Every finding on record at Ledgecrest Health Care Center

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for wandering behaviors and elopement risk, the facility failed to adequately identify, assess, care plan, implement necessary interventions, and provide effective supervision and functional safety systems to prevent elopement for a resident with known cognitive impairment, wandering behaviors and fall risk. These failures resulted in Resident #1 eloping from the facility unsupervised and unrecognized by staff. The findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, major depressive disorder, and history of falls.Hospital Emergency Department (ED) documentation dated 7/27/26 identified Resident #1 had a history of dementia, was confused, had sustained two (2) falls in the prior two (2) days, and had previously resided on a locked dementia unit. Physical Therapy (PT) evaluated Resident #1 and identified a need for minimal assist/contact guard for transfers with a 2-wheeled walker, with a goal of ambulating up to 100 feet.The Nursing admission Assessment by RN #1 dated 7/27/26 identified Resident #1 was cognitively impaired and required one (1) person assistance for positioning, transfers, and ambulation. The Elopement Risk Assessment identified Resident #1 could not meet minimal basic needs, was not mobile with or without an assistive device, and had no history of elopement, despite documentation that Resident #1 had previously resided on a locked dementia unit. The assessment identified Resident #1 as not at risk for elopement. The Fall Risk Assessment identified one (1) to two (2) falls in the prior six (6) months but was incomplete and did not identify fall risk status.The RCP dated 7/28/26 identified Resident #1 had impaired memory, recall, and decision-making due to dementia and was at risk for falls, with weakness and impaired safety awareness requiring assistance with locomotion. Interventions included orientation, monitoring for changes in mental status, and assistance with locomotion.A physician's order dated 7/29/26 directed one (1) assist for transfers and ambulation using a rolling walker.A nurse's note by RN #2 dated 7/29/26 at 10:57 PM identified Resident #1 was alert and oriented to name only and made numerous attempts to ambulate without assistance but was easily redirected.A nurse's note by RN #2 dated 7/30/26 at 8:15 PM identified he received a call from a passerby reporting a resident was outside the facility, sitting on the grass approximately five (5) feet from the sidewalk. The resident was identified as Resident #1, who had no apparent injuries and denied pain. Staff assisted Resident #1 into a wheelchair and returned him/her inside. A skin assessment identified no injuries. The resident representative and provider were notified, an Elopement Risk Assessment was completed, a Wanderguard was placed on Resident #1's right lower leg, and the unwitnessed fall protocol was initiated.The Elopement Risk assessment dated [DATE] identified Resident #1 was mobile with or without an assistive device, sought exit areas, had cognitive impairment, left the unit without staff knowledge, and was at risk for elopement.A physician's order dated 7/31/26 at 8:30 AM (12 hours and 15 minutes after the elopement) directed one-to-one observation for safety,The RCP dated 7/31/26 identified Resident #1 had wandering behaviors and attempted to leave the unit/building when not prevented due to cognitive impairment and feeling lost. Interventions included a Wanderguard bracelet, daily verification of the bracelet, increased monitoring, assistance locating his/her room, escorting to and from dining and activities, and allowing wandering on the unit.Observation of the East Unit and interview with the Director of Maintenance on 8/27/26 at 9:22 AM identified Resident #1's room was two (2) doors from the A exit door used to leave the building. At the time of the incident, the door had a maglock with an egress alarm, keypad, and backup chirp alarm. The door did not have a Wanderguard sensor before the incident. Following the elopement, a motion sensor alarm was placed on the door on 7/31/26 until a Wanderguard component was installed on 8/5/26.The Director of Maintenance reported staff identified after the incident that the egress alarm did not trigger as expected and only a few chirps were heard before stopping. He reported he was unable to open the door without forcefully pushing it for 30 seconds, at which time the egress alarm sounded. He was unable to determine how Resident #1 exited without staff knowledge and reported the door had alarmed and locked appropriately when he checked it earlier on 7/30/26.Interview with RN #1 on 8/27/26 at 11:41 AM identified she completed Resident #1's admission assessment and was unaware Resident #1 had previously resided on a secured memory care unit. She reported marking Resident #1 as not mobile on the Elopement Risk Assessment because therapy had not yet evaluated the resident and was unaware she should have based the assessment on her own observations. She also could not explain why the Fall Risk Assessment was incomplete. RN #1 reported that had she known Resident #1 previously resided on a secured memory unit, she would have identified an elopement risk, applied a Wanderguard, and initiated increased monitoring.Interview with RN #2 on 8/27/26 at 11:55 AM identified that on 7/29/26 Resident #1 was found multiple times ambulating without assistance and was repeatedly redirected. RN #2 identified Resident #1 as a fall and elopement risk. Prior to the 7/30/26 incident, he had not been notified that Resident #1 was wandering or exit-seeking and last saw Resident #1 calm in his/her room approximately 15 minutes before the incident. He did not hear an alarm and was unaware Resident #1 had exited until receiving a call that a resident was outside. RN #2 identified the A exit door was not Wanderguard equipped and was unsure how Resident #1 exited the facility. He directed NA #2 to provide one-to-one supervision for the remainder of the shift.Interview with LPN #1 on 8/27/26 at 12:07 PM identified she had observed Resident #1 walking and self-propelling in a wheelchair throughout the facility. She was unaware Resident #1 had exited until RN #2 alerted her. She did not hear a door alarm and was unaware of any issues with the A exit door.Interview with NA #1 on 8/27/26 at 12:24 PM identified that on the day of admission, Resident #1 took his/her roommate's walker, ambulated the halls, entered other residents' rooms, and stood by the front door. She frequently redirected Resident #1 and reported the behavior to the prior DON. On 7/30/26, Resident #1 continued wandering and was found in another resident's room. NA #1 last saw Resident #1 after dinner and did not hear the door alarm.Interview with NA #4 on 8/27/26 at 12:29 PM identified Resident #1 was wandering the halls on 7/30/26. She did not hear the door alarm and was unaware of any prior issues with the A exit door.Interview with NA #3 on 8/27/26 at 12:33 PM identified Resident #1 had wandered to her unit in the days prior to 7/30/26, entered other residents' rooms, and repeatedly required redirection. On 7/30/26, Resident #1 was again wandering the halls. NA #3 heard the door alarm chirp and stop quickly and assumed someone had turned it off. After Resident #1 was returned inside, she assisted with frequent checks but reported no one provided direct one-to-one supervision.Interview with NA #2 on 8/27/26 at 12:44 PM identified Resident #1 was confused and frequently wandered onto other units and into other residents' rooms. Earlier on 7/30/26, Resident #1 was found in another resident's room and was returned to his/her room. Approximately 10 minutes later, NA #2 heard three quick door-alarm chirps that stopped. She checked the hallway, did not see anyone near the A exit, and later found Resident #1 missing from his/her room and common areas. She notified RN #2, who received the call that Resident #1 was outside. NA #2 reported RN #2 did not direct her to provide one-to-one supervision following the incident and that prior to the incident the A exit door had consistently alarmed and remained locked when pushed.Interview with the Physical Therapy Assistant (PTA) #1 on 8/27/26 at 1:12 PM identified Resident #1's initial therapy evaluation occurred on 7/29/26 and included an order for one (1) assist with transfers and ambulation using a rolling walker. Resident #1 had not been evaluated for stairs or uneven surfaces before the 7/30/26 incident. PTA #1 reported Resident #1 was not safe to exit the facility and descend the ten (10) stairs without assistance and could have sustained a fall with fracture.Interview with the interim DON and Regional Nurse on 8/27/26 at 2:54 PM identified the facility failed to properly assess Resident #1's elopement and fall risks at admission, inaccurately documented mobility, and left the Fall Risk Assessment incomplete. They identified that the RCP did not reflect Resident #1's frequent wandering, exit-seeking, or history of residing on a secured memory care unit, and appropriate interventions such as a Wanderguard and increased monitoring were not initiated. They reported staff failed to act on repeated reports of unsafe ambulation and wandering, allowing Resident #1 to elope unnoticed and placing Resident #1 at risk for injury. They were unable to identify why Resident #1 was not immediately placed on one-to-one supervision following the incident.Interview with the Administrator on 8/27/26 at 3:21 PM identified she was notified of the elopement immediately after it occurred. She did not come to the facility that night to review camera footage and instead directed the Director of Maintenance to check the exit doors. The following morning, review of the cameras identified Resident #1 was able to quickly push open the A exit door, which opened without locking as it should have. The locking mechanism and egress alarm were determined to have malfunctioned. Resident #1 was placed on one-to-one observation at 8:30 AM until a motion sensor alarm was installed later that morning.Although attempted, interviews with Person #1, the prior DON, and NA #5 were not obtained.The Admission/readmission policy directed staff to complete all required nursing assessments and admission documentation accurately and to verify hospital discharge information, including comparing the W-10 and discharge summary for discrepancies.The Elopement Risk and Wandering Prevention policy directed that residents be evaluated for elopement or wandering risk upon admission, with individualized interventions based on identified risks and behaviors. The policy included wander-management devices, increased supervision or monitoring, environmental modifications, and care plan interventions. It also directed staff to communicate significant wandering or elopement concerns and ensure the care plan accurately reflected identified risks and interventions.

Based on review of the clinical record, facility documentation, and facility policy for 3 of 4 sampled residents (Resident #3, #15, #33) reviewed for the facility Water Management Plan, the facility failed to ensure a comprehensive Resident Care Plan that included a potential exposure to Legionella (a bacteria that causes Legionnaires Disease) and for the only sampled resident (Resident #47) reviewed for communication, the facility failed to develop a baseline Resident Care Plan identifying the need for a translator. The findings include: The facility tested positive for the presence of Legionella on 12/29/25. 1 Resident #3 's diagnoses included high blood pressure, seizure disorder, paraplegia, muscle weakness, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 was cognitively intact and required assistance for eating and maximum assistance for bathing, mobility, and self-care. The Resident Care Plan dated 3/18/26 failed to identify potential for exposure to Legionella. 2. Resident #15's diagnoses included dementia, high cholesterol, anemia, high blood pressure, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #15 was severely cognitively impaired and required maximum assistance for personal hygiene, bathing, and was independent with mobility. The Resident Care Plan dated 3/19/26 failed to identify potential for exposure to Legionella. 3. Resident #33's diagnoses included high blood pressure, dementia, Alzheimer's disease, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #33 was severely cognitively impaired and was independent with eating, bathing, personal care, and mobility. The Resident Care Plan dated 2/3/26 failed to identify potential for exposure to Legionella. Interview and record review with the Infection Prevention Nurse (RN #3) on 4/13/26 at 1:26 PM identified that Residents #3, #15, and #33 were not care planned to identify a potential Legionella exposure. RN #3 identified that staff were aware of a potential Legionella exposure and they were mitigating the risks by using bottled water. She acknowledged that new staff or agency staff might not be aware of the potential for exposure to Legionella if not documented in the resident's chart. Review of the Legionnaires Disease policy directed., in part, the facility should monitor and treat residents appropriately for potential exposure to Legionnaires Disease. Subsequent to surveyor inquiry all Resident Care Plans were updated to reflect monitoring for signs and symptoms of Legionella. 4. Resident #47 's diagnoses included sepsis, calculus of the gallbladder with chronic cholecystitis without obstruction and generalized anxiety. The admission Nursing assessment dated [DATE] identified Resident #47 had a Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment, required substantial maximal assistance with bed mobility, dressing, and personal hygiene, and was dependent on staff for toileting. The admission Nursing Assessment failed to identify that Resident #47 was Spanish only speaking and required a translator to communicate. Review of the Baseline Resident Care Plan dated 4/10/26 failed to identify the need of an interpreter on all shifts due to being able to communicate only in Spanish. The Occupational Therapy and Physical Therapy Evaluations, and Speech /Language Therapy screen, all dated 4/10/26 failed to identify Resident #47 was Spanish speaking only, required a translator to communicate, and failed to identify alternatives for staff to use to communicate such as a picture board or the availability of a translator as needed. Interview and clinical record review with Social Worker (SW) #1 on 4/14/26 at 9:45 AM indicated the resident spoke only Spanish and that she had communicated with Resident #47 through a family member, or if no family was available, a Spanish speaking staff member. Review of the baseline Resident Care Plan failed to identify Resident #47 only spoke and understood Spanish and failed to identify an alternate means to communicate with the resident. SW #1 stated Resident #47 should have had a communication Resident Care Plan, and that she would be entering one into the resident's clinical record. The Resident Care Plan dated 4/14/26 (5 days after admission), identified Resident #47 was Spanish speaking and required a translator with interventions to promote communication. Review of the Resident Assessment Instrument Manual (RAI) dated October 2023 directed, in part, within 48 hours of admission to the facility, the facility must develop and implement a Baseline Care Plan for the resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of care (42 CFR 483.21(a)). A review of the Resident's Rights policy directed, in part, you have the right to be treated with consideration, respect, full recognition of your dignity and individuality. You have the right to receive care and services with reasonable accommodation of your individual needs and preferences.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #47) reviewed for dignity, the facility failed to ensure toileting for a dependent resident was provided in a dignified manner. The findings include:Resident #47 's diagnoses included sepsis, calculus of the gallbladder with chronic cholecystitis without obstruction and generalized anxiety.The admission Nursing assessment dated [DATE] identified Resident #47 had a Brief Interview for Mental Status score of 8, indicating moderately cognitively impaired, required substantial maximal assistance with bed mobility, dressing, personal hygiene, was dependent on staff for toileting, and had episodes of both continence and incontinence. Resident #47 was Spanish speaking and required an interpreter for communication. The Resident Care Plan dated 4/10/26 identified Resident #47 needed staff assistance with Activities of Daily Living, assistive devices: wheelchair, and walker. Interventions included to assist as needed to meet toileting needs, incontinent care per policy, keeping commonly used/needed items within reach, Physical and Occupational Therapy as ordered, transfers per physician orders.A review of the Accident/Incident Report dated 4/10/26 identified a family member reported on 4/9/26 at 3:30 PM to Social Worker #1 (SW) that staff told Resident #47 to stay in bed for voiding.A review of NA #1's statement dated 4/9/26 indicated she asked NA #1 to assist with translating since Resident #47 was Spanish speaking only. NA #1 asked Resident #47 if he/she needed anything or if he/she wanted to use the bathroom. Resident #47 replied he/she did not want to go to the bathroom because of recent surgery, and he/she was in pain. NA #2 reassured Resident #47 not to worry that if he/she needed to, he/she could use the incontinent product he/she was wearing. NA #1 indicated she explained to Resident #47 how to use the call bell, and the NA would assist and change him/her as needed.A review of the Director of Nursing investigation dated 4/15/26 identified that a family member reported a concern that Resident #47 was instructed by staff to go in his/her brief. An investigation was immediately initiated. In the context of Resident #47 expressing discomfort and hesitation to move, NA #1 reassured Resident #47 if he/she experienced urgency and could not wait, staff would promptly assist with hygiene care and ensure he/she was cleaned and changed. This was intended to reduce anxiety given Resident #47's post operative status and new admission, not to discourage toileting or to replace assistance with the bathroom. The facility was not able to substantiate the allegation of neglect.Interview with Social Worker #1 on 4/14/26 at 9:45 AM identified that Resident #47 was Spanish speaking and a family member or a Spanish speaking staff member was able to translate. The family member came to her on Friday 4/9/26 very unhappy that the NA told Resident #47 to void in bed. SW #1 went to the Director of Nursing, and she took over the investigation.An interview with NA #2 on 4/14/26 at 12:53 PM indicated nothing happened on Friday 4/9/26 with Resident #47. When asked about the statement NA #1 had written, the phone disconnected. A reinterview was attempted but NA #1 did not answer the phone.An Interview with the Director of Nursing (DON) and Regional Nurse (RN #4) on 4/14/26 at 1:37 PM identified the Social Worker came to the DON with concerns from a family member identifying the staff had told Resident #47 to void in bed. Resident #47 was upset because the staff told him/her to void in bed. The family member engaged the call bell and the staff came, took Resident #47 to the bathroom, and he/she voided. NA #2 was assigned to Resident #47, NA #1 (who translated) was not assigned to the resident. Review of NA #1's statement identified that NA #1 had written she instructed Resident #47 to void in his/her incontinent product. The DON and RN #4 indicated instructing Resident #47 to void in his/her diaper was not appropriate. Additionally, NA #1 failed to notify the nurse that Resident #47 was having pain, and this was why Resident #47 did not want to get up to use the bathroom. The DON indicated that Resident #47 was continent with incontinence and retention and had a urology follow up.An interview with NA #2 was attempted but not obtained.A review of the Resident's Rights policy directed, in part, you have the right to be treated with consideration, respect, full recognition of your dignity and individuality. You have the right to receive care and services with reasonable accommodation of your individual needs and preferences, except when your health or safety or the health or safety of others would be endangered by such accommodation

Based on observations, review of the clinical record, facility policy and interviews for 2 of 2 sampled residents (Resident #3 and Resident #31) reviewed for activities, the facility failed to ensure activity preferences were provided. The findings include:1.Resident #3's diagnoses included generalized muscle weakness, paraplegia, anxiety, and depression.An annual Recreation assessment dated [DATE] at 3:55 PM identified that it was very important for Resident #3 to do his/her favorite activities, be around animals such as pets, to keep up with the news, and get some fresh air.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status of 15 indicating intact cognition and required maximum assistance for dressing, oral hygiene and set up assistance for eating. The Resident Care Plan dated 12/16/25 identified Resident #3 would engage in activities of their own choosing. Interventions included offering a calendar of activities, encouraging the resident to attend activities of his/her choice, offering materials for in-room activities, and the Recreation Director would provide a weekly 1:1 visit to determine interests and offer support and encouragement. Interview with Resident #3 on 4/10/26 at 12:35 PM identified that the only activity he/she engaged in was self-propelling around the facility in his/her wheelchair 80 to 100 times per day. Additionally, Resident #3 indicated that there were no activities of interest for residents who were younger than the majority of residents in the facility.Review of the recreation participation documentation from 3/1/26 to 4/14/26 identified Resident #3 had participated in 3 out of 45 recreational opportunities, and the 3 activities attended consisted of a weekly 1:1 visit with the Recreation Director. Resident #3's participation record failed to identify the Recreation Director had visited the resident weekly (per the Resident Care Plan) as 2 of the 5 visits were missing. Further, the recreation participation documentation failed to indicate Resident #3's choices, that were identified during the annual Recreation Assessment on 12/15/25 as being very important to him/her were attempted or provided including contact with animals/pets, news, and being taken outside for fresh air, anytime during the remaining 42 days.2. Resident #31's diagnoses included muscle weakness, overactive bladder, diabetes, depression, and anxiety.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #31 had a Brief Interview for Mental Status of 15 indicating intact cognition and was independent for dressing, oral hygiene and required set up assistance for eating.The Resident Care Plan dated 1/21/26 identified Resident #31 would need leisure and diversional activities to adjust to their new environment in the facility. Interventions included offering a calendar of activities, encouraging the resident to attend activities of their choice, offering materials for in room activities, and the Recreation Director would provide a weekly 1:1 visit to determine interests and offer support and encouragement.Interview with Resident #31 on 4/10/26 at 12:40 PM identified that the facility did not provide activities he/she was interested in such as photography and sign language courses. Resident #31 stated he/she was bored. Although the facility had provided a tablet there were so many blocks it was difficult to use.An annual Recreation assessment dated [DATE] at 12:08 PM identified that it was very important for Resident #31 to do their favorite activities, be around animals such as pets, to keep up with the news, do things with groups of people and to get some fresh air.Interview and clinical record review with Social Worker #1 on 4/14/26 at 9:49 AM identified that available resident activities included word find games, exercising, social gatherings, and outside and picnicking when it was nice. Review of Resident #3 and Resident #31's Resident Care Plans failed to identify individualized preferences for recreational activities. Social Worker #1 indicated that it was the responsibility of the Recreation Director to personalize Resident #3 and Resident #31's Resident Care Plans to include recreational activity preferences and ensure residents received the activities of their choice.Interview and review of Resident #3 and Resident #31's clinical records on 4/14/26 at 10:05 AM with the Recreation Director failed to identify that residents' personal preferences had been added to the Resident Care Plans. The Recreation Director stated that she was unaware that it was her responsibility to individualize the Resident Care Plans to include residents preferred recreational activities. Resident #3's recreational preference included being able to go outside in his/her wheelchair, but that would be difficult due to a lack of available staff to accompany the resident. Although Resident #31 preferred and had been previously provided with 4 tablets, the tablets had broken and there were no further recreational activities that had been offered to him/her. A review of individualized participation records for Resident #3 and Resident #31 was attempted; however, the Recreation Director concluded the interview stating she had to get to her next activity.Review of the Care Plan policy dated 10/30/20 directed, in part, a comprehensive plan of care based on the identified needs, strengths, and preferences will be developed for each resident by the Interdisciplinary Team which includes social work and recreation.Although requested, a facility policy for Activities was not provided.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #3) reviewed for positioning and mobility, the facility failed to ensure a custom wheelchair was regularly reviewed per the facility policy and physician orders. The findings included:Resident #3 's diagnoses included paraplegia, generalized osteoarthritis and muscle weakness.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment and was totally dependent on staff for dressing, toileting, bed mobility, and transfers, had a functional limitation in range of motion with impairment on both sides of the lower extremities, used a wheelchair independently, and was at risk for pressure ulcer development.The Resident Care Plan dated 4/1/26 identified Activities of Daily Living (ADLs) needing staff assistance with ADLs due to quadriplegia, assistive devices used a wheelchair required a total mechanical lift. Interventions included assisting as needed to meet toileting needs, incontinent care per policy, side rails per physician's orders to assist with bed mobility, transfers per physician's orders.Physician's orders effective 2/1/26 through 4/14/26 directed to transfer the resident from bed to the motorized wheelchair with a mechanical lift, offer to transfer out of bed after morning care, offer to transfer back to bed after lunch or by resident request, schedule was subject to change per resident tolerance, 24-hour positioning plan in place, and to complete custom wheelchair nursing review on the 15th of each month on the 7:00 AM to 3:00 PM shift.Observations of Resident #3 throughout the survey on 4/10, 4/13, 4/14, and 4/15/26 identified daily placement in his/her CWC.A review of the 24-hour positioning plan for Resident #3 identified to offer to transfer out of bed to the custom wheelchair after morning care. Please offer to transfer back to bed after lunch meal or by request. Schedule was subject to change per Resident #3 tolerance with transfer bed to wheelchair as needed. The 24-hour positioning plan failed to identify times or time frames within the 24-hour time period to be out of bed in the custom wheelchair, back to bed or any specific positions in or out of bed.A review of the undated initial quarterly Rehab Review for Custom Wheelchair (CWC) and 24-hour Positioning Plan identified Resident #3 would transfer out of bed to a CWC daily via mechanical lift with the assistance of 2 staff members and would remain in the CWC as tolerated with repositioning per policies and return to bed via mechanical lift with assistance of 2 staff members for rest periods with repositioning every 2 hours. Initial positioning on return to bed should be supine. Transfer to CWC via mechanical lift with assistance from 2 staff members refer to 24-hour positioning plan. Education for the CWC was noted as having been provided on 9/11/23.Although an annual Rehab Review dated 2/6/26 identified there were no health issues related to the use of the CWC, the facility was compliant with the CWC and continued to be appropriate without recommendations or modifications, the clinical record failed to reflect the facility had followed their policy for quarterly rehabilitation documentation for a CWC and was missing quarterly Rehabilitation Reviews for 7/2024, 10/2024, 1/2025, 4/2025, 7/2025, and 10/2025.Review of the clinical record, monthly Custom Wheelchair nursing review failed to include nursing documentation was completed on 1/15/25, 2/15/25, 3/15/25, 4/15/25, 5/15/25, 6/15/25, 9/15/25, 12/15/25, and 2/15/26, per the physician order, for the use of Resident #3's CWC.Interview and clinical record review with the Director of Rehabilitation on 4/14/26 at 10:01 AM identified Resident #3's 24-hour Custom Wheelchair (CWC) positioning plan per the Physical Therapy Discharge summary dated [DATE] identified staff would be educated and compliant with Resident #3's 24-hour positioning plan to maintain skin integrity and promote quality of life and interaction with the environment. The CWC positioning plan did not include specific times for Resident #3 to be out of bed in the CWC and specific times to go back to bed. The Director of Rehabilitation indicated that this was the way the plan was to be written and Resident #3 knew how to tilt the CWC and reposition him/herself. She indicated that the positioning plan was based on Resident #3's preferences. The Director of Rehabilitation indicated that facility policy directed the Rehabilitation Department to conduct quarterly CWC reviews and although Nursing Department was to conduct monthly CWC nursing reviews, the nurses often missed documentation.Review of the Custom Wheelchair policy dated December 2008 directed, in part, Licensed staff were responsible for monthly notes, and overall compliance, PT/OT were responsible for quarterly notes, see custom wheelchair notebook for specific instructions on unit, daily documentation on positioning in flowsheets needed to be completed by NA daily.Sec. 17-134d-46. Customized wheelchairs in nursing facilities as defined in 42 USC 1396r(a), as amended from time to time, directed in part, the 24 hour positioning plan shall describe periods of time when the patient shall be seated in the customized wheelchair and shall also describe a time schedule for the patient to be therapeutically positioned in bed, on mats or with other pieces of adaptive equipment. The positioning plan shall take into account the patient's ability to be seated in a customized wheelchair for limited or extended periods of time, depending on the circumstances of the patient. Emphasis must be placed on seating the patient in a customized wheelchair at mealtime. The positioning plan must be modified, as needed, depending on the circumstances of the patient in order to promote enhanced psychosocial functioning made possible by seating in a customized wheelchair for longer periods of time as the patient develops increased physical capacity for being adaptively seated. The 24-hour positioning plan adopted by the attending physician must indicate the name and title of the individual responsible for overseeing implementation.

Based on review of the clinical record, facility documentation/policy, and interviews for one (1) of one (1) sampled resident (Resident #53) reviewed for adequate supervision, the facility failed to ensure adequate supervision and implementation of interventions following an initial physical altercation, when staff did not maintain continuous observation of Resident #53 despite known agitation and violent behavior. This failure was not in accordance with facility policy requiring one-to-one supervision during emergent situations and subsequently Resident #53 re-engaged in violent behavior, resulting in a second altercation and injuries to both the resident and a staff member. The findings include:Resident #53's diagnoses included vascular dementia, history of a traumatic brain injury, and chronic kidney disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #53 had moderately impaired cognitive function (Brief Interview for Mental Status (BIMS) score of 12) and was independent with all care including bed mobility and transfers in and out of the bed and chair.The Resident Care Plan dated 12/23/25 identified Resident #53 had anxiety, dementia and was at risk for mood changes. Interventions directed to encourage relaxation techniques such as music therapy, talking with the resident, medications as ordered, use of short and simple sentences, offer support, and report changes in mental status.The nurse's note dated 3/24/26 at 10:37 PM by RN #5 (the 3:00 PM to 11:00 PM supervisor) identified at approximately 7:00 PM, Resident #53 was seen by NA #4 taking food from another resident who was sleeping. Resident #53 became upset and threw the croissant at NA #4 hitting NA #4 in the face. RN #5 summoned LPN #1 (the 3:00 PM to 11:00 PM charge nurse) for assistance. The situation was diffused and the police were called. Next, Resident #53 was witnessed grabbing a pencil from the desk and trying to stab NA #4. The police arrived and Resident #53 and NA #4 were separated. Resident #53 was taken to the hospital to be evaluated.The nurse's note dated 3/24/26 at 11:39 PM by LPN #1 identified he/she was called to deescalate a situation with Resident #53 and escort him/her back to his/her room. Shortly after, there was another commotion and NA #4 and Resident #53 were seen standing in front of the nurse's station holding onto each other's clothing. LPN #1 observed blood coming from Resident #53's forehead and left wrist and separated them. The police arrived on scene and prevented further altercation.An interview with NA #5 (the 3:00 PM to 11:00 PM nurse aide) on 4/20/26 at 11:15 AM identified on 3/24/26 NA #4 went to the break room and told NA #5 that she saw Resident #53 go into another resident's room and take a croissant that his/her family provided. NA #4 told Resident #53 to put it back and when NA #4 tried to take it from Resident #53, Resident #53 struck NA #4. While discussing the incident, NA #5 witnessed Resident #53 charge at NA #4 who was standing at the open door of the break room. Resident #53 began punching NA #4 and NA #4 was shielding herself with her hands. LPN #1 arrived and tried to pull Resident #53 away from NA #4 while NA #5 and another staff member tried to pull NA #4 away from Resident #53. Once separated, NA #4 went to the bathroom which was near the nurse's station to tend to her bleeding mouth. As she walked out of the bathroom, Resident #53 grabbed a pencil from the nurse's station and tried to run towards NA #4 but was stopped by LPN #1. NA #5 further identified during the altercation that NA #4 inadvertently struck Resident #53 while trying to protect herself because Resident #53 kept charging at her and saying, I'm going to kill you.An interview with LPN #1 on 4/20/26 at 11:30 AM identified on 3/24/26 RN #5 asked him/her to assist with Resident #53 and escort Resident #53 back to his/her room to prevent agitation because there had been an altercation between Resident #53 and NA #4. During the walk back to the room Resident #53 repeatedly expressed he/she was not a thief. LPN #1 left Resident #53 in his/her room and proceeded to pass medications. When LPN #1 walked past the nurses station, LPN #1 overheard NA #4 state she was going to call the police because Resident #53 struck her. LPN #1 did not return to Resident #53's room and Resident #53 was left unattended for approximately ten (10) to fifteen (15) minutes before LPN #1 saw that Resident #53 exited his/her room and was in front of the nurse's station holding NA #4 by the shirt collar. NA #4 was attempting to pry Resident #53's fingers off and LPN #1 was trying to separate them. Other staff were present and tried to assist until the police arrived. During the altercation Resident #53's glasses were broken and Resident #53 sustained a scrape to the head and wrist. NA #4 was injured with a cut to the forehead. RN #5 was present throughout the entire event and never directed LPN #1 to stay with Resident #53. LPN #1 could not recall if he had been trained to stay with a resident during an emergency until Emergency Medical Services (EMS) arrived.Interview with the Assistant Director of Nursing (ADON) on 4/20/26 at 12:00 PM identified on 3/24/26 NA #4 reported the sequence of events that occurred. The ADON viewed video footage and identified Resident #53 and NA #4 were in the hallway when Resident #53 threw a croissant at NA #4 then struck NA #4 several times and tried to grab NA #4. NA #4 raised her hands trying to block Resident #53. Resident #53 then grabbed a pencil from the nurses station and went after NA #4. The remainder of the incident was out of video frame. Video footage supported that Resident #53 grabbed and struck NA #4. No one stayed with Resident #53 after the initial altercation in the hallway and the ADON identified a staff member should have remained with Resident #53 until EMS arrived. The ADON further identified the facility failed to follow its Emergency Policy.Review of annual training for LPN #1 identified he received emergency training within the year.Although attempted, interviews with RN #5, NA #4, or by Person #1 were not obtained.Review of the facility policy titled Emergency Care identified the Nursing Supervisor or designee will direct the provision of emergency care until relieved by EMS to include assessing & ensuring scene safety - protect resident, visitors, and staff and ongoing monitoring. The policy further identified condition specific emergency response for Psychiatric Emergencies (acute disturbance) would include calling 911, removing potential harmful objects and providing 1:1 supervision.

Based on observations, interviews, facility record review and policy review for 1 of 1 medication rooms reviewed, the facility failed to ensure emergency stock controlled (narcotic) medications were not expired and were not administered past the labeled expiration date. The findings include:Observation and interview with the supervising Registered Nurse (RN) #1 on 4/10/26 at 11:30 AM identified that emergency stock, controlled medications were counted daily at change of shift; however, the process did not include verification of medication expiration dates. A review of the emergency stock medications with RN #1 identified the following:Hydrocodone Bitartrate and Acetaminophen 5/325 mg tablets (opioid pain reliever): 20 tablets with an expiration date of 6/2025 and 24 tablets with an expiration date of 9/2025Alprazolam 0.25 mg (anti anxiety medication) 12 tablets with an expiration date of 11/2025The Controlled Substance Disposition Record (used to identify distribution of narcotic medications) identified the expired Alprazolam 0.25 mg was administered 15 times past the labeled expiration date in the timeframe of 11/22/25 through 3/19/26 as follows: Resident #6 was administered expired Alprazolam 0.25 mg 2 timesResident #15 was administered expired Alprazolam 0.25 mg 6 timesResident #36 was administered expired Alprazolam 0.25 mg 6 timesResident #49 was administered expired Alprazolam 0.25 mg 1 timeInterview with RN #1 identified it was the responsibility of all nurses to check expiration dates prior to dispensing so expired medications were not administered but could not explain why the expired medications were not removed from stock or why they had been administered after their labeled expiration dates.Subsequent to surveyor inquiry, RN #1 removed the 44 expired Hydrocodone Bitartrate and Acetaminophen 5/325 mg tablets and 12 Alprazolam 0.25 mg tablets from the emergency stock.Interview with the Director of Nursing Services (DNS) on 4/13/26 at 12:24 PM identified that it was the responsibility of the DNS, the nursing staff, and the pharmacy to remove expired medications. Additionally, the DNS stated she just reordered them, but was unable to explain why the expired medications were dispensed and remained in use. Interview with Pharmacist #1 on 4/14/26 at 9:25 AM identified that expiration dates for emergency controlled stock were checked by the pharmacy before the medications were sent to the facility. Pharmacist #1 stated once delivered from the pharmacy it became the responsibility of the nursing staff to check to see if a medication was expired prior to dispensing to the residents. Further, administering expired Alprazolam could result in the medication not producing its intended effect (to calm a person experiencing anxiety).Review of the Medication Storage in the Facility Policy dated 1/26 directed in part that outdated, contaminated, or deteriorated medications are immediately removed from stock, and disposed of according to the procedures for medication destruction and reordered from the pharmacy.

Based on observation, interviews, facility documentation review and policy review for 2 of 2 sampled residents (Resident #6 and Resident #22) reviewed for the Infection Control program, the facility failed to follow the manufacturer's guidelines for disinfecting and cleaning a multi-use glucometer (blood device used to measure blood sugar levels). The findings include:1.Resident #6's diagnoses included type 2 diabetes mellitus, depression and hypertension.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #40 had a Brief Interview of Mental Status of 15 indicating intact cognition, and was independent for eating, dressing and toileting.The Resident Care Plan dated 2/8/26 identified Resident #6 had diabetes, was at risk for hyperglycemia and/or hypoglycemia, and increased risk for complications. Interventions included finger sticks (blood glucose monitoring) as ordered and as needed and to check the blood sugar if complaints of hunger, sweating, confusion, dizziness, increased thirst, nausea or vomiting, abdominal discomfort or changes to mental status were present.A physician's order dated 3/27/26 directed to obtain a blood sugar check every Tuesday and Friday at 6:30 AM for type 2 diabetes mellitus.2. Resident #22's diagnoses included type 2 diabetes mellitus, congestive heart failure, and end stage renal disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #22 had a Brief Interview of Mental Status of 13 indicating intact cognition and was independent for eating, dressing, and toileting.The Resident Care Plan dated 4/9/26 identified Resident #22 had diabetes, was at risk for hyperglycemia and/or hypoglycemia, and increased risk for complications. Interventions included finger sticks (blood glucose monitoring) as ordered and as needed and to check the blood sugar if complaints of hunger, sweating, confusion, dizziness, increased thirst, nausea or vomiting, abdominal discomfort or changes to mental status were present.A physician's order in effect on 4/14/26 directed to administer Insulin Lispro Subcutaneous Solution Pen Injector 100 unit/ml before meals per sliding scale according to the blood sugar reading. What were the hours of checks?Observation, interview, and facility documentation review with Licensed Practical Nurse (LPN) #2 on 4/14/26 at 6:07 AM identified LPN #2 cleansed the glucometer with an alcohol prep pad to prior to obtaining Resident #6's blood glucose level. After obtaining Resident #6's blood glucose level, LPN #2 again cleansed the glucometer with a new alcohol prep pad indicating this was facility policy and proceeded to obtain Resident #22's blood glucose level. LPN #2 explained that the facility directed the use of alcohol prep pads to disinfect the glucometer between residents with particular emphasis on the test strip port. On review of the facility cleaning and disinfecting policy with LPN #2, it was identified that CaviWipes (hard surface cleaner and disinfectant) were required to be used per the manufacturer guidelines. LPN #2 indicated that she was unaware of this, did not use CaviWipes, and didn't know if CaviWipes were even available in the facility.Interview and facility documentation review with the Director of Nurses (DNS) on 4/14/26 at 7:04 AM identified that the facility's policy requires multi use glucometers to be cleaned and disinfected with Medline Micro-kill One wipes (EPA registered, one step disinfectant wipes intended for hard, non porous surfaces in healthcare settings) stating alcohol wipes were not appropriate for cleaning and disinfecting the glucometers. Additionally, review of the glucometer user's guide with the DNS showed that, per manufacturer guidelines, CaviWipes or other EPA registered disinfectant wipes must be used to clean and disinfect the meter prior to use and between each patient.Review of the Point of Care Blood Glucose Testing Policy directed, in part, to clean and disinfect the glucometer with germicidal wipes and allow the glucometer to remain wet for the amount of minutes directed per manufacturer recommendations prior to performing the blood glucose test. Additionally, clean and disinfect the glucometer with germicidal wipes and allow the glucometer to remain wet for the number of minutes as per manufacturer recommendations after performing the blood glucose test.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) who was a new admission, the facility failed to develop and implement interventions to address a resident who was incontinent of urine. The findings include:Resident #2's diagnoses included dementia and benign prostatic hyperplasia. The admission nursing assessment dated [DATE] identified Resident #2 was incontinent of bowel and bladder. Review of the baseline care plan given to the resident/representative on 6/23/25 identified Resident #2 was at risk for skin breakdown. Interventions directed to keep the skin clean and dry and apply barrier cream with incontinent care. Upon further review, the care plan failed to address Resident #2's incontinence. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating Resident #2 had poor memory recall deficits, required extensive assistance of one (1) staff for toilet use, limited one (1) person assistance with transfers, and was occasionally incontinent of urine and frequently incontinent of bowel. Review of the bladder flowsheets from 9/10/25 through 9/30/25 identified Resident #2 was incontinent of urine on at least one (1) shift for twelve (12) out of twenty-one (21) days and four (4) out of twenty-one (21) days did not have any documentation for the 3-11:00 PM shift. Review of the Accident and Incident (A&I) form dated 10/3/25 at 12:20 AM identified Resident #2 attempted to go to the bathroom unassisted and fell. Although the risk for falls care plan was updated on 10/8/25 with the intervention to offer and assist with toileting at the beginning of third shift, the care plan failed to identify Resident #2's incontinence was addressed. Interview and record review with the Corporate Nurse on 10/9/25 at 1:45 PM identified upon review of Resident #2's care plan, the only information it contained in regards to Resident #2's incontinence was under the skin breakdown care plan with the intervention to apply barrier cream with incontinence episodes. Review of the care planning policy directed that a comprehensive and individualized plan of care will be developed for each resident. The care plan will guide caregivers to assist residents to achieve or maintain their highest practical level of wellbeing. The policy directed that the care plan will include a statement of the problem/focus, reasonable and measurable goals, interventions to achieve these goals and the discipline(s) responsible for carrying out the interventions.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of two (2) sampled residents (Resident #1) who received a scheduled and as needed pain medication, the facility failed to document the administration and follow up of the as needed pain medication. The findings include:Resident #1's diagnoses included malignant cancer and lumbar radiculopathy (compression of nerves in lower back). The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, received a scheduled and as needed pain medication regimen, the pain was frequent, occasionally effected the sleep pattern, almost constantly interfered with day-to-day activities, and rated the pain on the scale, seven (7) out of ten (10). The Resident Care Plan dated 8/20/25 identified Resident #1 was at risk for pain and discomfort. Interventions directed to administer medications as ordered and determine the level of pain using the pain scale before administering the medications. Review of the September 2025 control drug record identified on 9/26/25 Resident #1 received Oxycodone 5 milligrams (mg) at 9:30 PM. Review of the September 2025 Medication Administration Record (MAR) failed to identify documentation that the Oxycodone was administered at 9:30 PM and a follow up response (effective or ineffective) to the as needed medication. Interview with the 3-11PM nurse, Registered Nurse (RN) #1, on 10/9/25 at 12:45 PM identified on 9/26/25 she administered 5 mg of Oxycodone to Resident #1 around 9:30 PM. RN #1 explained she forgot to enter the administration of the medication into MAR and she believed she had followed up with Resident #1 about an hour later and Resident #1 was resting in bed. Interview with the Corporate Nurse on 10/9/25 at 1:45 PM identified narcotic sheets are not part of the resident's clinical record and when a medication is administered this should be documented on the MAR or in a nurse's note. Review of the liberalized medication administration policy directed PRN (as needed) medications are administered as needed for physician's order, with documentation reflecting indication and effectiveness. Review of the pain management policy directed to document all findings in the resident's medical record. Reassess pain levels after any intervention to evaluate effectiveness. Document all pain assessments, interventions and resident responses in the medical record.

Based on clinical record review, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure staff did not move a resident with visible head injuries after an unwitnessed fall with major injuries (closed head injuries and multiple fractures). The findings include: Resident #1's diagnoses included heart failure, anxiety and chronic pain. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 10). The Resident Care Plan (RCP) dated [DATE] identified a risk for falls. Interventions directed to transfer with an assist of one (1) and rolling walker, ensure call bell was within reach and encourage use of a call bell for assistance. A Physician order dated [DATE] directed siderails: two (2) half up for bed mobility, elevate head of bed to prevent hypoxia while lying flat, assist of one for transfers with rolling walker, and Aspirin 81 mg (milligrams) one tablet at bedtime for heart health. A psychotherapy note dated [DATE] identified Resident #1 was alert, oriented to person, place, time and situation, forgetful, goal directed with good to fair attention, judgment and insight. Review of the Reportable Event dated [DATE] at 4:30 AM indicated Resident #1 had an unwitnessed fall. Resident #1 was observed lying face down next to his/her bed with his/her head under the overbed table on the side of bed closest to bedroom door. Resident #1 was noted to have a large lump to the back of the head and to the left forehead, a cut to the outer corner of the left eye, an abrasion to the left neck and complained of discomfort to the left wrist. The APRN was notified, Resident #1 sent to the Emergency Department (ED) for evaluation, and an investigation was initiated. Review of the Situation Background Assessment Request (SBAR) and nurse progress note dated [DATE] identified Resident #1 had a fall with a change in condition. Resident #1 fell from bed and was found lying face down on the floor with a large lump to the left forehead, back of head, a cut on outer corner of the left eye, abrasion to the left neck and complained of pain to the left wrist. Resident #1's description of the event, I was going to the bathroom. The call light was within reach. Resident #1 was on an anticoagulant and was transferred to the hospital. Emergency Medical Services (EMS) run sheet dated [DATE] identified EMS was called at 4:28 AM. The run sheet identified Resident #1 had been assisted back to bed via mechanical left after an unwitnessed fall out of bed, facial injuries, and injuries to the neck and left wrist. Resident #1 was placed in a cervical collar and moved to a stretcher, edema and ecchymosis (bruising) was noted to the right femur, and Resident #1 had complaints of nausea en-route to the hospital. Hospital documents dated [DATE] identified Resident #1 was diagnosed with traumatic subdural hematoma, subarachnoid hemorrhage, left maxillary sinus fracture, left distal radius and ulnar fracture, scattered contusions, hematoma inferior to platysma (platysma muscle is a thin, sheet-like muscle located in the neck, primary functions of lowering the lower lip and mouth corner, and assisting in facial expressions like frowning, smiling, and grimacing) and a T8 (thoracic spine) fracture, was placed on spine precautions, neuro checks, monitoring of airway given the location of platysma hematoma and was admitted to the surgical intensive care unit. Further review indicated CT Scan of thoracic/lumbar spine T8 level spine new discontinuity of unknown chronicity, but new from [DATE], and [DATE] CT scan of thoracic spine re-demonstrated acute/recent appearing fracture involving the anterior (front) and posterior (back) of T8 vertebral body, extending to the T8-9 disk posteriorly, increased displacement of fracture fragments both in superior-inferior and anterior and posterior directions, and widening of T8-9 facet joint, also new from prior. Further indicated was Resident #1 expired [DATE]. Interview and record review with LPN #1 on [DATE] at 11:18 AM identified she last observed Resident #1 at 1:30 AM in his/her bedroom for as needed medication administration, the call bell was within reach and clamped to the blanket, she elevated Resident #1's head of bed, bed rails were up, and at the time of Resident #1's fall, she was on break. Interview on [DATE] at 11:32 AM with NA #2 identified she last saw Resident #1 at 4 AM lying in bed with bed rails up. NA #2 indicated when she arrived to the room after the fall incident, Resident #1 was on the floor and indicated he/she was trying to go to the bathroom. NA #2 indicated RN #1 (RN supervisor), directed her (NA #2) to assist RN #1 and two (2) other aides to assist Resident #1 back to bed via the mechanical lift. Interview and record review on [DATE] at 11:52 AM with RN #1 identified she last saw Resident #1 during rounds at 4 AM, laying on his/her back, asleep in bed, with the bed rails up. RN #1 further indicated she was called to the room around 4:30 AM when Resident #1's roommate called for help. Resident #1 was observed face down on the floor near his/her bed, his/her head was near the head of the bed under the bedside table and his/her neck was on the bar under the bedside table. She rolled Resident #1 over for assessment, called 911, and assisted Resident #1 back into bed with assistance from NAs. She identified that they rolled Resident #1 to the side, tucked the mechanical lift sling under Resident #1, and used the mechanical lift to transfer Resident #1 into bed. RN #1 indicated that, based on her assessment, Resident #1 had head injuries, left wrist pain, and could have injured his/her back/spine but she wanted to make Resident #1 comfortable, therefore, transferred Resident #1 back to bed. RN #1 indicated she should have made Resident #1 comfortable on the floor while awaiting EMS. Interview with APRN #1 on [DATE] at 12:32 PM identified Resident #1 should not have been moved while awaiting EMS arrival after the fall out of bed on [DATE]. Interview with NA #1 on [DATE] at 12:45 PM identified she was responsible for providing care for Resident #1 on [DATE], last provided incontinence care at 2:30 AM, and last observed Resident #1 lying in bed at 4 AM with the call bell within reach and bed rails up. She further indicated that around 4:30 AM she assisted RN #1 and other NAs to roll Resident #1 onto the mechanical lift sling and transfer Resident #1 to bed. Interview on [DATE] at 2:15 PM with the DNS identified she could not determine if the staff working on [DATE] should have transferred Resident #1, who sustained a visible head injury and potential spinal injury, back to bed, or if Resident #1 should have been made comfortable and remained on the floor while waiting for EMS arrival. Review of facility Falls: Minimizing Risk of Injury Policy directed, in part, its purpose is to minimize injuries when a fall occurs. Review of Taber's Medical Dictionary directed in part, when a resident falls with a head strike, to assess the severity of the head impact and evaluate for injuries. Observe for mental status changes, neurological abnormalities or bleeding.

Based on clinical record review, facility documentation review, facility policy and interviews for 1 of 3 sample residents (Resident #149) reviewed for abuse, the facility failed to ensure Resident # 149 was free from physical abuse by Resident #28. The findings include: 1. Resident #28 's diagnoses included Alzheimer's disease, mood disorder due to known physiological condition with depressive features, and type 2 diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 had severe cognitive impairment and noted independent with bed mobility, toileting, dressing, hygiene, transfer, and ambulation without use of assistive device. The Resident Care Plan (RCP) dated 1/10/24 identified Resident #28 had chronic and progressive decline in intellectual functioning related to Alzheimer's disease. Interventions directed to introduce yourself to the resident, explain each activity or care procedure prior to starting the procedure, repeat communications to the resident more than one method such as: words, gestures, and facial expressions, and to administered medications per physician orders. The nurse's notes dated 3/8/24 at 2:00 PM identified Resident #28 hit Resident #149 on the left arm and left leg with a plate cover with spilled drink. Resident #28 was also noted to scatter personal belongings on the floor. Resident #28 was placed on 1 to 1 direct observation. The Advanced Practice Registered Nurse (APRN) psychiatrist, medical APRN, Administrator, responsible party and police department were all notified. Resident #28 was evaluated via telehealth by the APRN psychiatrist with new physician's orders to discontinue 1 to 1 direct observation, administered Trazodone(anti-depressant) 50 Milligrams (MG) by mouth for one dose, Trazodone 25 MG by mouth daily for 7 days, Trazodone 25 MG by mouth every 8 hours as needed for 7 days, collect urine for urinalysis and culture. Resident #28's family members went to the facility to provide support to the resident. The psychiatrist APRN progress note dated 3/8/24 identified Resident #28 was evaluated via telehealth related to striking another resident (Resident # 149). The evaluation identified Resident #28 became upset when someone came into his/her house and took out his/her belongings. Resident #28 had assumed Resident #149 removed his/her belongings out of the room and subsequently hit Resident #149. Resident #28 has a history of yelling out and packing belongings. However, Resident # 28 had no history of physical aggression toward others. The APRN identified Resident # 28's belief that his/her belonging was moved out of the room was the exacerbating factor that resulted to hitting Resident # 149. The social worker progress notes written by Social Worker (SW #2) on 3/11/24 at 12:30 PM identified s/he spoke to Resident #28 related to the incident that had occurred with Resident #149. Resident #28 was receptive to the SW #2 visit and Resident #28 had difficulty recalling the incident that occurred. Resident #28's demeanor was calm, laughing, and engaging. 2. Resident #149's diagnoses included lymphedema, low back pain, spinal stenosis, type 2 diabetes mellitus, and morbid obesity. The RCP dated 1/10/24 identified Resident #149 needs staff assistance with Activity Daily Living (ADL's). Interventions directed to assist resident with toileting as needed, keep commonly used items within resident reach, delivered meal and set-up as needed, and transfer per physician orders. The admission MDS assessment dated [DATE] identified Resident #149 with intact cognition and dependent for bed mobility, toileting, dressing, hygiene, and transfer. The nurse's note dated 3/8/24 at 2:11 PM identified Resident #149 had been hit on the left arm and leg with a plate cover by Resident #28. Resident #149 was assessed and noted with redness to the left arm and denied any pain. Resident #149 was moved to another room and was adjusting well to the new room. A Reportable Event form dated 3/8/24 identified Resident #149 was lying in his/her bed when Resident #28 walked across the room and hit him/her on the left arm with a breakfast plate cover. The revised RCP dated 3/9/24 identified Resident #149 was hit with a plate cover by another resident (Resident # 28). Intervention directed to move resident to another room. The nurse's note dated 3/10/24 at 2:30 PM identified Resident #149 had a bruise to the left arm and left pinky finger. Resident #149 had denied any pain or discomfort and indicated s/he was adjusting well to his/her new room. The social worker progress note written by SW #2 on 3/11/24 at 9:06 AM identified Resident #149 had an incident with Resident #28. Resident #149 was able to recall the incident with Resident #28 and s/he reported bruising to the left arm. Resident #149 reported s/he was emotionally fine, and s/he was not afraid of Resident #28. Resident #149 was aware that Resident #28 had cognitive issue and s/he would not retaliate, but s/he did curse in frustration at the time of the incident. Interview with Nurse Aide (NA #1) on 8/8/24 at 1:30 PM identified Resident #28 became upset when s/he (NA#1) cleaned out Resident # 28's room and took out the old linen from his/her room. NA #1 further identified Resident #28 alleged his/her roommate told her/him to clean out his/her room. NA #1 further indicated s/he did not witness when Resident #28 hit Resident #149 with a plate cover. NA#1 also identified that s/he did not let Resident #28 know s/he would take out the old linen and NA #1 did not expect Resident #28 to become upset and hit Resident #149 with a plate cover. NA #1 further identified this was the first time Resident #28 hit another resident. Interview with SW #2 on 8/12/24 at 12:50 PM identified s/he was filling in at the facility at the time of the altercation between Resident #28 and Resident #149. SW#2 could not recall the details of the altercation between Resident #28 and Resident #149; however, SW#2 identified Resident #149 was able to recall that Resident #28 hit him/her with a breakfast plate cover and Resident #149 had a bruise to left arm after s/he got hit with a plate cover. Interview with the Administrator on 8/12/24 at 1:00 PM identified Resident #28 was in the bathroom and NA#1 was cleaning and fixing his/her room. When Resident #28 came out from the bathroom, Resident #28 became upset and alleged his/her roommate (Resident # 149) told NA #1 to clean out his/her room. The Administrator identified Resident #149 had no cognitive impairment and was able to report and recall the hitting incident. Resident #149 reported that s/he got hit with a plate cover on his/her left arm and left leg. The Administrator confirmed that Resident #149 developed a bruise to the left arm after s/he was hit with a plate cover. The Administrator further identified Resident #149 requested a room change after the incident and was immediately removed from his/her room. The facility failed to protect Resident #149 from physical abuse by Resident # 28. A review of facility nursing policy titled Abuse/Resident identified the facility will ensure that each resident is treated with kindness, compassion, and in a dignified manner. Abuse Prevention notes residents have the right to be free from verbal, sexual, physical, mental, corporal punishment, mistreatment, neglect and misappropriation of property. The facility staff will monitor and supervise the delivery of resident care and services to assure the care was provided as needed. The facility will identify, correct and intervene in situations in which abuse has occurred. The facility would take appropriate action to treat all consequent ill effects experienced by the resident for the alleged incident and to safeguard the resident from further incident re-occurrence.

Based on review of the clinical record, review of facility policy and interviews for 1 of 4 Residents (Resident #31) reviewed for Pressure Ulcers, the facility failed to ensure staff obtained a physician's order for the use of fastening offloading boot devices, monitoring the effectiveness of the boot devices as a nursing measure and failed to ensure all staff was made aware of the wound physician's recommendation to stop using the green offloading boots. The findings include. Resident #31's diagnosis included Parkinson's Disease, severe protein-calorie malnutrition, failure to thrive and Stage 3 Pressure ulcer. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 as severely cognitively impaired and dependent on 2 staff members for bed mobility, transfer and dressing and noted limited mobility of both arms and legs. The RCP dated 8/2/2024 for Resident #31 identified at risk for skin breakdown due to immobility, incontinence, poor nutrition, pronounced body prominence, poor circulation altered sensation and mechanical forces. Interventions included: to inspect skin when providing care for signs and symptoms of skin breakdown, off load heels while in bed, pressure reducing mattress on bed and in the wheelchair, and to turn and reposition per standards of nursing practice. Further interventions included inspecting skin during care for signs of skin breakdown. A wound physician's progress note dated 8/6/2024 directed to hold off using the heel booties as increasing pressure to the lateral foot may be contributing to the declining wound. An observation on 8/7/2024 at 10:17 AM identified two puffy green boots each with a strap on Resident #31's bedside table while Resident #31 was in bed. An interview with NA#3 indicated s/he had worked the 3-11 PM shift and now works 7-3 PM and noted the utilization of the boots. NA#3 indicated hearing from the nurse or the off going NA if the boots were to be used or not used. NA #3 also indicated s/he did not recall if the booties were listed on Resident #31's assignment and could not explain why Resident # 31's booties were not applied today. An interview with charge nurse LPN #1 on 8/8/2024 at 2:55 PM identified the boots have been used for quite some time. LPN #1 indicated the boots were used while up in the wheelchair but not in bed. LPN #1 further indicated s/he did not know who recommended the use of the booties but thought it may have been the therapy department. An interview and record review with Physical Therapist (PT #1) on 8/8/2024 at 2:58 PM indicated Resident #31 remained on therapy and was evaluated 3/21/2024 with the mention of offloading boots in a long-term goal. PT #1 indicated the therapy notes from 7/19/2024 through 8/1/2024 indicated the donning of the green booties to Resident #31's bilateral feet. PT #1 also indicated therapy never recommended the use of the green booties as it was nursing who implemented the use. S/he also indicated PT #1 was unaware of the 8/6/2024 wound physician recommendation to use the green booties. PT #1 indicated the Rehabilitation Director who is currently off are made aware of changes during morning report. However, a review of the clinical record from 7/19/24 through 8/6/24 failed to reflect a physician's order and nursing measures for the utilization of the green booties. The clinical on 8/6/24 failed to reflect the physician's order and recommendation not to utilize the booties due to wound worsening. An interview and clinical record review with the DNS and RN#6 on 8/8/2024 at 1:15 PM indicated there was no physician's orders for use of the booties and RN #6 indicated the booties were used as a nursing measure to off load heels. Although, the use of nursing measures is not a standard of professional nursing practice, the DNS and RN #6 indicated they would look for facility policies for use of offloading boots and the use of nursing measures. However, no policies were found. An interview with Medical Doctor (MD #2) on 8/8/2024 at 2:01 PM indicated Resident #31's stage 3 pressure ulcer was becoming worse and on 8/6/2024 s/he recommended holding off using the boots due to pressure as the lateral foot might be contributing to the wounds decline. MD#2 further indicated Resident #31's foot had become red and swollen and the resident was started on antibiotic therapy and was being evaluated for osteomyelitis (bone infection) which could be a large contributing factor to the wounds decline. MD #2 further indicated s/he did not recommend the booties this was a nursing measure. MD#2 also indicated s/he could not say that using the booties without specific orders for use and monitoring could have caused the wound to decline. An interview with the DNS on 8/13/2024 at 10:15 AM indicated his/her understanding was that booties used in the facility were a nursing measure for offloading. The facility policy labeled Wound and Skin Care Protocols indicated in part the interdisciplinary plan of care would address interventions directed toward the prevention and/or treatment of pressure ulcers.

Based on review of the clinical record, review of facility policy and interviews for the 1 of 1 sampled resident (Resident #45)) reviewed for urinary retention, the facility failed to follow their policy regarding the maximum amount of urine to be removed at one time. The findings include: Resident #45's diagnoses included retention of urine, neuromuscular dysfunction of the bladder, chronic kidney disease Stage 3A and malignant neoplasm of prostate. A physician's order dated 7/1/24 directed to straight catheterize Resident #45 every shift for urinary retention. A nurse's note dated 7/1/24 at 6:19 PM identified Resident # 45 was straight catheterized in the morning and 1300 cubic centimeters (cc) of urine was removed. A nurse's note dated 7/2/24 at 11:00 PM written by RN#5 identified Resident # 45 was straight catheterized during the 3:00-11:00 PM shift and 1200 cc of urine was removed. The discharge Minimum Data Set assessment dated [DATE] identified Resident #45 as cognitively intact and required moderate assistance for personal hygiene, toileting, and maximal assistance for bathing. Interview with RN #5 on 8/8/24 at 3:33 PM identified s/he was aware of the facility policy on catheterization; however, s/he was unaware that there was a maximum amount of urine that could be removed at any one time. RN# 5 further stated you keep going until the bladder is empty and no more urine is coming out. In an interview and clinical record review with the DNS on 8/8/24 at 3:40 PM, 1000 cc's is the maximum amount of urine that could be removed from the bladder at a time. Upon review of the clinical record documentation, the DNS identified 2 separate occasions where more than 1000 cc' were removed from the bladder. Review of the Catheterization policy undated directed, in part, not to remove more than 1000 cc at one time.

Based on clinical record reviews, review of facility policy and interviews for 2 of 4 residents (Resident#31) reviewed for pressure ulcers and (Resident # 44) reviewed for nutrition, the facility failed to ensure the residents were reweigh for potential weight loss per the facility policy and the dietician was notified of a weight loss. The findings included. 1. Resident #31's diagnoses included Parkinson's Disease, severe protein-calorie malnutrition, failure to thrive, dementia and stage 3 pressure ulcer. A physician's order dated 5/15/2024 directed to obtain a weekly weight every Tuesday. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 as severely cognitively impaired and dependent on 2 staff members for bed mobility, transfer and dressing and noted limited mobility of both arms and both legs. The RCP dated 4/10/2024 indicated Resident #31 received an artificial means of nutrition related to weight loss and swallowing difficulty. Interventions included: monitoring weights, laboratory blood work and toleration of the feedings. The dietitians note dated 6/19/2024 at 10:19 2024 indicated in part questioned the accuracy of the 6/5 and 6/18/2024 weights as Resident #31's weights had been in the low 100's. On 8/8/2024 at 1:48 PM a call was placed to the dietician with no response. An interview and record review with the DNS and RN # 6 on 8/8/2024 at 1:40 PM indicated on 6/11/2024 Resident #31's weight was 101.4 pounds. The next weight on 6/18/2024 was 75.6 pounds (a weight loss of 25.0 pounds) and on 6/25/2024 the weight was 76.5 and the next day on 6/26/2024 the weight was 100.00 pounds (a gain of 23.5 pounds). The DNS and Regional RN both indicated Resident #31 should have been reweigh on 6/18/2024 and 6/26/2024 and indicated they could not explain why Resident #31 was not reweigh to determine an accurate weight. The facility policy labeled Weight Monitoring indicated in part if there is a 5 pound weight discrepancy (plus or minus), a reweight should be obtained, the charge nurse is to compare the weight to last previous weight and determine if there was a 5 percent change in weight in 30 days or 10 percent over 180 days and if so to notify the MD, responsible party, dietitian, the DNS/ Assistant Director of Nursing Services (ADNS) and the Care Plan Coordinator. 2. Resident #44 's diagnoses included dysphagia, Gastro-Esophageal Reflux Disease and Multiple Sclerosis. The RCP dated 7/3/24 indicates potential for nutritional decline related to medical problems. Interventions included to provide my diet as ordered and to weigh as ordered The admission MDS assessment dated [DATE] identified the resident as cognitively impaired, requiring supervision or touching assistance for eating. The assessment also noted dependent for sitting to laying and maximum in bed mobility and no swallowing issues. A physician's order dated 7/2/24 directed to give regular diet regular texture, thin liquids consistency, for all meats cut into soft bite size. The nutritional assessment dated [DATE] indicated admission weight as 186 pounds. Additionally, noted recorded intake 25-75%. A review of Resident #44's Electronic Medical Record (ER) records identified Resident #44 weight was 186 pounds on admission and on 8/2/24 weighed 161 pounds indicating the resident had a 25 pound or 13 % weight loss in 1 month. However, the clinical record failed to identify a reweight was conducted Interview with LPN #1 on 8/8/24 at 1:48 PM identified once a weight discrepancy is determined then the facility usually will do a reweight to ensure the weight was accurate. LPN #1 further indicated the dietician would be informed via dietician book. Review of the Dieticians Book on 8/8/24 at 1:50 PM for the month of July 2024 and August 2024 failed to indicate Resident #44 weight change was reported to the dietitian and a reweight was conducted. Interview with RN #2 on 8/08/24 at 1:54 PM, indicated s/he would notify Dietician of changes via weight book or Point Click Care (PCC). RN #2 identified Resident #44 has a weight warning on her/his profile. RN # 2 reported once a weight discrepancy is identified then a reweight would be done, s/he was unable to identify that Resident #44 was reweigh. RN # 2 reported s/he was unable to locate Resident # 44's weight for the last 4 weeks. After surveyor inquiry, the staff reweigh Resident # 44 Interview with Dietician on 8/08/24 at 3:00 PM indicated there was a weight discrepancy. The Dietician also reported s/he was at the facility on 8/7/24 and was not informed of Resident # 44's weight loss. S/he would expect to be notified via book or consults in PCC and or during risk meeting. The Dietician reported if s/he was informed, s/he would have asked for a re weight, put interventions in place and would notify the MD and family. Facility policy indicates Residents will be weighted weekly for 4 weeks on upon admission. The policy further indicated if 5 lbs weight discrepancy a reweight should be obtained, the charge nurse should then review the weight and compare the weight to the previous weights to determine if a 5% weight change occurred in 30 days. This should be reported to physicians/APRN, responsible party, Registered Dietician, DNS/ADNS and Care Plan Coordinator. 49100

Based on clinical record review and staff interviews for 1 of 5 residents for (Resident #41) reviewed for Unnecessary Medications, the facility failed to ensure monthly Medication Regimen Reviews (MRR) were completed for a resident on psychotropic medications. The findings include: Resident #41 's diagnoses included anxiety disorder, unspecified dementia with other behavioral disturbances and type 2 diabetics mellitus. A physician's order dated 2/28/24 directed to start Lorazepam 5 MG by mouth when needed for 60 days. On 7/10/24 a physician's order for when needed Lorazepam was ordered for anxiety and combativeness. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #41 as cognitively impaired and required (full) dependent assistance with eating, transfers and bed mobility. The MDS also identified Resident #41 received antipsychotic and anti-anxiety medications. The RCP dated 7/19/24 identified psychotropic drug use. Interventions included to monitor routinely for medication specific side effects and to have Medical Doctor (MD) evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. A review of the pharmacy consultations from February 2024 to July 2024 identified Resident #41 did not receive monthly Medication Regimen Reviews (MRR) by the pharmacy consultant for the months of May 2024 and June 2024. Interview with DNS on 8/08/24 at 12:45 PM indicated s/he was unable to locate the Medication Regimen Reviews (MRR) and s/he would contact the pharmacist to request the information.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one of three sampled residents (Resident #1) who sustained a third degree burn to left foot, the facility failed to ensure a new treatment order was transcribed into the Electronic Treatment Administration Record (eTAR) in accordance with the standards of practice. The findings include: Resident #1's diagnoses included Alzheimer's disease, repeated falls, abnormalities of gait and mobility, and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required partial/moderate assistance with sit to stand positioning, chair/bed-to-chair transfer and had two (2) falls without injury. The Resident Care Plan dated 11/15/23 identified Resident #1 was at risk for skin breakdown due to poor nutrition, pronounced body prominences, poor circulation, altered sensation and mechanical forces. Interventions directed treatment as ordered. The Facility Reported Incident form dated 1/2/24 at 10:30 PM identified Resident #1 attempted to get out of bed on his/her own without assistance, Resident #1 was found on the floor by his/her bed on his/her left side with the left side of the foot under the radiator. The report identified Registered Nurse assessed Resident #1 after the fall and noted an open area to the left side of foot, upon further evaluation, the area was noted to be a full thickness burn measuring 4.0 by 6.0 centimeters (cm) and a dressing was applied to the area. The nurse's note dated 1/2/24 at 10:44 PM identified the Advanced Practice Registered Nurse (APRN) was notified of Resident #1's fall and injury. The note identified the APRN directed to follow in house Fall Protocol, Xeroform dressing to the skin tear and obtain neurochecks. Review of the January 2024 Treatment Administration Record failed to reflect that the treatment to the left foot was transcribed on 1/2/24 and the treatment to the left foot was documented as administered from 1/2/24 through 1/4/24. Interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, on 1/29/24 at 3:35 PM identified he assessed Resident #1 after the fall and noted a skin tear to the left side of Resident #1's foot measuring 6.5 by 4.0 by 0.1 cm. RN #1 indicated he obtained an order for Xeroform followed by a protective dressing to the left foot, however he was unsure as to why the order was not transcribed into the eTAR. Interview with the Director of Nursing (DON) on 1/30/24 at 11:36 AM identified she reviewed the Facility Reported Incident form, and she noticed the order for Xeroform treatment to the wound on the form however she did not check to ensure the treatment order was transcribed into eTAR. The DON indicated it was the responsibility of the nurse to obtain the treatment order, transcribe the treatment order and administer the treatment as ordered. Review of the Physician/Prescriber Authorization and Communication of Orders to pharmacy policy directed facility should ensure that the person receiving a verbal order immediately records it in the resident's chart or electronic order system, including the date and time of the order, the name of Physician/Prescriber, and the signature of the person recording the order. All verbal orders should be recorded by a licensed nurse.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one of three sampled residents (Resident #2) who was dependent on staff for getting in and out of the bed and chair and was at risk for falls, the facility failed to follow the plan of care to ensure the resident was in a supervised area when out of bed. The findings include: Resident #2's diagnoses included Alzheimer's disease, history of falling, muscle weakness, and unsteadiness on feet. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or never made decisions regarding tasks of daily life, was dependent on staff with positioning from sit to stand, bed-to-chair transfer and had no falls since admission, entry, reentry or prior assessment. The Resident Care Plan dated 1/10/24 identified Resident #2 was at risk for falls related to a history of falls. Interventions directed Resident #2 should be in visible sight at all times whenever Resident #2 was out of bed. The nurse's note dated 1/19/24 at 7:00 PM identified the 3-11PM nurse aide came to the nurse's station stating she heard Resident #2 yelling and Resident #2 was on the floor, the nursing supervisor and charge nurse immediately went to Resident #2's room. The note indicated Resident #2 was lying on his/her right side with his/her head facing the closet and under the wheelchair with blood under Resident #2's head. The note identified Resident #2 was unable to tell the nurse what had happened or why he/she fell , 911 was called immediately, when the Emergency Medical Technicians lifted Resident #2 off the floor a laceration was noted above the left eyebrow and Resident #2 was transferred to the hospital. The nurse's note dated 1/20/24 at 12:05 AM identified Resident #2 returned from the hospital at 11:30 PM, Resident #2 was noted to have four (4) stitches above the left eye, bruising around bridge of the nose and a nasal fracture was reported. Interview with the 3-11PM nurse aide, Nurse Aide (NA) #2, on 1/29/24 at 3:17 PM identified she wheeled Resident #2 in his/her wheelchair from dining room to Resident #2's room to provide evening care and transfer Resident #2 to bed. NA #2 indicated she left Resident #2 in his/her wheelchair next to Resident #2 roommate's bed and stepped out of the room to get a johnny for Resident #2. NA #2 identified she stepped out to the closet located two (2) rooms away from Resident #2's room, and once at the closet she heard Resident #2 screaming. NA #2 indicated she went back to the room, saw Resident #2 on the floor on his/her right side, noticed blood coming out of Resident #2's right side of the face and notified a nurse. NA #2 identified she was aware Resident #2 was not to be left alone in his/her room however she thought she could go and grab the johnny because it was two (2) rooms down and come back. Interview with the Director of Nursing (DON) on 1/30/24 at 9:25 AM identified based on Resident #2's plan of care, Resident #2 should not have been left alone in his/her room while NA #2 left the room to get the supplies. Review of the Falls: Minimizing Risk of Injury Policy directed an individualized care plan will be develop and updated to identify interventions to prevent falls and minimize injuries. Review of Care Planning policy directed a comprehensive and individualized plan of care will be developed for each resident. The care plan will guide caregivers to assist residents to achieve or maintain their highest practical level of wellbeing.

Based on clinical record reviews, observations, facility documentation review, facility policy review and interviews for one of three residents (Resident #1), reviewed for abuse, the facility failed to ensure the resident was treated in dignified manner. The findings include: Resident #1's diagnoses included cerebral infarction with hemiplegia, vascular dementia, malignant neoplasm of bladder, anxiety disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition and was dependent of two (2) person assistance with ADLS, bed mobility, transfers, dressing, toilet use, and personal hygiene. The Resident Care Plan (RCP) dated 6/15/2023 identified Resident #1 was at risk for skin breakdown due to decreased mobility and incontinence. Interventions directed to provide incontinent care as indicated. A reportable event form and investigation dated 6/22/2023 at 10:00 AM identified during AM care, nursing staff overheard Resident #1 saying God, my back and NA #1 responded you are calling on God for your back, but you are the devil. The investigation summary identified NA #1 did not communicate in a dignified manner to Resident #1, and NA #1 was subsequently terminated from her position. Review of statement written by NA #1, dated 6/22/2023 identified when Resident #1 complained of back pain, NA #1 responded to Resident #1 by saying you are calling on God for your back, but you are the devil. NA #1 indicated she said it in a joking way to try to calm Resident #1. Interview with NA #6 on 9/15/2023 at 1:15 PM identified on 6/22/2023 when she and NA #7 were at the nurse's station she heard Resident #1 calling in a loud voice, help me, help me. NA #6 indicated she then heard NA #1 respond you are the devil or something similar with the word devil in the sentence. Interview with the DON on 9/10/2023 at 2:40 PM identified on 6/22/2023 NA #1 was alleged staff heard Resident #1 complain of back pain and NA #1 responded you are calling on God for your back, but you are a devil. The DON indicated the facility substantiated the comments and indicated NA #1 should not have spoken in that manner toward a resident; she indicated it was a dignity issue. Although attempted, interviews with NA #1, and NA #7 were unable to be obtained during survey. Review of the Resident Rights Policy identified residents have the right to be treated with consideration, respect and full recognition of your dignity and individuality.

Based on clinical record reviews, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2), reviewed for quality of care, the facility failed to ensure the resident was provided a weekly shower per the plan of care. The findings include: Resident #2's diagnoses included multiple sclerosis, left femur fracture, osteoarthritis, and depression. Review of the Hospital Discharge Summary dated 6/29/2023 identified Resident #2 may shower. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented, and required extensive assistance for personal hygiene. The Resident Care Plan (RCP) dated 7/14/2023 identified Resident #2 required assistance with ADL's (activities of daily living). Interventions directed to provide care as indicated. Additional review failed to identify a care plan that indicated Resident #2 refused care. Interview with Resident #2 on 9/15/2023 at 10:50 AM identified he/she did not receive a weekly shower since admission into the facility in July 2023 until 9/14/2023 after he/she requested the shower. Review of the facility shower schedule identified Resident #2 was scheduled to receive showers on the 3:00 PM to 11:00 PM shift weekly, on Tuesdays. Review of the nursing progress notes for the months of July, August, and September 2023, identified Resident #2 had no documented refusals of care/showers during the time from 7/1/2023 through 9/15/2023. Clinical record review of the NA Documentation in the electronic charting system for the month of July 2023, failed to identify showers were provided on Tuesdays during the 3 to 11 PM shift, in accordance with the weekly shower schedule for Resident #2. Further review failed to identify any date in July that Resident #2 was provided a shower. Although clinical record review of the NA documentation in the electronic charting system for the month of August 2023 identified NA #2 provied Resident #2 a shower/bath on 8/8, 8/11, 8/12, 8/17, 8/26 and 8/28/2023 during the 7 AM to 3 PM shift, review failed to identify showers were provided on 8/1, 8/8, 8/15, 8/22, and 8/29/2023, in accordance with the weekly shower schedule for Resident #1. Further review identified any date in Review of facility documentation identified NA #4 and NA #5 were assigned to Resident #2 on 8/1, 8/8, 8/15, 8/22 and 8/29/2023 on the evening shift (3:00 PM to 11:00 PM). Interview with NA #2 on 9/15/2023 at 11:20 AM identified she has never given Resident #2 a shower or bath. NA #2 indicated the documentation reflects that she gave Resident #2 a bed bath, likely with morning care, but verified she did not bring Resident #2 into the shower room and perform a regular shower/bath. Interview with NA #3 on 9/15/2023 at 11:35 AM identified NA #3 has never given Resident #2 a shower or bath. NA #3 indicated the documentation reflects that she gave Resident #2 a bed bath, likely with morning care, but verified she did not bring Resident #2 into the shower room and perform a regular shower/bath. Interview with NA #4 on 9/15/2023 at 12:30 PM identified she had never given Resident #2 a shower. NA #4 noted she will give Resident #2 bed baths as needed, but confirmed she has not provided a shower to Resident #2 during his/her stay at the facility. Interview with NA #5 on 9/15/2023 at 2:25 PM identified she has never given Resident #2 a shower but indicated he/she did refuse a shower one time about 2-3 months ago. NA #5 was unable to recall what day is Resident #2's shower day, but indicated she would follow the shower schedule to ensure residents receive a shower during her shift. Interview with DON on 9/15/2023 at 2:40 PM identified although showers are provided weekly, the DON was unable to explain why Resident #2 did not receive weekly showers. The DON indicated if a resident refuses a shower, it should be documented, and if it is not documented, it would be identified as not performed. Review of the Bathing/Shower Policy identified the facility will provide/offer each resident a full bath/shower at least weekly.

Based on clinical record review, review of facility documentation and interviews for one of three sampled residents (Resident # 60) reviewed for accidents, the facility failed to ensure the resident was free from an injury. The finding include: Resident #60's [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A physician's orders [REDACTED]. A care plan dated 03/22/17 identified the resident had poor safety awareness and had interventions in place that included to place a call bell within reach when in the bed and directed may use a standing mechanical lift with the assistance of two as needed. A quarterly MDS assessment dated [DATE] identified the resident had moderate cognitive impairment and required extensive assistance of two with transfers. The signed physician's orders [REDACTED]. A review of the Reportable Event dated 05/19/17 identified at 10:35 P.M. the resident was found lying in bed with the left side of her/his head on the call bell and the call bell clipper. The resident was noted with a moderate amount of blood coming from a scalp laceration on the left side of his/her head. Further review of the Reportable Event dated 5/19/17 identified pressure was applied to the area for 10 minutes to stop the bleeding. The resident's head was assessed and noted with a laceration to the head that measured 2.2 Centimeters (CM) in length and 0.2 CM in width with approximately a 0.2 CM in depth. Resident # 60 was sent to the hospital emergency department to be evaluated and returned to the facility with three staples to the left scalp laceration area. The call bell with the medal clip was removed and a flat call bell applied. A review of the facility investigation dated 5/19/17 identified NA # 10, in a written statement identified that Resident # 60 played with his/her call bell and clip in the past. The nurse's note dated 5/20/17 at 12:11 A.M. identified a NA at 10:35 P.M. asked the charge nurse to check on Resident # 60 who was noted with blood on the pillow, leaning with her/his left side of the head on the clipper of the call bell. A laceration was noted on the resident's head. Additionally, the nurse's note identified pressure was applied with ice for 10 minutes to stop the bleeding to the resident's head. The APRN was notified and directed to transfer the resident to the Emergency Department for an evaluation. The nurse's note dated 5/20/17 at 3:53 A.M. identified Resident # 60 returned to the facility with 3 staples to his/her left scalp. An interview with Nurse Aide (NA) # 10 on 08/22/17 at 3:44 P.M. identified she/he placed the resident in the bed sometime between 7:30 P.M. and 8:30 P.M. NA # 10 further indicated she/he transferred the resident by her/ himself from the wheelchair to the bed. NA # 10 also indicated she/he was not sure of what position she/he left the call light in but did note that she/he had not clipped the call bell to itself and/or to the bed. An interview with the Staff Development Nurse on 08/23/17 at 10:00 A.M. identified that when nurse aides are oriented they are instructed to loop the call bell over the side rail and use the clip to clip the call light cord to itself when a resident is in bed. The Staff Development Nurse indicated Resident #60 would play with the call bell at times but could not unclip the call bell and/or move the call bell to another position. The Staff Development Nurse further indicated that the resident required assistance to change position. An interview with the DNS on 08/23/17 at 1:04 PM identified the facility could not figure out what happened exactly during the incident but did acknowledge that sometimes the nurse aides clip the call bell to the bed when the resident is not in the bed and that when the resident was placed in the bed, the nurse aide may have inadvertently neglected to reposition the call bell and the resident was placed on the call bell in error.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #40) who were reviewed for an allegation of abuse, the facility failed to ensure the resident was free from an abusive action. The findings include: Resident #40's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified that Resident #40 had modified independence in decision making skills, required limited to total assistance with activities of daily living, and functional limitations in range of motion to one side of the body. The resident care plan dated 7/25/12 identified that the resident was not always able to communicate effectively related to the [MEDICAL CONDITION]. Interventions directed to use gestures to enhance the ability to understand, use short simple sentences, and ask yes and no questions and if not understanding what was being said, repeat the question. The nurse's note dated 7/29/12 at 1:45 PM identified that Resident #40 approached the nurse and showed his/her left wrist. Upon questioning, the resident acknowledged that a Nurse Aide (NA) #1 caused the wrist to be red and scratches were noted on the wrist. The nurse's note dated 7/29/12 at 4:00 PM identified that Resident #40 came to the nurses' station "very upset" and showed the left wrist. Observations at that time identified four visible fingerprint marks and two small scratches and the resident stated NA #1 squeezed the wrist and walked away without saying a word. The Social Service note dated 7/30/12 identified Resident #40 had reported that with both hands NA #1 grabbed the resident's left arm and held the arm down. The note identified that when the resident showed the Social Worker the wrist bruises were observed. The Reportable Event Form dated 7/29/12 at 1:45 PM identified Resident #40 presented with scratches and red marks to the left wrist, caused by a NA. The facility's investigation identified that NA #1 had stated Resident #40 grabbed her wrist and was saying something loudly, so NA #1 grabbed the resident's wrist and held it down. At the conclusion of the investigation NA #1 was terminated. Interview with the Nursing Supervisor, Registered Nurse (RN) #1 on 4/16/13 at 1:05 PM identified that Resident #40 approached her and showed her the left wrist. RN #1 stated that there were four visible fingerprint marks and two small scratches on the left wrist and the resident reported that NA #1 had grabbed his/her wrist. RN #1 further stated that when she spoke to the nurse aide, NA #1 stated that as she walking down the hall Resident #40 grabbed her wrist and therefore she (NA #1) grabbed the resident's wrist to remove the hand. Interview with the Director of Nurses (DON) on 4/16/13 at 1:00 PM identified that when Resident #40 grabbed NA #1's arm, NA #1 grabbed the resident's left wrist and held it down. The DON indicated that Resident #40 was aphasic and had difficulty communicating at times, but was not aggressive. The DON stated that NA #1 should have never held the resident's hand down.

Based on observation, review of the clinical record, review of facility documentation, and staff interviews for one of three sampled residents (Resident #31) reviewed for falls, the facility failed to assess the resident for the use of side rails and/or revise the plan of care to prevent an injury related to the use of siderails and/or resident behavior. The findings include: Resident #31's [DIAGNOSES REDACTED]. Review of the care plan dated 12/7/11 identified the resident was a fall risk with interventions that included to transfer with a mechanical lift and the use of two half siderails. The physician's orders [REDACTED]. The nurses' notes dated 1/17/12 at 11:30 PM identified the resident was sitting on the edge of the bed, and on 1/22/12 at 6:00 AM identified the resident was restless, removing bed linens and trying to get out of bed. Nurse's notes dated 1/18/12 and 1/19/12 indicated the resident was up in the wheel chair at the change of shift (11:00 PM) with wakefullness and/or restlessness. Facility documentation and the nurse's notes dated 1/25/12 identified Resident #29 was found kneeling at the beside at 4:00 AM with his/her arm caught in the siderail. Subsequently 911 was called, the resident was sent to the hospital and an open reduction and internal fixation for radius and ulnar fractures was performed. Interviews with Nurse Aide (NA) #1 and NA #2 on 3/28/12 at 4:15 PM and 5:10 PM indicated the resident was frequently found trying to get out of bed and/or up in the wheel chair when they arrived on shift at 11:00 PM. Further interview also noted that on the night of 1/25/12, NA #1 and NA #2 had repositioned Resident #31 approximately 10 to 20 minutes prior to finding the resident on the floor. Review of the Antipsychotic Monthly Flow Record for January 2012 identified the resident was monitored for agitation (0 episodes), hallucinations (0 episodes), playing in feces (0 episodes) and removing linens or briefs (3 episodes). Review of the Comprehensive Siderail assessment dated [DATE] with the Director of Nursing (DNS) and Registered Nurse (RN) #5 identified that the assessment was incomplete and lacked recommendations for the use of the siderails and/or a review for the appropriateness of the use of siderails. Review of the current care plan identified that although the resident's restless behavior, attempts to get out of bed and insomnia did not resolve with the medication changes on 1/17/12, no new interventions were implemented in the care plan to maintain the resident's safety from falls and/or injury related to the siderails and restlessness.