternate liquids and solids, feed and eat slowly and small frequent meals. The Resident Care Plan dated 6/2818 identified the resident had mild dysphagia related to advanced [MEDICAL CONDITION] and was at risk for aspiration. Interventions directed to use the standard aspiration precaution, alternate solids and liquids, cue the resident to fully chew the food with regular diet consistency and thin liquids, no corn, no peas, no sausage, no salad, no hamburgers, no rice, no couscous, no bacon, no oranges, no apples with skin, and a speech therapy screen as needed. A physician's order dated 7/19/18 directed a regular consistency texture diet, thin liquids, no corn, no peas, no sausage, no salad, no hamburgers, no rice, no couscous, no bacon, no oranges, no apples with skin, aspiration precaution, upright at 90 degrees for meals, to eat at a slow rate, take small bites, alternate solids and liquids, to cue resident to fully chew food, and do not keep the head tilted back when swallowing. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #14 made reasonable decisions regarding tasks of daily living and was totally dependent on one (1) person with eating. The nutritional assessment dated [DATE] identified Resident #14 was served an early tray for extra time allotted at meals, was fed by the caregiver and aspiration precautions were in place. The nurse's note dated 8/11/18 at 5:00 PM identified that the charge nurse was summoned to dining room by a nurse aide and upon arrival Resident #14 was observed to be in distress, with no audible breath going in and/or coming out. The note indicated the resident was helped to lean forward in the wheelchair, abdominal thrusts times three (3) were performed at which time food and mucus was ejected from the resident's mouth. The Reportable Event Form dated 8/11/18 at 5:00 PM indicated Resident #14 coughed while eating a hamburger and required the [MEDICATION NAME] maneuver to clear the passage. In an interview with Resident #14 on 9/24/18 at 11:55 AM, Resident #14 indicated that he/she choked on a hamburger while being fed by a nurse aide. Resident #14 stated that the hamburger was served to him/her by a nurse aide and he/she took a bite out of the burger. Resident #14 identified that a staff member from the recreation department assisted him/her with selecting food items on menu. In an interview and review of the written statement with the 3-11PM nurse aide, Nurse Aide (NA) #1 on 9/24/18 at 12:27 PM NA #1 indicated she assisted Resident #14 during supper on 8/11/18 and the meal consisted of a hamburger. NA #1 stated she was aware that Resident #14 should not have hamburger, however the hamburger was on the tray and she offered it to Resident #14. NA #1 identified that she did not report to the charge nurse that the hamburger was on the resident's tray and/or she did not offer Resident #14 an alternate meal choice. NA #1 stated that after Resident #14 took a bite of the hamburger, the resident had difficulty chewing and talking. In an interview and review of the clinical record with Speech Therapist #1 on 9/24/18 at 1:50 PM she indicated that Resident #14 had advanced [MEDICAL CONDITION], dysphagia, was a high risk for aspiration and Resident #14 did not want to downgrade the regular diet to a mechanical soft therefore the resident had agreed to have the regular diet with restrictions. Speech Therapist #1 stated that a hamburger should not be given to Resident #14 as it was one of the restricted food items. In an interview with the Assistant Director of Nursing (ADON) on 9/24/18 at 2:10 PM she indicated that on the evening of 8/11/18 she was informed Resident #14 had a choking episode during the evening meal. The ADON stated that the nurse aide should not have given the hamburger to Resident #14 and should have consulted with the charge nurse prior to offering the hamburger. In an interview with the Director of Nursing (DON) on 9/24/18 at 2:55 PM she indicated that Resident #14 required total assistance with meals. The DON stated it was her understanding that the nursing staff are aware of Resident #14's food restrictions. In an interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #5 on 9/25/18 at 12:51 PM, she indicated it was brought to her attention that Resident #14 was having difficulty swallowing. LPN #5 stated upon entering the dining room the resident was noted to be in distress, and after performing abdominal thrusts, the resident was able to expel the food. LPN #5 indicated that Resident #14 should not have been given a hamburger. LPN #5 stated in the event the resident asked for a hamburger and/or if the hamburger was placed on the resident's tray, the nurse aide should have alerted her. Review of the facility's aspiration precaution policy indicated that aspiration precautions will be utilized to reduce the risk of aspiration of food and/or liquids into a resident's lung. Review of the facility's documentation identified a plan of correction was developed and implemented on 8/11/18 prior to the immediate jeopardy which was identified on 9/24/18 and review of the facility's documentation identified the facility was in compliance on 8/16/18. The plan of correction: -All staff involved in meal service were re-inserviced regarding aspiration precaution, identification of varied therapeutic diets and the diets consistencies and location of information for each resident. -The resident affected diet was reviewed and modified -All other residents with unique diet restriction diets were reviewed -The affected resident meal tray is checked by a licensed nurse prior to it being served to resident -Audits are being conducted on accuracy of meal trays and meal tickets. 2. Resident #472 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A resident care plan dated 1/15/18 identified Resident #472 was admitted with large circular, flat, dry patches, the size resembling the leads of an electrocardiogram (EKG), and related to an allergic reaction. Interventions included to apply [MEDICATION NAME] 1% cream to the chest rash per physician's order. The physician's order dated 1/15/18 directed to apply [MEDICATION NAME] 1% cream to chest and abdomen contact [MEDICAL CONDITION] every evening shift. The 5 day scheduled minimum data set (MDS) assessment dated [DATE] identified Resident #472 was cognitively intact and required extensive assistance with activities of daily living. Review of Resident #472's treatment administration record (TAR) for (MONTH) (YEAR) directed to apply [MEDICATION NAME] 1% cream to chest and abdomen contact [MEDICAL CONDITION] every evening shift with start date of 1/15/18 and discontinuation date of 1/29/18. Review of the nurse's signatures from the TAR indicated that the treatment was completed every evening from 1/15/18 through 1/28/18. Review of facility documentation identified that on 1/24/18, Person #2 reported that Resident #472 had not received the prescribed treatment to the chest area as scheduled. The facility's investigation identified LPN #4, who was Resident #472's nurse on 1/18/18, 1/19/18 and 1/23/18 provided a statement which indicated that although he/she had signed off the [MEDICATION NAME] cream as being applied, he/she did not actually apply the cream. LPN #4 further identified that he/she had not looked closely at the treatment order. An interview with LPN #4 on 9/25/18 at 3:20 PM identified that on 1/18/18, 1/19/18 and 1/23/18, he/she signed off Resident #472's TAR quickly and had not read the order closely therefore had not realized the cream had to be applied. Additionally, LPN #4 identified that Person #1 and/or Person #2 had not mentioned anything at the time. Review of the facility policy for avoiding medication errors identified the 7 rights of medication administration include right resident, right drug, right dose, right time, right route, right reason and right documentation. Additionally, while dispensing medications, check the order 3 times: read the order prior to dispensing, re-read and compare the order to the blister pack/bottle/inhaler (while dispensing) and read a final time before returning medication to the drawer.

Based on record review, review of facility policy and staff interview for 2 of 6 sampled residents reviewed for accidents (Resident #473 and Resident #82), the facility failed to provide adequate supervision to prevent a fall (Resident #473) and/or the facility failed to ensure a resident was free from the risk of injury (Resident #82). The findings include: 1. Resident #473's [DIAGNOSES REDACTED]. The significant change Minimum (MDS) data set [DATE] identified Resident #473 was severely cognitively impaired and required extensive assistance of one person with toilet use. Additionally, Resident #473 was not steady moving from a seated to a standing position, moving on and off toilet and/or during surface to surface transferring. The MDS further identified Resident #473's functional range of motion was impaired on 1 side of lower extremity, he/she used a walker and/or wheelchair for mobility and had 1 fall with injury since the prior assessment. The care plan dated 12/21/17 identified Resident #473 required assistance with functional care needs. Interventions included bed mobility with extensive assist of one, transfer stand-pivot with extensive assist with one and ambulation with a rolling walker with extensive assist of one. Further, Resident #473 was at risk for falls secondary to decreased mobility. The fall risk assessment dated [DATE] identified Resident #473 was at risk for falls. The physician's orders [REDACTED].#473's was to transfer via stand pivot with extensive assistance of 1 and to ambulate with a rolling walker, with extensive assistance of 1. The physcian's order further identified precautions related to Resident #473 being a fall risk. Review of the reportable event dated 1/27/18 at 6:30 PM, Resident #473 fell while in the bathroom and hit the back of his/her head on the wall radiator sustaining a laceration. Resident #473 was sent to the Emergency Department and received 6 staples. Functional status before and after the event identified Resident #473 was alert and confused requiring 1 person assistance with activities of daily living. A review of the facility's investigation and statement by LPN #2 dated 1/27/18, identified that he/she had assisted Resident #473 to the bathroom and while Resident #473 was on the toilet, LPN #2 stood by the door. LPN #2 informed Resident #473 he/she could not close the door completely and waited outside the door with it partially opened. When Resident #473 indicated his/her brief was wet, LPN #2 turned his/her back to Resident #473 to reach for a brief that was on a chair in Resident #473's room. At that moment, Resident #473 stood up and fell on to the floor, hitting back of head on the wall radiator. An interview with LPN #2 on 9/25/18 at 9:00 AM identified that on 1/27/18 he/she assisted Resident #473 to the bathroom, left Resident #473 on the toilet, and stood by the partially opened door. LPN #2 indicated Resident #473 stood up from the toilet and fell when LPN #2 turned his/her back to reach for a brief on the chair in the room. LPN #2 further identified that although there was no one around to assist at the time, he/she should not have taken his/her eyes off of the resident. An interview with RN #2 on 9/26/18 at 9:00 AM identified he/she was very familiar with Resident #473 who was a very high fall risk. RN #2 identified Resident #473 was very confused, forgetful and had poor safety awareness and no short term memory. Additionally, although the resident was a stand-pivot transfer and he/she had the strength to hold onto the grab bar to assist with toilet transfer, RN #2 identified he/she would not leave Resident #473 alone in the bathroom. Additionally, RN #2 identified that an arm's length was a safe distance to be from Resident #473 during toilet use (and LPN #2 was further that an arm's length away). 2. Resident #82's [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] identified Resident #82 had a problem with short/long term memory, had verbal behaviors, required extensive assistance with activities of daily living, was always incontinent of bowel and was non ambulatory. The Resident Care Plan dated 7/11/18 identified a problem with having a risk for falls, secondary to decreased endurance /strength. Interventions included to leave the wheel chair at the bedside, do not leave Resident #82 alone in the bathroom, keep the call bell in reach and apply gripper socks. Reportable Event documentation dated 8/13/18 at 9:00 AM identified that a blanket was found draped over Resident #82 and secured to the back of Resident #82's wheelchair's headrest. The investigation identified that Nurse Aide #3 (NA) reported that Resident #82 repeatedly removed his/her gown/blanket and that NA #3 attempted to keep Resident #82 warm by tying the blanket to the back of the wheelchair's headrest. Nurse notes dated 8/13/18 at 10:01 AM identified that a blanket was found loosely secured to Resident # 82's wheelchair head rest. It further identified that Resident #82 was exhibiting [MEDICAL CONDITION] and restless behavior. Interview with LPN #3 on 9/25/18 at 7:43 AM indicated that Resident #82 had the usual behavior of trying to climb out of bed, yell out for help, and tried to swing his/her legs over the side of his/her wheelchair. LPN #3 further identified that after breakfast on 8/13/18, he/she observed a blanket covering Resident #82. The blanket was loosely tied to the back of Resident #82's wheelchair's headrest and that he/she then removed the blanket and reported the observation. During the interview and demonstration with LPN # 3 on 9/25/18 at 9:03 AM and utilizing the same blanket type that was used on Resident #82, he/she demonstrated on him/herself the manner in which she/she had found the blanket tied around Resident #82. The blanket was noted to be over the chest, upwards around the neck and tied in a knot around the headrest of the wheelchair. Surveyor applied force to free the blanket from around the LPN #3's neck and noted resistance to release the tied blanket, thus creating a potential safety hazard. A subsequent observation amongst the survey team noted the blanket material was textured and when tied around the surveyors neck noted resistance to be released. Interview with LPN #6 on 9/25/18 at 9:03 AM identified that he/she worked on the 11:00 PM to 7:00 AM shift on 8/13/18. LPN #6 further identified that he/she observed a blanket covering Resident #82. LPN #6 further identified that he/she attempted to re-cover Resident #82 with the blanket that Resident #82 kept removing, but NA #3 took over and re-covered Resident #82 with the blanket. Interview with NA # 3 on 9/25/18 at 9:44 AM identified the he/she worked on the 11:00 PM to 7:00 AM shift on 8/13/18. NA #3 indicated that while giving care to other residents, Resident #82 was yelling for help and was attempting to get out of bed. NA #3 indicated that he/she then gave care to Resident #82, dressed him/her, transferred him/her to the wheelchair and placed Resident #82 in the hallway near the Nurse's Station. NA #3 indicated that Resident #82 continued yelling and removing his/her gown and was complaining of being cold, so he/she placed a blanket on Resident #82 . NA #3 indicated that Resident #82 was pulling the blanket off so he/she subsequently placed the blanket around Resident #82's chest and upwards around Resident #82's neck and tied the blanket behind the back of the wheelchair's headrest in an attempt to keep Resident #82 warm. NA #3 further indicated that he/she had reported and made the LPN #6 aware of Resident #82's behaviors of yelling for help and attempting to get out of bed that morning. Interview with the DNS on 9/25/18 at 1:23 PM indicated that it was not facility practice to secure and/or tie blankets around residents.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #14) who was at risk for aspiration, totally dependent on staff with eating, and had a restriction of specific food items, the facility failed to ensure the resident was not served a restricted food item. The findings include: Resident #14's [DIAGNOSES REDACTED]. The Fiberoptic Endoscopic Evaluation of Swallowing (FEES) dated 6/27/18 identified Resident #14 was seen for worsening cough, increased mucous and expectoration of food particles from the oral cavity. The FEES was ordered to assess the resident's current swallow function, anatomy and physiology and to provide recommendations regarding the least restrictive diet for the highest level of safety and compensatory strategies. The recommendations for feeding: upright during and after meals, alternate liquids and solids, feed and eat slowly and small frequent meals. The Resident Care Plan dated 6/2818 identified the resident had mild dysphagia related to advanced [MEDICAL CONDITION] and was at risk for aspiration. Interventions directed to use the standard aspiration precaution, alternate solids and liquids, cue the resident to fully chew the food with regular diet consistency and thin liquids, no corn, no peas, no sausage, no salad, no hamburgers, no rice, no couscous, no bacon, no oranges, no apples with skin, and a speech therapy screen as needed. A physician's orders [REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #14 made reasonable decisions regarding tasks of daily living and was totally dependent on one (1) person with eating. The nutritional assessment dated [DATE] identified Resident #14 was served an early tray for extra time allotted at meals, was fed by the caregiver and aspiration precautions were in place. The nurse's note dated 8/11/18 at 5:00 PM identified that the charge nurse was summoned to dining room by a nurse aide and upon arrival Resident #14 was observed to be in distress, with no audible breath going in and/or coming out. The note indicated the resident was helped to lean forward in the wheelchair, abdominal thrusts times three (3) were performed at which time food and mucus was ejected from the resident's mouth. The Reportable Event Form dated 8/11/18 at 5:00 PM indicated Resident #14 coughed while eating a hamburger and required the [MEDICATION NAME] maneuver to clear the passage. The investigation identified in a written statement dated 8/13/18 Cook #2 indicated that on the evening of 8/11/18 the supper meal consisted of pizza with a hamburger as the alternate. Cook #2 identified he served the meal based on what was called by the dietary aide and he does not look at the ticket during tray line. In an interview with Resident #14 on 9/24/18 at 11:55 AM, Resident #14 indicated that he/she choked on a hamburger while being fed by a nurse aide. Resident #14 stated that the hamburger was served to him/her by a nurse aide and he/she took a bite out of the burger. Resident #14 identified that a staff member from the recreation department assisted him/her with selecting food items on menu. In an interview and review of the written statement with the 3-11PM nurse aide, Nurse Aide (NA) #1 on 9/24/18 at 12:27 PM NA #1 indicated she assisted Resident #14 during supper on 8/11/18 and the meal consisted of a hamburger. NA #1 stated she was aware that Resident #14 should not have hamburger, however the hamburger was on the tray and she offered it to Resident #14. In an interview and review of the written statement with Dietary Aide #1 on 9/2/18 at 1:30 PM he indicated that on the evening of 8/11/18 he assisted with the tray line and called the food choice according to what was on the meal ticket. Dietary Aide #1 stated he could not recall what the meal choice for Resident #14 was on 8/11/18. In an interview and review of the clinical record with Speech Therapist #1 on 9/24/18 at 1:50 PM she indicated that Resident #14 had advanced [MEDICAL CONDITION], dysphagia, was a high risk for aspiration and Resident #14 did not want to downgrade the regular diet to a mechanical soft therefore the resident had agreed to have the regular diet with restrictions. Speech Therapist #1 stated that a hamburger should not be given to Resident #14 as it was one of the restricted food items. In an interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #5 on 9/25/18 at 12:51 PM, she indicated it was brought to her attention that Resident #14 was having difficulty swallowing. LPN #5 stated upon entering the dining room the resident was noted to be in distress, and after performing abdominal thrusts, the resident was able to expel the food. LPN #5 indicated that Resident #14 should not have been given a hamburger. LPN #5 stated in the event the resident asked for a hamburger and/or if the hamburger was placed on the resident's tray, the nurse aide should have alerted her. Review of the facility's documentation identified a plan of correction was developed and implemented on 8/11/18. The plan of correction: -All staff involved in meal service were re-inserviced regarding aspiration precaution, identification of varied therapeutic diets and the diets consistencies and location of information for each resident. -The resident affected diet was reviewed and modified -All other residents with unique diet restriction diets were reviewed -The affected resident meal tray is checked by a licensed nurse prior to it being served to resident -Audits are being conducted on accuracy of meal trays and meal tickets.

Based on clinical record review and interviews for three of six sampled residents reviewed for accidents (R# 68, R#106, R#167) the facility failed to implement measures to prevent falls with injury and/or to prevent an elopement. The findings include: 1. Resident#68's [DIAGNOSES REDACTED]. A significant change MDS assessment dated [DATE] identified short and long term memory problems, severe impairment in cognition, requiring extensive assistance of one staff for ADLs, not steady and requiring assistance with moving from seated to standing position/walking/turning/moving on and off toilet, and recent falls with minor injury. Resident care plan for falls secondary to previous falls, impaired sense of balance, unsteady gait and cognitive impairment includes intervention to apply a self-releasing seat belt for safety. Physician order [REDACTED]. A fall risk assessment dated [DATE] scored 11 and identified at risk for falls with disorientation, 3 or more falls in the past 3 months and balance problems while standing. Facility documentation dated 9/08/16 indicated Resident#68 was taken to the bathroom in a wheelchair by NA#4, the NA was in back of the resident locking the wheelchair and the resident suddenly jerked forward hitting R#68's head on the toilet paper holder and then falling to the floor. Resident#68 sustained a laceration to the right forehead requiring 11 staples and fracture of the C1-C2 vertebrae requiring a cervical collar. Interview with the DNS on 1/04/17 at 12:15 PM indicated Resident #68's seat belt was not applied at the time of the fall and was part of the resident's plan of care. The DNS further indicated inservice education was completed. Inservice attendance sheet dated 9/15/16 with NA#4, instructed when a resident has compulsive behaviors, staff members should stand in front of the resident when locking wheelchairs to prepare for a transfer. Interview with NA#4 on 1/06/17 at 10:30 AM indicated the seatbelt was not applied because the NA did not expect the resident to move so fast and, that to happen. NA#4 indicated she was aware the use of a seatbelt was part of the resident's care plan and care card. Facility's Fall Management policy indicates the interdisciplinary team will develop, initiate and implement an appropriate individualized care plan based on the fall risk evaluation score. 2. Resident#106's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified short and long term memory problems, severe impairment in decision making, extensive assistance of one staff for ADL's, not stable and requiring staff assistance for stabilization with moving from seated to standing position/walking/turning around/moving on and off toilet/transfers and no recent falls. The resident care plan identified R#106 at risk for falls secondary to previous falls, impaired sense of balance and unsteady gait. Physician order [REDACTED]. The Physican orders also lists behaviors to be monitored to be flight of ideas and agitation. Initial facility documentation dated 11/12/16 indicated NA#4 left the resident in the wheelchair in the bathroom with a lap belt on and went to get maintenance to plunge the toilet. When the NA returned the resident was standing and holding onto a rail. NA#4 rushed over to help the resident and while giving care the NA noticed the resident had scraped his/her back and the nurse was notified. On 11/15/16 NA#4 was reinterviewed and indicated when the NA returned to the bathroom, the resident was on the floor, panicked and picked the resident up from the floor. Investigation identified a 9.0 cm x 2.0 cm abrasion to the back. Interview with NA#4 on 1/06/17 at 10:30 AM described the events of the 1/15/16 interview: NA#4 found the resident on the floor, picked up the resident and returned the resident to the wheelchair, transferred the resident from the wheelchair to the toilet, noticed a bruise to the resident's back and contacted the nurse. NA#4 further indicated the resident should not have been left alone in the bathroom and did so because NA#4 thought she could leave the resident for this short period of time. Although review of the facilty Falls Management policy does not include nursing assessment after a fall, interview with the DNS on 1/04/17 at 12:15 PM indicated facility policy is for a RN assessment before movement of the resident after a fall. The DNS further indicated NA#4 should have taken R#106 out of the bathroom if the NA was unable to stay with the resident. NA#4 was terminated on 11/21/16 . 3. Resident#167's [DIAGNOSES REDACTED]. An elopement and wandering assessment completed on 9/01/16 identified the resident not at risk for elopement. An initial care plan dated 9/01/16 identified a history and episodes of anxiety with interventions that included to encourage resident to verbalize feelings and thoughts related to anxiety, offer support and reassurance and psychiatric evaluation and follow-up. An admission MDS dated [DATE] identified the resident with moderately impaired cognitive skills, presence of mood and behavior symptoms and independent for transfers, ambulation and locomotion on and off the unit. Nurse's note dated 9/07/16 identified the resident expressed a desire to walk around the building and started to go to the elevator. The resident was then accompanied outside and supervised from a distance. The nurse's note indicated that the resident requested a cigarette from a random person, was given one and immediately threw it, when asked by the staff. At 5:45 PM the resident was noted arguing with his/her visitor, then going outside and sat on the bumper of the visitor's car while still arguing. The resident's visitor later requested to take the resident back in and the resident stayed in the room when the visitor left. The nurse's notes identified the resident was then placed on close supervision. Nurse's note dated 9/08/16 identified that at 2:23AM the resident was observed with packed bags by the elevator and indicated that he/she called a cab for transport out of the facilty. Nurse notes dated 9/08/16 at 8:31 AM identified the resident left the building and went to the street wanting to go to the store and was found ten minutes later by staff with no injury. One to one supervision was then initiated. Facility documentation review and interview with NA#7 on 1/06/17 at 8:15 AM identified that she/he was instructed at the start of the shift on 9/07/16 at 11:00 PM to closely monitor the resident and keep an eye on the resident. NA#7 was instructed to report to the nurse if the resident leaves his/her room and goes down the elevator. Further interview however indicated that NA#7 continued to be assigned to care and provide services for 17 other residents in the unit and was not even aware that R#167 had left the building. NA#7 indicated that the resident left the unit while she was assisting another resident. Interview and facility documentation review with RN#2 on 1/06/17 at 8:35 AM indicated that she/he was made aware that the resident packed his/her belongings, went to the elevator and expressed a desire to leave the facility. RN#2 indicated that she/he stayed with the resident for 3 hours until about 5:00 AM, until the resident expressed to go back to his/her room. RN#2 however indicated that additional guidance/instructions was not provided to staff after 5:00 AM. RN#2 identified the resident had calmed down by then. Clinical record review and interview with the DNS on 1/06/16 at 2:30 PM identified that there was no policy in place for close monitoring and a review of the one to one policy will be done. The DNS further indicated that the staff member assigned to closely monitor the resident must stay with the resident and be aware of the resident's where about at all times.

Based on review of the clinical record, acute care record, facility documentation, facility policies and/or procedures, and interviews for the only sampled resident reviewed for a surgical wound (R #71), the facility failed to notify the physician and/or responsible party when the resident experienced a change in condition and/or for one of five residents reviewed for Preadmission Screening and Resident Review (PASRR) (R # 201), the facility failed to notify the assigned Department of Developmental Services (DDS) case manager when the resident was sent to the hospital. The findings included: 1. Resident#71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. R#71's RCP dated 5/5/14 identified a risk for altered skin integrity. Interventions included treat as ordered, and monitor left hip incision for signs and/or symptoms of infection. admission orders [REDACTED]. A review of nurse's notes during the period of 5/2/14 to 5/5/14 identified R#71 had a left hip incision (approximated) with steri-strips in place, no signs and/or symptoms of infection and dry and intact dressing (bandage). An admission assessment dated [DATE] identified the resident was severely impaired cognitively, required extensive and total assistance from 1-2 staff for activities of daily living, and had one stage IV pressure ulcer and one DTI. A weekly wound assessment note dated 5/21/14 identified the left hip incision was closed and indicated that no further documentation would be noted unless there was a change in the wound's (incision's) condition. On 5/22/14, nurse's notes identified that dark brown, bloody drainage was oozing from the left incision site. It was further noted that although the APRN was notified and that the resident's attending physician (MD #1) was expected to be notified by the RN Supervisor, documentation was lacking to reflect that the resident's orthopedic surgeon (MD#2) was notified of the change in status of the resident's left hip surgical incision. On 10/8/14 at 1:48 P.M., a review of the clinical record, facility documentation and interviews with RN#4 (Regional Wound Specialist), RN#5 (Regional Infection Preventionist), and the DON indicated that MD#1 was made aware of changes to the resident's left hip incision and R#71 and his/her POA gave consent for the wound specialist (MD#3) to treat all the resident's wounds (i.e. left hip incision, stage IV pressure ulcer and DTI), and the facility believed that to be sufficient. On 10/8/14 at 11:47 A.M. during an interview and review of the clinical record with R #71's orthopedic surgeon (MD#2), he/she stated, "absolutely" in terms of his/her expectation of being notified of the change in status regarding the left hip incision. MD#2 further indicated that he/she had been concerned about the resident being that he/she had missed the two week post-op appointment as a follow-up to the left hip surgery and by happenstance, he/she discovered the resident on 6/7/14 at 3:00 A.M., in the ED with an infected left hip incision while treating another patient. R#71 was later transferred to the OR for culturing and wound debridement. On 10/9/14 at 1:21 P.M. an interview with MD#1 indicated that although s/he was made aware of the change in the left hip incision and that MD#3 had been treating all of the resident's wounds, notifying MD#2 of the change to resident's surgical incision "was not unreasonable". Subsequent to the resident's transfer to the ED on 6/7/14, a review of R #71's acute care records identified that the resident was admitted to the acute care facility on 6/8/14 with [DIAGNOSES REDACTED]. b. R#71's RCP dated 5/5/14 identified a risk for unexplained bleeding and/or uncontrolled bruising. Interventions included report any bleeding, and utilize a gentle approach with care. Wound MD (MD#3) progress notes dated 5/7, 5/14, 5/21, 5/28 and 6/4/14 identified that the stage IV pressure ulcer of the coccyx/sacrum was debrided and/or removal of devitalized necrotic tissue was performed on a weekly basis by MD#3. On 10/8/14 at 12:40 P.M., an interview with Person#1 (R #71's POA) indicated that he/she had given consent for the MD#3 to treat the resident's wounds, but felt that it had been somewhat excessive being that the resident seemed to be oozing blood from the stage IV pressure ulcer almost daily and that the resident had to receive a blood transfusion. A consult dated 5/19/14 identified that R #71 was transferred to an acute care facility for a blood transfusion and received 3 units of packed RBCs (red blood cells) and was transferred back to the facility on the same day. A review of laboratory results dated [DATE] identified the resident's Hematocrit was 26.3% (normal range 35-46%) and Hemoglobin was 8.2 g/dl (normal range 14-16 grams per/deciliters). An APRN progress note dated 5/23/14 noted that the assessment and/or plan included that the APRN would request less aggressive wound treatment if possible to decrease need for [MEDICAL CONDITION]. On 10/10/14 at 8:45 A.M. and 4:34 P.M. an interview and review of the clinical record with the APRN indicated that because his/her days in the facility overlapped with MD#3 causing him/her to be unavailable when MD#3 was in the facility for wound rounds, the APRN voiced his/her concerns with the former wound nurse (RN#7) and asked the wound nurse to relay the matter to MD#3 for him/her. The APRN further noted that the resident's attending physician (MD#1) was also aware of his/her concerns and acknowledged his/her awareness via co-signing the APRN's progress note of 5/23/14 on 5/26/14. On 10/10/14 at 4:45 P.M. an interview and review of the clinical record with RN#7 indicated that although he/she recalls relaying the APRN's concerns to MD #3 regarding a less aggressive approach to the resident's wound; RN#7 could not recall when he/she spoke with MD#3 regarding the APRN's concerns and/or MD#3's response when informed of the matter. Further review of the clinical record failed to reflect that MD#3 was made aware of these concerns. It was further noted the resident continued in having his/her wound debrided by MD#3 on two more occasions (5/28 and 6/4/14) after these concerns were noted on 5/23/14 and acknowledged by the attending physician (MD#1) on 5/28/14. The resident was transferred to an acute care facility on 6/7/14. A review of the resident's acute care record dated 6/8/14 identified that the resident was admitted with [DIAGNOSES REDACTED].e.[MEDICAL CONDITION] infection of wounds) and the resident required a blood transfusion on admission. The resident's hematocrit and hemoglobin continued to trend downwards during his/her hospitalization requiring R #71 to receive several blood [MEDICAL CONDITION] for a total of 6 prior to his/her discharge from the acute care facility, due to the increased drainage from the resident's wound site. Attempts made to contact MD#3 on 10/9/14 at 12:15 P.M., 10/10/14 at 9:05 A.M., 9:43 A.M., 10:00 A.M., 1:00 P.M. and at 4:30 P.M. and 5:00 P.M. were all unsuccessful as the physician failed to respond to the surveyor's calls. According to the facility policy and/or procedures regarding change of a resident's condition, when a resident has a significant change of condition which might include new and/or severe worsening of existing pressure sores and/or wounds; the physician is to be notified in a timely manner of the change in the resident's condition. 2. Resident # 201's [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE] indicated the resident was confused at times, required assistance with ADL's and vision was adequate. A directive in the clinical record from DDS indicated to contact DDS when the resident is hospitalized and/or has a significant change. A nurse's note dated 10/4/14 at 2:43 PM indicated the resident reported he/she had lost vision to the left eye which occurred temporarily in the morning. The Physician and legal guardian were notified. At 2:30 PM, 911 was called and the resident was sent to the hospital emergency room for evaluation. An interview on 10/8/14 at 4:40 PM with the DDS case manager indicated he/she was not aware and/or notified that R # 201 had gone to the emergency room . Although the resident was not admitted to the hospital he/she would have expected to have been notified of the transfer to the emergency room and/or of the incident that precipitated the resident being sent to the hospital. An interview on 10/9/14 at 7:45 AM with the DNS indicated he/she was not aware that DDS was not notified when R # 201 was sent to the hospital emergency room for evaluation.

Based on clinical record review, review of acute care records and interviews for one of three sampled residents reviewed with wounds (R#71), the facility failed to provide appropriate care and services to an incision to prevent infection [MEDICAL CONDITION] and/or failed to provide appropriate wound care to prevent [MEDICAL CONDITION]. The findings include: Resident#71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] identified the resident was severely impaired cognitively, required extensive and total assistance from 1-2 staff for activities of daily living, and had one stage IV pressure ulcer and one DTI. a. The RCP dated 5/5/14 identified a risk for altered skin integrity. Interventions included treat as ordered, and monitor left hip incision for signs and/or symptoms of infection. admission orders [REDACTED]. A review of nurse's notes during the period of 5/2/14 to 5/5/14 identified R#71 had a left hip incision (approximated) with steri-strips in place, no signs and/or symptoms of infection and dry and intact dressing (bandage). A weekly wound assessment note dated 5/21/14 identified the left hip incision was closed and indicated that no further documentation would be noted unless there was a change in the wound's (incision's) condition. On 5/22/14, nurse's notes identified that dark brown, bloody drainage was oozing from the left incision site. It was further noted that although the APRN was notified and that the resident's attending physician (MD #1) was expected to be notified by the RN Supervisor, documentation was lacking to reflect that the resident's orthopedic surgeon (MD#2) was notified of the change in status of the resident's left hip surgical incision. On 10/8/14 at 1:48 P.M., a review of the clinical record, facility documentation and interviews with RN#4 (Regional Wound Specialist), RN#5 (Regional Infection Preventionist), and the DON indicated that MD#1 was made aware of changes to the resident's left hip incision and R#71 and his/her POA gave consent for the wound specialist (MD#3) to treat all the resident's wounds (i.e. left hip incision, stage IV pressure ulcer and DTI), and the facility believed that to be sufficient. On 10/8/14 at 11:47 A.M. during an interview and review of the clinical record with R #71's orthopedic surgeon (MD#2), he/she stated, "absolutely" in terms of his/her expectation of being notified of the change in status regarding the left hip incision. MD#2 further indicated that he/she had been concerned about the resident being that he/she had missed the two week post-op appointment as a follow-up to the left hip surgery and by happenstance, he/she discovered the resident on 6/7/14 at 3:00 A.M., in the ED with an infected left hip incision while treating another patient. R#71 was later transferred to the OR for culturing and wound debridement. On 10/9/14 at 1:21 P.M. an interview with MD#1 indicated that although s/he was made aware of the change in the left hip incision and that MD#3 had been treating all of the resident's wounds, notifying MD#2 of the change to resident's surgical incision "was not unreasonable". Subsequent to the resident's transfer to the ED on 6/7/14, a review of R #71's acute care records identified that the resident was admitted to the acute care facility on 6/8/14 with [DIAGNOSES REDACTED]. b. The RCP dated 5/5/14 identified at risk for unexplained bleeding and/or uncontrolled bruising. Interventions included report any bleeding, and utilize gentle approach with care. A consent form dated 5/6/14, and wound specialist progress notes dated 5/7, 5/14, 5/21, 5/28 and 6/4/14 identified in part that R #71 gave consent for care and/or treatment of [REDACTED].#3. On 10/8/14 at 12:40 P.M., an interview with Person#1 (R #71's POA) indicated that he/she had given consent for the MD#3 to treat the resident's wounds, but felt that it had been somewhat excessive being that the resident seemed to be oozing blood from the stage IV pressure ulcer almost daily and that the resident had to receive a blood transfusion. A review of a consult form dated 5/19/14 identified that R #71 was transferred to an acute care facility for a blood transfusion and received 3 units of packed RBCs (red blood cells) and was transferred back to the facility on the same day. A review of laboratory results dated [DATE] identified the resident Hematocrit of 26.3% (normal range 35-46%) and Hemoglobin of 8.2 g/dl (normal range 14-16 grams per/deciliters). An APRN progress note dated 5/23/14 noted that the assessment and/or plan included that the APRN would request less aggressive wound treatment if possible to decrease need for [MEDICAL CONDITION]. On 10/10/14 at 8:45 A.M. and 4:34 P.M. an interview and review of the clinical record with the APRN indicated that because his/her days in the facility overlapped with MD#3 causing him/her to be unavailable when MD#3 was in the facility for wound rounds, the APRN voiced his/her concerns with the former wound nurse (RN#7) and asked the wound nurse to relay the matter to MD#3 for him/her. The APRN further noted that the resident's attending physician (MD#1) was also aware of his/her concerns and acknowledged his/her awareness via co-signing the APRN's progress note of 5/23/14 on 5/26/14. On 10/10/14 at 4:45 P.M. an interview and review of the clinical record with RN#7 indicated that although he/she recalls relaying the APRN's concerns to MD #3 regarding a less aggressive approach to the resident's wound; RN#7 could not recall when he/she spoke with MD#3 regarding the APRN' concerns and/or the physician's response when informed of the matter. Upon further review of the clinical record it was identified that although the APRN's concerns were known to MD#1 and RN #7, documentation was lacking to reflect that MD#3 was made aware of these concerns. It was further noted the resident continued in having his/her wound debrided by MD#3 on two more occasions (5/28 and 6/4/14) after these concerns were noted on 5/23/14 and acknowledged by the attending physician (MD#1) on 5/28/14. Upon further review of the clinical record it was noted that the resident was transferred to an acute care facility on 6/7/14. A review of the resident's acute care record dated 6/8/14 identified that the resident was admitted with [DIAGNOSES REDACTED].e.[MEDICAL CONDITION] infection of wounds) and the resident required a blood transfusion on admission. The resident's hematocrit and hemoglobin were stable for some time, but continued to trend downwards during his/her hospitalization requiring R #71 to receive several blood [MEDICAL CONDITION] for a total of 6 prior to his/her discharge from the acute care facility, given the increased drainage from the resident's wound site. In addition, attempts made to contact MD#3 on 10/9/14 at 12:15 P.M., 10/10/14 at 9:05 A.M., 9:43 A.M., 10:00 A.M., 1:00 P.M. and at 4:30 P.M. and 5:00 P.M. were all unsuccessful According to the facility policy and/or procedures regarding change of a resident's condition, when a resident has a significant change of condition which might include new and/or severe worsening of existing pressure sores and/or wounds; the physician is to be notified in a timely manner of the change in the resident's condition.

Based on observations, clinical record reviews and interviews for 2 of 6 residents reviewed for accidents (R#89 and R#132), the facility failed to transfer residents in a safe and hazard free manner. The findings included: 1. Resident #89's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident had severe cognitive impairment, required extensive assistance from staff for ADL's, and was totally dependent for bed mobility, personal hygiene/bathing and locomotion on unit. Nursing assessment dated [DATE] identified that R# 89 was unable to demonstrate leg strength during a "kick out and raise leg" assessment. The resident care plan (RCP) dated 9/16/14 identified the resident required assistance with daily care. Interventions included provide assistance with meals and fluids. It directed to encourage R#89 to alternate between sips and bites and provide assistance with all transfers. Physician orders [REDACTED]. Nurse's notes dated 10/3/14 at 10:58 PM identified that R#89 fell and sustained an laceration to left eyebrow that measured approximately 3.5 CM x 0.2 CM. Facility documentation dated 10/3/14 identified that while NA#3 was transporting R#89 via a wheelchair, the resident fell face down out of the wheel chair sustaining a laceration injury to his/her left eye. It identified that R#89 was sent to the hospital and received six (6) sutures. It further identified that NA#3 had reported that s/he had removed the footrest from the resident's wheelchair when s/he brought him/her to the bathroom but had not replaced them before attempting to transport the resident back to bed. S/he had indicated that although s/he repeatedly encouraged R#89 to lift his/her legs, he/she suddenly put his/her legs down and fell forward facedown out of the wheelchair. Interview with NA#3 on 10/8/14 at 8:25 AM indicated that although it was usual practice for R#89 to utilize footrests on his/her wheelchair, s/he had not replaced the footrest to R#89's wheelchair because s/he did not think anything would happen. Interview with Physical Therapist (PT#1) on 10/8/14 at 9:26 AM indicated that R#89 frequently fatigues requiring more assistance and that all residents require leg rests on wheelchairs during transport for their safety. Interview with RN#2 on 10/8/14 at 9:56 AM indicated that foot rests should be used when transporting residents via a wheelchair no matter what the circumstance. 2. Resident #132 was readmitted to facility on 9/11/14 with [DIAGNOSES REDACTED]. A significant change assessment dated [DATE] identified the resident had severe cognitive impairment, was totally dependent on staff for all ADL's and had experienced falls with resulting fractures in past six (6) months including a major injury. The RCP dated 9/29/14 identified a high risk for falls related to a history of falls. Interventions included "on 8/28/14 I fell and fractured my left hip-I was readmitted on [DATE]; I am now a mechanical lift (Hoyer) with all transfers to maximize care and safety needs." Facility accident incident documentation dated 10/02/14 identified that at 6:30 PM, the resident sustained [REDACTED]. It further identified that NA#5 and NA#4 indicated that the resident slid out of the Hoyer lifting pad striking his/her head on the Hoyer lift. physician's orders [REDACTED].#132's transfer via a Hoyer with three (3) facility staff. The care plan updated 10/4/14 indicated that staff involved should be educated on Hoyer lift transfers. Observation of R#132 on 10/8/14 identified the location of the laceration on the top of the resident's head. Interview with NA#5 on 10/09/14 at 9:57 AM indicated that although s/he does not know how it happened, during the transfer (from chair to bed), R#132 was over the bed in the lift and suddenly slid (down and off) very fast with his /her legs hanging off the lifting pad and hit his/her head on the Hoyer (lifting device) bar. Interview with the Director of Nursing on 10/09/14 at 10:15 AM indicated that re-enactment by NA#4 and NA#5 of the transfer failed to determine how (if the resident was positioned properly in the lift and sling), R#132's head laceration /injury occurred. The nurse aides were re-educated on mechanical lift transfers.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #5) who were dependent on staff for mobility and/or transfers in and out of the bed and chair, the facility failed to ensure that appropriate supervision and/or interventions were implemented during a transfer to prevent an injury. The findings include: Resident #5's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified that Resident #5 had no cognitive impairments, was dependent on two staff members for bed mobility and transfers, was non-ambulatory and no history of falls in the past ninety days. The resident care plan dated 6/26/14 identified that the resident needed assistance with bed mobility and transfers. Interventions directed to utilize a Hoyer lift with the assistance of two staff for transfers between the bed and the wheelchair. Review of activities of daily living flow records from 6/26/14 through 6/30/14 identified that Resident #5 was transferred between the bed and wheelchair via the Hoyer lift and assistance of two staff. The nurse's note dated 6/30/14 at 7:30 PM identified that Resident #5 complained of left knee pain. The resident's bilateral extremities were assessed with [REDACTED]. The nurse's note identified that the Advanced Practice Registered Nurse (APRN) #1 was aware and when APRN #1 attempted to see the resident, the resident asked APRN #1 to come back later. Tylenol 650 milligrams (mg) were administered and the resident verbalized relief. The nurse's note dated 7/1/14 at 12:47 AM identified that Resident #5 was medicated with Tylenol 650 mg for generalized discomfort. Resident #5 was restless throughout the night, complained that his/her legs were jerking and refused the Riboxin because the medication made him/her weak. Review of APRN #2's progress note dated 7/1/14 identified that Resident #5 was seen for a complaint of knee and ankle pain. The evaluation identified Resident #5 stated that two days prior he/she was being transferred with a Hoyer lift and had to be lowered to the floor. Resident #5 identified that he/she was gently lowered yet his/her knees and ankles were on the floor flexed and since that time he/she had been unable to bear weight to the right leg and pain in both knees. APRN #2 directed that x-rays of both legs be obtained. Review of x-ray report dated 7/1/14 identified that the resident sustained [REDACTED]. The resident was transferred to the Emergency Department on 7/1/14 at 6:00 PM and returned with a cast on the left leg. The nurse's note dated 7/1/14 at 3:00 PM identified that Resident #5 informed staff that he/she was in pain because on 6/30/14 when the nurse aides were putting him/her to bed a stand-turn pivot technique was utilized and not a hoyer lift transfer. The nurse aides could not support Resident #5 and had to lower the resident to the floor. Review of the facility's investigation with the Director of Nurses (DON) on 7/17/14 at 10:45 AM identified that on 6/30/14 at approximately 2:00 AM, Nurse Aide (NA) #6 and #7 tried to stand and pivot Resident #5 from the wheelchair to the bed. During the transfer the resident was lowered to the floor and while being lowered the resident stated that he/she heard a pop. The DON identified that the nurse aides should not have transferred the resident without the use of a Hoyer lift. NA #6 indicated that Resident #5 wanted the nurse aides to use the pivot disk to put him/her to bed. Resident #5 wheeled up to the bed, stood up and we turned the resident. The resident was seated halfway off of the bed and started slipping so we lowered him/her to the ground. NA #6 stated that she and NA #7 transferred the resident with the pivot disk because that was what the resident wanted. NA #6 identified that she stayed with Resident #5 while NA #7 went to get the charge nurse Licensed Practical Nurse (LPN) #4. Interview with NA #7 on 7/17/14 at 1:00 PM identified that on 6/30/14 at about 2:00 AM she assisted NA #6 transfer Resident #5 from his/her wheelchair to the bed without the use of a Hoyer lift or a pivot disk. NA #7 stated that Resident #5 stood and pivoted but as the resident sat on the bed he/she began to slip and they lowered Resident #5 to the floor. NA #7 stated that the resident's legs were under him/her and while NA #6 held Resident #5 in a sitting position NA #7 got LPN #4. NA #7 stated that she, NA #6 and LPN #4 used the hoyer lift to get Resident #5 off of the floor and onto the bed. NA #7 stated that when LPN #4 asked Resident #5 if he/she was alright the resident said yes. Review of the facility's investigation, LPN #4's written statement dated 7/4/14 identified that on 6/30/14 at approximately 1:00 AM he was called to Resident #5's room and when he arrived Resident #5 was seated upright on the floor leaning against the bed. LPN #4 indicated that he asked Resident #5 if he/she had injuries or pain and the resident said "no". LPN #4 indicated that he assessed for injuries and did not see any bruises, deformities and/or marks on the resident's body. LPN #4 identified that he did not perform a ROM assessment because he knew that the resident had spasms when his/her legs were moved. LPN #4 stated that he and NA #6 and #7 transferred the resident from the floor to the bed via the hoyer lift and the resident voiced no complaints during the transfer. LPN #4 indicated that he did not notify the Nursing Supervisor of the incident to ensure that the resident was assessed after a fall. Attempts to interview LPN #4 were unsuccessful. Review of the facility's Mechanical transfer policy identified that the purpose of the mechanical lift is to safely transfer residents who are unable to stand and pivot or require lifting from bed to chair. The policy directed that at least two people are required to transfer a resident using a mechanical lift.

Based on clinical record reviews, review of policies and procedures and interviews with facility personnel for 1 of 4 sampled residents (Resident# 115) who sustained an injury following an accident, the facility failed to ensure that the resident was supervised to prevent an injury. The findings include: Resident #115's [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] identified that the resident was alert, non-verbal and needed extensive assistance with transfers and bed mobility. Review of the physician's order [REDACTED]. A facility investigation dated 7/15/13 identified that; Nurse Aide (NA) #1 had placed the resident in the tilt-n-space wheelchair, walked behind the resident and positioned the wheelchair in an upright position using the handles, a tilt-n-space feature. NA # 1 then walked to the front of the resident to move the bedside table. NA #1 identified that while he/she was moving the bedside table, the resident leaned forward and to the side, fell out of the wheelchair, hit her head hard and the resident ' s head started to bleed. NA #1 identified that he/she put the resident back to bed and then went to get the charge nurse. Resident #115 was sent to the hospital and sustained five staples to the right side of his/her head. Interview with Licensed Practical Nurse (LPN) #1 on 11/14/13 identified that she was not aware of how the resident fell because when the nurse aide came and got her, the resident was already placed back in bed and everything was cleaned up. Review of facility policy identified that when an accident occurs, the employee should render immediate assistance and not move the victim until he/she is examined for possible injuries.

Based on clinical record review and staff interview for the only resident in the survey sample reviewed for hydration (R # 175), the facility failed to review and revise the resident careplan when the resident was not meeting his/her assessed fluid needs to attempt prevention of dehydration. The findings include: Resident # 175's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] indicated R #175 had no cognitive deficits and was independent with eating. A care plan dated 7/26/13 noted a problem with oral dysphagia and sometimes coughs. Interventions included encourage to drink since needs are greater than usual due to body mass. A nutritional assessment dated [DATE] noted R#175's assessed fluid needs were 2,020 cc/day. Review R#175's 24-hour fluid intakes noted the following: 8/6/13 = 1420 cc 8/7/13 = 1440 cc 8/8/13 = 1660 cc 8/9/13 = 1620 cc 8/10/13 = 1560 cc 8/11/13 = 1420 cc 8/12/13 1400 cc A dehydration evaluation dated 8/10/13 noted no signs or symptoms of dehydration. Review of laboratory results noted the following: 7/6/13 BUN was 24 (8-21) and Cr was 1.4 (.5-1.3). 8/5/13 BUN was 32 (8-21) and Cr was 2.1 (.5-1.3). Review of a nurse's note dated 8/13/13 indicated R #175 was seen by the APRN to evaluate increased confusion. Lab work showed acute [MEDICAL CONDITION] and dehydration. Resident sent to the emergency room for evaluation. An emergency room note dated 8/13/13 indicated R#175 had altered mental status, weakness, and a decreased intake. A hospital nephrology consult sheet dated 8/13/13 indicated R #175 had acute [MEDICAL CONDITION], most likely secondary to volume depletion from decreased intake and was noted to have a BUN of 37 on admission to the emergency department. The resident was admitted and returned to the facility on [DATE] with discharge [DIAGNOSES REDACTED]. A review of the clinical record and interview on 11/18/13 at 1:00 PM with the DNS indicated the dietician was not notified that the resident was not meeting his/her assessed fluid needs as indicated in the facility policy. Additionally, although the nurse's notes noted intermittent documentation that fluids were encouraged, the DNS was unable to provide documentation that the resident care plan was reviewed and revised to increase the resident's fluid intake after 2 consecutive 3-day periods of not meeting his/her assessed fluid needs. The resident's labs on 8/19/13 indicated a BUN of 17 (8-21) and Cr of 1.5 (.5-1.3). A facility policy on hydration indicated if the resident consumed less than estimated needs/day for 3 consecutive days, the resident is evaluated for signs and symptoms of dehydration, and the physician and dietician are notified. The resident care plan is to be reviewed/revised with interventions to promote hydration.

Based on review of the clinical record, review of facility policies and interviews for one of three residents (Resident #8) reviewed with a history of pressure ulcers, the facility failed to implement wounds treatment orders as directed by the physician. The findings include: Resident #8 (R# 8) had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified that the resident was cognitively impaired and required extensive assistance of two staff persons for bed mobility and toilet use and was totally dependent on two staff persons for transfer, dressing, personal hygiene and bathing. The care plan dated 2/21/13 identified R#8 was at risk for skin breakdown due to decreased mobility, incontinence and the potential for scratching. Interventions included weekly skin audits and pressure relieving mattress on the bed and cushion in the chair. The progress note dated 3/15/13 by APRN#1 identified R# 8 had [DIAGNOSES REDACTED]tous [MEDICATION NAME] eruption to the back and a focal Stage II wound to the lumbar spine. The physician's order dated 3/15/13 direct R#8 be administered [MEDICATION NAME] 1% cream topically to a rash on his/her back twice daily for seven days and cleanse the wound on the mid-back with normal saline then apply trimmed Replicare Thin as needed for fourteen days. Review of the Pressure Wound Initial assessment dated [DATE] described the mid-back wound as a deep crater exposing subcutaneous tissue, measuring 0.6 cm by 1.0 cm. covered by 75% slough. The physician's order dated 4/16/13 directed R#8's mid-back wound be cleansed with wound cleanser, patted dry and apply Santyl and cover with Allevyn daily. Review of APRN #2's wound notes dated 4/30/13 identified R#8 had an unstageable pressure ulcer on the lumbar spine with recommendations to irrigate the wound with 100 cubic centimeters of normal saline, then apply Mesalt to the wound and cover with Allevyn foam. Review of the facility documentation dated 4/25/13 indicated the conclusion of the facility investigation verified the treatment ordered 3/15/13 had been recorded on 3/15/13 with no further documentation of the treatment. Although attempts to interview LPN #7 were unsuccessful, LPN#7's statement dated 4/25/13 noted the last day he/she had recalled providing the treatment to R#8's lower back was 4/11/13 (after the date of the 3/15/13 treatment order). Review of the wound care Specialist evaluation dated 5/29/13 identified that R#8 had an unstageable necrotic pressure area on the lower back measuring 0.5 centimeters (cm) by 0.5 cm 100% covered with thick necrotic tissue. Also the consultation indicated the wound required surgical excisional debridement of the subcutaneous tissue. Further recommendations indicated that Santyl be applied to the wound and covered with a dry protective dressing. Subsequently, the Wound Care Specialist evaluation dated 6/12/13 noted the wound was [MEDICATION NAME] and resolved. Interview and review of the treatment administration record on 7/2/13 at 1:00 P.M. with the Director of Nursing (DNS) identified that an investigation of family concerns reported on 4/16/13, identified although the treatment to the mid back directed on 3/15/13 had been applied initially, no further treatment had been administered until 4/16/13 and had not been re-evaluated on 3/28/13. According to further interview with the DNS, LPN #1 and LPN #7 were identified as the staff persons who did not provide the wound treatments from 3/15/13 to 3/28/13. Subsequently, LPN #1 and LPN #7 were re-inserviced on 4/29/13 and disciplinary actions were taken dated 4/29/13 for LPN #7 and 5/1/13 for LPN# 1. Review of the facility policy related to prevention and management of pressure ulcers, in part, directed that a resident who enters the facility without a pressure ulcer does not develop one unless the individual's clinical condition demonstrates that the pressure ulcer was unavoidable. The policy further directs that pressure ulcers were assessed at least weekly until the ulcer was resolved.

Based on clinical record reviews, observations, review of facility investigations, review of facility policies, and interviews for 7 of 11 residents reviewed for incident/accidents (R#4, 7, 12, 20, 66, 182, 193), the facility failed to ensure that appropriate supervision, and/or assistance, and/or interventions were provided to prevent accidents/incidents. The findings include: 1. Resident #4's [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] identified that the resident was severely cognitively impaired, displayed no problem behaviors, was totally dependent on 2 staff members for all bed mobility and transfers, could not ambulate, could not feed, bathe or dress self, was always incontinent of bowel and bladder, and had no foot problems. The care plan dated 12/20/11 indicated a problem with osteoporosis and a goal to be free from fractures. Interventions included fall prevention, a winged air mattress, and the bed in the low position, total care with all ADL's, and Hoyer lift with assist of 2 for all transfers. Physician orders [REDACTED]. On 2//1/12 at 9:45 PM, orders directed to send the resident to the orthopedist on 2/2/12 for a fracture of the right great toe. An xray report dated 2/1/12 identified a fracture of the 1st proximal phalanx without displacement. There was associated soft tissue swelling. Osteoporosis is present. It concluded that there was an acute fracture of the right great toe. Review of the facility investigation noted that a nurse aide reported seeing a bruise on the resident's right great toe to the charge nurse on 1/31/12 during the evening shift. The nurse neglected to document the bruise or report it to the supervisor. On 2/1/12 on the day shift, the nurse aide removing the booties prior to transferring the resident noted the bruise and reported it to the nurse. All staff were interviewed and statements obtained. No one noted any problems with any transfers or transportation of the resident during the day or evening shifts on 1/31/12. Interview and clinical record review with the DNS on 8/16/12 at 1:15 PM noted that the resident was unable to move independently and she felt the injury occurred during Hoyer transfer, transport in the wheelchair and/or in the dining area. The DNS noted that she neglected to interview the NA that assisted in the transfer prior to the discovery of the injury. Review of the care plan with the DNS at that time noted that although the care plan mentions the risk for fractures related to osteoporosis, the care plan lacked specific interventions to prevent fractures for the resident. 2. Resident #66's [DIAGNOSES REDACTED]. The resident had been discharged from physical therapy on 3/29/11 with directions to ambulate 200 feet with a rolling walker and "close/distant" supervision. The care plan dated 6/1/11 identified that the resident was at risk for falls, Interventions included that the resident enjoyed walking independently around the facility and to offer help when seems to be forgetting his/her way. The resident was found on the floor on 6/1/11 at 3:20 AM. Interventions were initiated to have non skid socks on at bedtime and to ensure that the walker is near the bed. Nurse's notes dated 6/16/11 indicated that the resident fell in the bathroom at 8:15 PM. On 7/11/11, the resident had a fall in his/her room at 11:45 PM. Nurse's notes identified that on 8/8/11 at 9 AM, the resident got up from the dining room table and fell sustaining a small red bruise on the right side of the head. At 10 AM, the resident was seated in a wheelchair at the nurse's station, stood and fell . An APRN note on 8/9/11 indicated a bruise to the head was noted and breath sounds were decreased. A chest xray was ordered. The chest xray report dated 8/9/11 identified rib fractures that were not necessarily acute, of ribs 7, 8 and 9. Interview and review of the clinical record with the DNS on 8/16/12 at 10 AM failed to provide documentation that the resident's plan of care was reviewed and/or revised after falls on 6/16/11 and 7/11/11 to prevent further falls and/or that appropriate supervision was provided to prevent falls. Although review of the xray and clinical record failed to provide any documentation that the resident experienced any pain related to the rib fractures or notes indicating when they may have occurred, the record lacked thorough assessments of the resident after each fall including, skin condition, range of motion and/or tenderness/pain. 3. Resident #20's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as having intact cognition and requiring total assistance with activities of daily living. Physician orders [REDACTED]. A care plan dated 3/8/12 identified a problem with performing activities of daily living. Interventions included to provide assistance of two staff members with bed mobility and to transfer with a Hoyer lift and assist of 2 staff members. A facility investigation dated 4/20/12 at 11:30 AM identified the resident was being transferred into the wheelchair via a Hoyer lift, and while the resident's position was being "adjusted", the wheelchair tires lifted off the floor and rested on the Hoyer frame leg. The resident moved forward in the wheelchair and bumped his/her left lower eye area on the center part of the Hoyer frame. Nurse's notes dated 4/20/12 at 10:53 PM identified the resident's left eye began to swell and ice was applied. Interview with the DNS on 8/16/12 at 10:30 AM noted a representative from the lift company came to the facility to check the lift and maintenance also checked the resident's wheelchair and no problems with the equipment were identified. 4. Resident #12's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as having moderate impairment with cognition and requiring extensive assistance with activities of daily living. A care plan dated 4/30/12 identified a problem with muscular/skeletal impairment. Interventions included to provide assistance with hygiene and transfer from bed to w/c with assist of 2, transfer from w/c to toilet with assist of 2. A physical therapy evaluation dated 4/4/12 noted that nursing reported the resident is at risk of falling related to resident cannot always maintain grasp on the grab bar with the right hand in the bathroom. Therapy evaluation further noted the resident cannot maintain her/his balance during clothing management. A Hoyer transfer was recommended when the appropriate Hoyer sling arrived. The Nurse Aide care card dated 4/3/12 noted to use a Hoyer lift only for transfers. Facility investigation dated 6/20/12 at 8:30 PM identified the resident was totally dependent for transfers using a Hoyer lift. The investigation noted that 2 NA's were transferring the resident from the w/c to the toilet when they lowered the resident to the floor in front of the toilet without using the Hoyer lift. Interview with RN#2 on 8/16/12 at 12:00 PM identified that the NA were to have used the Hoyer lift to transfer the resident to the toilet. 5. Resident #182's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident as having moderately impaired cognition, required extensive assistance with bed mobility, transfers and toileting, and limited assistance with walking, dressing and personal hygiene. A care plan dated 6/12/12 noted pain in the right knee with interventions that included to assist the resident as needed when she/he calls for assistance. Facility investigation dated 6/18/12 at 5:00 AM identified the resident wheeled himself/herself to the shower room and refused to transfer to a shower chair. The NA provided assistance with the shower and the resident remained in the w/c. During the shower, the resident began to slide out of the w/c, the NA called for help and supported the resident's legs to prevent falling. Bruises were observed to the resident's right upper posterior arm, measuring 11 cm by 10 cm, and left lateral upper arm. On 8/16/12 at 1:40 PM an interview with the DNS identified the the NA was to have notified the Charge Nurse (prior to proceeding with showering the resident in a wheelchair). The DNS further noted that the NA stated "things went very quickly" and the NA just wanted to help the resident. Facility investigation disposition directed to utilize a shower chair and the supervisor to be called to assist NA with the resident. 6. Resident # 193's [DIAGNOSES REDACTED]. Resident #193 was admitted to the facility on [DATE]. Physical therapy evaluation dated 6/20/12 noted the resident had severe impairment with sitting static and sitting dynamic balance. A fall risk assessment dated [DATE] identified the resident was at risk for falls. Facility policy on falls identified that residents who are at high risk for falls, must have a fall prevention plan immediately developed and implemented. Facility investigation dated 6/21/12 at 12:45 AM identified that Resident #193 was observed lying in the bathroom on the right arm with her/his head beneath the sink. The resident was placed back to bed after being assessed by the RN via a Hoyer lift and a hematoma to the head was noted. Facility investigation further identified NA#1 left the resident unattended in the bathroom to assist another resident to bed. Facility safety policy identified that residents who have poor safety awareness and who do not have trunk control should not be left unattended in the bathroom. On 8/15/12 at 1:20 PM an interview with the DNS noted that NA#1 was disciplined and employment status is still pending. On 8/15/12 at 1:20 PM, an interview with the DNS noted that a fall prevention plan would be part of the care plan. Review of the care plan at that time with the Corporate Nurse failed to identify a care plan had been developed identifying a fall prevention plan. 7. Resident # 7's [DIAGNOSES REDACTED]. Observation on 8/15/12 at 9:50 AM noted the resident lying in bed with his/her head resting on the unpadded right side rail. The siderail pad had been placed on the outside of the siderail instead of the inside. At 9:55 AM after surveyor inquiry, NA #2 repositioned the resident. A reddened area was noted on the forehead with indentations from the siderail. Interview with NA#2 on 8/15/12 at 9:50 AM, indicated she last repositioned the resident at 8:00 AM with the assistance of NA #4. NA#2 indicated that the siderail pads "move", but when asked if the resident was able to move him/herself, NA #2 indicated "no, we reposition (him/her) every 2 hours".