Every finding on record at Lions Rehab Center

Based on the review of a facility reported incident interviews, medical record review and review of facility policy, it was determined that the facility staff failed to ensure that medication was administered correctly. These failures led to the findings of actual harm to Resident #7. This was evident during the review of 1 of 1 Residents (#7) The findings include:Brief interview for mental status (BIMS) used to determine the individual's attention, orientation and ability to register and recall new information.Resident #7 was admitted to the facility with an assessed BIMS of 15, meaning that s/he was cognitively intact and would verbalize his/her needs and was self-directed in activities.Review of the facility reported incident 3013734 on 9:40 AM on 6/26/26 revealed and incident occurring on 5/13/26 where LPN #5 had prepared medications for the resident in bed 'A.' However, when she went in the room, the resident bed 'B' had a beverage spill, so she reportedly became distracted, went to bed 'B' to assist and set the cup of prepared medication for bed 'A' down on the bedside table assigned to bed 'B.' Once the mess was cleaned, she then gave the medications sitting on the bedside table for bed 'B' to resident in bed 'B,' Resident #7. LPN #5 proceeded to the hall like normal to sign off the administered medications and immediately noted the medication administration error. She checked on Resident #7 and notified the attending physician around 7:55 AM that at 7:45 AM she gave the resident the wrong medication. Not long after at approximately 8:10 AM, Resident #7 was wheeled into the hall for an appointment scheduled at 8:30 AM, and was noted to become lethargic with head drooping and became unresponsive. A call and subsequent order was placed for Resident #7 to be sent to the emergency room for further assessment and monitoring. Resident #7 was documented to arrive at the hospital with treatment in place by 9:00 AM on 5/13/26.According to the hospital admission records reviewed on 6/29/26 at 1:45 PM revealed that Resident #7 was in appropriately administered the roommate's Clozapine 100 mg, (an atypical antipsychotic that requires careful monitoring including lab work on prescribed individuals), and Amantadine 100 mg which can cause confusion and is filtered in the kidneys, potentially detrimental for someone with Kidney cell carcinoma which Resident #7 had. Upon arrival at the hospital resident Glasgow Coma Score (GCS) was 4. GCS is a clinical scoring tool used to objectively measure a person's level of consciousness and assess the severity of acute brain injuries. Scores range from 3, deep coma or death to 15, fully awake. Secondary to Resident #7's Do Not Resuscitate status, s/he was not intubated. On admission to the hospital, the diagnosis included adverse effects of drugs. Poison control was consulted by the emergency room and recommended supportive management as no antidote was available. The resident was hypotensive with blood pressure 70/40's. The resident was managed in the ICU for pancytopenia (a dangerous medical condition characterized by a shortage of all three major types of blood cells, though rare, a serious side effect of Clonazipine) requiring multiple transfusions, hypotension and hypothermia over the next several days as well as requiring norepinephrine (a strong vasoconstrictor to treat low blood pressure and shock) and IV fluids and received antibiotics along with transfusion support (blood products) for anemia (low blood count). Lab work, including complete blood counts that would show signs of pancytopenia, reviewed on 6/29/26 at 3:32 PM from Resident #7's admission to the facility revealed s/he was stable prior to this hospital admission. Resident #7 began to regain some mentation on 5/14/26, however after discussion with the POA and palliative care team, Resident #7 was placed on comfort measures only, with focus on symptom management. On 5/15/26 s/he continued with documented lethargy and required more blood transfusions. The facility was notified on 6/29/26 at 2:55 PM of the severity of the identified concerns of LPN #5 administering the incorrect medications to Resident #7 who then required a higher level of care including the use of resuscitative interventions after those medications were administered. At this time the facility DON reviewed the training the facility implemented and the new policy they developed on 5/13/26 for the 10 resident rights of medication administration. The education further elaborated into avoiding distractions as was the root cause determined in this incident. LPN # 5 received individual education from the facility ADON. The DON stated that the unit managers are supposed to be completing observations and audits of staff completing medication passes. The DON stated that all staff were educated on the facility policy of the 10 rights of medication administration, this was done by pop up educational in-services. A review of LPN #5's file, on 6/26/26 revealed that she was up to date on all of her training and education and had not had any other write ups or concerns in the past related to resident care or medications administration.

Based on record review and interview, it was determined that facility staff failed to ensure residents were free from abuse. This was evident for 1 (#1) of 4 residents reviewed for abuse.The findings include:On 6/26/26 at 10:59 AM a medical record review for Resident #1 revealed no evidence that the resident lacked capacity to make decisions. A review of the care plan revealed that on 10/21/25 a focus for the resident's hoarding behavior was initiated. There were interventions initiated on 10/21/25, however, no revisions since that time. A review of the psychiatric nurse practitioner (NP) #12's notes between 9/25 to time of survey revealed the resident had a generalized anxiety disorder. On 5/1/26 NP #12 documented he was visiting the resident due to staff concerns with the resident hoarding things. He documented that the resident reported they were keeping the stuff to sell and there were no interventions for the hoarding behavior suggested. A review of the attending physician's note for a visit conducted on 5/2/26 revealed no psychiatric concerns were documented.On 6/26/26 at 10:00 AM a review of the facility's investigation file for the facility reported incident #3026098 was conducted. A review of the initial report form revealed that on 5/27/26 the facility reported to the State Agency (SA) an allegation of abuse for Resident #1. The report documented that Resident #1 reported that when s/he returned from an appointment on 5/18/26, s/he was approached by staff to help clean out their room. The resident reported that during this room clean out s/he was injured by the Nursing Home Administrator (NHA) while struggling over a bag a food they were trying to throw away. The resident reported that it was a container of food that s/he purchased after their appointment earlier that day. A review of the statements provided by the staff who were present during the room cleanout revealed that when they started to throw away the resident's spoiled food containers that s/he became increasingly upset and anxious. At some point, the NHA came to the room to assist because the resident was yelling and screaming. He reported that he asked to see the food s/he was claiming to have bought that morning and it appeared to be moldy. While the NHA administrator was telling the resident they could not allow him/her to consume the moldy food, the resident attempted to grab the bag from the NHA. They struggled over the bag of food, causing it to rip and the contents to fall on the floor. The NHA documented that he became frustrated and handed the resident a $20 bill to cover the cost of the food and left the room. The final report documented Resident #1 reported that s/he had developed bruises on both wrists and facility staff assessed and documented the bruises. During an interview with Resident #1 on 6/26/26 at 10:27 AM, s/he reported that the bruising had come from the altercation with NHA #1 and that s/he became very angry every time s/he had seen him since.The Administrator in Training (AIT) was interviewed on 6/29/26 at 12:52 PM. She stated that she had assembled a team of staff to go to Resident #1's room on 5/18/26 to assist the resident to clean up due to some other residents complaining. She stated the resident was agreeable at first, but then as they were throwing spoiled food away, Resident #1 became belligerent. She reported that since she was not the Administrator, she asked someone to ask the NHA to come to the room. She stated that she witnessed the NHA telling the resident s/he was not allowed to have the spoiled food to consume and a struggle between the NHA and the resident over a bag of food occurred causing the contents to be spilled on the ground. She reported that she would not have handled the situation in that manner. She reported she did not think that abuse occurred because the NHA never touched the resident. Then the resident reported an allegation of abuse on 5/26/26 to her, the Regional Director of Clinical Services Staff, and the Social Services Director. The resident alleged that s/he was bruised during the altercation over the bag of food, however, since the AIT was present during the incident, she failed to report the allegation of abuse. Furthermore, there was no assessment of the resident's injuries at the time of the allegation.An interview with the Social Worker (SW) on 6/26/26 at 12:06 PM revealed that she was asked by the AIT to be a witness to the room clean out for Resident #1. She stated that when staff started throwing away the resident's food containers, the resident became belligerent. She was asked by the AIT to get the NHA to assist. When he came into the room, the ADON was handing the resident a bag of food that had been thrown in the trash, and he took the bag from the resident. She reported that she heard the NHA tell the resident that he, the NHA, was not going to allow him/her to consume spoiled foods. She stated she did not see exactly what happened next but a struggle between the two occurred over the bag of food. The bag broke and the contents spilled on the floor. She stated the NHA took money out of his pocket and handed it to the resident as payment for the food. When asked if she had concerns about the interaction, she stated they all had concerns and talked afterward. When asked why this was not reported, she stated that it was witnessed by the AIT.An Interview with Assistant Director of Nursing (ADON) on 6/26/26 at 1:09 PM revealed that she was present in the room during the attempt at cleaning the Resident #1's room on 5/18/26. She reported the same incident as the other staff. When asked why she had not reported the incident, she stated that she knew the NHA did not mean any harm. However, she admitted to being taken aback by what she had witnessed and if she had seen that with any other staff member she would have removed them from the unit and reported abuse.An interview with the NHA on 6/30/26 at 2:25 PM revealed that he was called to Resident #1's room on 5/18/26 because staff found spoiled food in the room and the resident was upset that they were throwing it out. He stated that when he got to the room, he asked to see the bag of food the resident was reporting that s/he had just purchased that day. He stated that he looked at it and it had what appeared to be mold growing on it. He stated that he told the resident that she could not have the food because it was spoiled. He stated that the resident was upset and yelling and they struggled over the bag of food. This caused the bag to tear, and the content spilled on the floor. When asked if the resident was capable of making his/her own decisions, he stated that the resident was capable, but he was not going to allow the resident to eat spoiled food.The Director of Nursing (DON) was Interviewed on 6/26/26 at 12:08 PM. She reported she had no knowledge of the events that occurred on 5/18/26 or the allegation of abuse that was reported on 5/26/26. She stated that when she received the allegation of abuse on 5/27/26, she went to the Regional Director of Clinical Services. She reported she did so because it involved the NHA.An interview with the Regional Director of Clinical Operations on 6/29/26 at 1:52 PM revealed she was present at the meeting on 5/26/26 with the resident, the AIT and SW. She stated that the resident was complaining about the altercation with the NHA, but she doesn't recall the resident talking about being bruised. However, she talked with the staff members who were present, to include the NHA, and she decided that the allegation of abuse had not warranted a report to the SA. The next day on 5/27/26 when the resident reported the same allegation of abuse to the Maintenance Director, it was then reported. When asked what the difference was between what was reported on 5/26/26 to what was reported the next day, she stated it was the context. She further stated that she does not report all allegations of abuse because it can hurt people, she stated she investigates them first to determine if they should be reported or not. Cross Reference: F609

Based on the review of a facility reported incident 3054507, medical record review, interview with facility staff, it was determined that the facility failed to ensure that residents medications were secure, maintained and free from misappropriation. This was evident for 1 of 2 (9) residents reviewed for medication misappropriation during a complaint survey. The findings include:Brief interview for mental status (BIMS) used to determine the individual's attention, orientation and ability to register and recall new information. Resident #9 was recently admitted to this facility for rehabilitation and pain management. S/he was assessed on admission as having a BIMS of 15, meaning that s/he is cognitively intact. Resident #9 was also noted as his/her own responsible party. Review on 6/30/26 at 11:50 AM of the facility reported incident 3054507 occurring on 6/21/26 during the 7:00 PM shift change between LPN#6 who was leaving and LPN #17 who was returning after leaving that morning. When the narcotic count was completed on shift change that morning between LPN #6 and LPN #17 there were no noted discrepancies. However, upon LPN #17's return, when the count was completed, there were 2 controlled substances missing and unaccounted for. The Unit manager and DON as well as the patient were notified and the facility was searched for the missing medication, however it was not located. LPN #6 was suspended during the investigation. The DON's documented investigation and interviews with LPN #6 in the facility investigation packet revealed that LPN #6 who was responsible for the medications at the time they went missing, self-reported to have a history of leaving both the medication cart and the secure narcotic box unlocked and unmonitored while in charge of said medication cart. LPN #6 was terminated from the facility. Record review of Resident #9's medication administration record (MAR) as well as interviews with the resident on 6/30/26 at 11:50 AM revealed that s/he did not miss receiving the administration of any medication and further had no verbal effects of pain from potentially missing medication from this incident. The DON was interviewed on 6/30/26 at approximately 1:00 PM regarding the missing medications. She verbalized that the facility replaced the medications and that the resident never went without pain medication. The concern that a controlled medication went missing and the LPN admitted to not following the facility policy, after a new policy was implemented on 5/13/26 was reviewed. We reviewed the training at this time and LPN #6's name was on the education sign in sheet from the 5/13/26 in-service for Safe Medication Administration Guide which included storing medications safely.

Based on interview and record review, it was determined that facility staff failed to report all allegations of abuse to the State Agency (SA) as required. This was evident for 1 (#1) of 4 residents reviewed for abuse.The findings include:During an interview with Resident #1 on 6/26/26 at 10:27 AM, s/he reported that the bruising had come from the altercation with NHA #1 and that s/he became very angry every time s/he had seen him since.During an interview with the Administrator in Training (AIT) 6/29/26 at 12:52 PM regarding the facility reported incident #3026098, she reported that she had witnessed a verbal and physical altercation between Resident #1 and the Nursing Home Administrator (NHA) on 5/18/26. She stated she failed to report this altercation as abuse because she knew that the NHA had no ill intentions. She further reported that during a meeting with Resident #1, the Social Services Director, and the Regional Director of Clinical Services, the resident reported that s/he had bruising on both wrists from the physical altercation with the NHA. She stated that she failed to report the allegation of abuse because she had been present during the altercations and the bruises had not come from the altercation. An interview with the Social Services Director on 6/26/26 at 12:06 PM revealed that she was present during the room clean out and witnessed the verbal and physical altercation between the resident and the NHA. She reported she had concerns about the interaction, she stated they all had concerns and talked afterward. When asked why this was not reported, she stated that it was witnessed by the AIT. In addition, she reported she was at the meeting on 5/26/26 with the AIT and Regional Director of Clinical Services and heard the allegation of abuse from Resident #1. She thought that it was reported to the SA after the meeting.An interview with the Regional Director of Clinical Operations on 6/29/26 at 1:52 PM revealed she was present at the meeting on 5/26/26 with the resident, the AIT and SW. She stated that the resident was complaining about the altercation with the NHA, but she doesn't recall the resident talking about being bruised. However, she talked with the staff members who were present, including the NHA, and she decided that the allegation of abuse had not warranted a report to the SA. On 6/26/26 at 10:00 AM a review of the facility's investigation file for the facility reported incident #3026098 was conducted. A review of the initial report form revealed that on 5/27/26 at 11:00 AM the facility reported to the State Agency (SA) an allegation of abuse for Resident #1. The report documented that Resident #1 reported that when s/he returned from an appointment on 5/18/26, s/he was approached by staff to help clean out their room. The resident reported that during this room clean out s/he was injured by the Nursing Home Administrator (NHA) while struggling over a bag a food they were trying to throw away. The resident reported that it was a container of food that s/he purchased after their appointment earlier that day. A review of the statements provided by the staff who were present during the room cleanout revealed that when they started to throw away the resident's spoiled food containers that s/he became increasingly upset and anxious. Based on the NHA's statement, at some point he came to the room to assist because the resident was yelling and screaming. He wrote that he asked to see the food the resident was claiming to have bought that morning and it appeared to be moldy. While the NHA administrator was telling the resident they could not allow him/her to consume the moldy food, the resident attempted to grab the bag from the NHA. They struggled over the bag of food, causing it to rip and the contents to fall on the floor. The NHA documented that he became frustrated and handed the resident a $20 bill to cover the cost of the food and left the room. The final report documented Resident #1 reported that s/he had developed bruises on both wrists and facility staff assessed and documented the bruises.On 7/1/26 at 1:18 PM the concerns were reviewed with the AIT and Regional Director of Clinical Services.Cross Reference: F600

Based on observation, resident interview, record review, and staff interview, it was determined that facility staff failed to ensure that residents had behavioral health services to help achieve their highest practical level of functioning. This was 1 (#1) of 1 resident reviewed for behavioral health concerns.The findings include:Diagnostic and Statistic Manual of Mental Disorders V - the following criteria for hoarding disorder:Persistent difficulty discarding or parting with possessions, regardless of their actual value.This difficulty is due to a perceived need to save the items and to distress associated with discarding them.The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder). Care plan - is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Person-centered care: means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.During an observation on 6/26/26 at 8:15 am of Resident #1, the resident was observed asleep in bed. There was a breakfast tray sitting on a rollator as there was no room to place it on the over-the-bed table or bedside stand. Due to the items piled up in the room, there was no pathway to get to the over-the-bed table or the bedside stand. There was approximately a 30 to 45 degree angled path from the middle of the bed to the foot of the bed that opened to the center of the room, however, there was no straight path to the head of the resident's bed. On the right side of the bed was a rollator walker holding the breakfast tray and behind it was a dresser that was completely covered with items. There were 3 reusable shopping bags full of items sitting in front of the window. There were other items that were so many it was difficult to identify them that filled the space between the bags and the bedside stand.A medical record review on 6/26/26 at 10:59 AM for Resident #1 revealed the resident was admitted in May 2025. A review of the care plan revealed on 10/21/25 Registered Nurse (RN) #8 initiated a care plan for hoarding behaviors. The goal was that the resident's inappropriate behaviors will be managed with minimal stress for the resident and others, which was not a resident-centered goal. The interventions were all initiated at the time of the care plan was developed and included the following; distract the resident with conversation, singing, something warm and comforting to hold, etc.; document behaviors and effectiveness of interventions before using medications; monitor behavior for clues; look for time, location, activity at time, environmental factors, others and their responses; set limits prior to provision of care; explain/review what behavior is appropriate and inappropriate; and Social Worker to visit with resident and/or family as needed.Further review of the care plan meeting notes, physician visit notes, Psychiatric Nurse Practitioner Staff #12's visit notes for 9/16/25, progress notes dates 10/1/25 - 10/21/25, nursing assistant behavior documentation and the medication/treatment administration records for 8/25, 9/25, and 10/25 revealed no evidence as to why the hoarding care plan was initiated.A review of psychiatric consult notes, since the time of admission to current, revealed the resident was visited by a psychotherapist and a Licensed Certified Social Worker - Clinical, however, there was no indication in their notes that the resident was receiving therapy for hoarding behaviors. The visits were conducted by telehealth; therefore, they had not been in the resident's room to observe the hoarding behaviors. A visit conducted by Staff #12 on 5/1/26 revealed that facility staff had a concern with the resident's hoarding behavior. However, there was no documentation regarding what he observed in the resident's room. He stated the resident denied hoarding behaviors and stated s/he was keeping the items to sell later. Staff #12 documented on 6/5/26 that he was asked to see the resident due to staff to patient conflict, however, there was no indication in the notes that he had discussed with the resident what occurred during the conflict and noted that the resident was not in psychosocial distress.A review of facility investigation file for a facility reported incident #302098 dated 5/27/26 revealed that on 5/27/26 Resident #1 alleged s/he was injured during an altercation with the Nursing Home Administrator over some bags of food. The final report stated that management approached Resident #1 as a team to assist him/her with cleaning out their room.On 6/30/26 at approximately 2:50 PM an interview with Resident #8 revealed s/he was residing in the same room as Resident #1. The resident reported that while they got along with Resident #1, the clutter coming to his/her side of the room, the smell, the pest that the stored food attracted was too much. Resident #8 reported that s/he had asked for a transfer and when s/he was told there were no other rooms available she requested to move to another facility because the living conditions were so bad. An interview with certified nursing assistant II (Aid) #9 on 7/2/26 at 9:34 AM revealed that she could not recall when Resident #1's hoarding behaviors became apparent. She stated that upon admission the resident would not allow them to take his/her meal tray until the next one was delivered. She stated that this posed an issue in the evenings since there were no more trays until breakfast and would result in the resident having a meltdown by yelling and screaming at staff. She stated that they would report to the nurse, but when they tried to intervene the resident would become argumentative and hostile with them. She stated at some point the resident was accumulating so much stuff in his/her room and staff were unable to figure out where the resident was getting the stuff from because the resident had not had many visitors. She reported the resident was observed by another certified nursing assistant getting into a van in the parking lot and taking stuff out. Aid #9 recalled the first time she observed the van in the parking lot, she could see in the windows and now she couldn't. Aid #9 reported that more recently NHA #1 and the Administrator in Training (AIT) had told the resident a timeframe that s/he had to clean out the stuff in his/her room. She reported that the resident's meltdowns had become more frequent in the past month. She reported she had not had training on hoarding or how to deal with these behaviors.During an interview with Aid #14 on 6/30/26 at 1:00 PM, she reported that Resident #1 was hoarding shortly after arrival in May 2025. She was unsure when the resident's van was brought to the facility. She stated that she and other staff were concerned about the resident's safety due to the amount of things s/he had collected. When asked about training, she reported there had been no training given on how to deal with the resident's behaviors.An interview on 7/2/26 at 10:05 AM with Registered Nurse (RN) #10 revealed she was unable to recall when the resident's hoarding became an issue or when the van showed up. She stated that she was aware of the issue with food hoarding since admission. She stated that it was after the resident was transferred to a 4-person room that his/her things started to pile up. She reported the same behaviors regarding food that Aid #8 reported. When asked about the van, she reported that once they noticed the van the resident seemed to be accumulating more items in the room. RN #10 reported that the resident had meltdowns with screaming and yelling but does not always share the reason and would become hostile when asked. She failed to document these behaviors in the resident's medical record. She reported that she thought the resident was being seen by Psychiatric Nurse Practitioner Staff #12 for hoarding behaviors, however based on the notes and interviews this was not the case. She reported the facility had not given any training on how to deal with the resident's behaviors.During an interview with RN #8, who was the MDS nurse, on 7/2/26 at 10:36 AM she reported that she was not certain why she had initiated the care plan for hoarding. She stated it was possible it was a result of discussing the resident during the facility staff's morning clinical meetings. She reported she had little knowledge of the resident's behaviors and when they started. The interventions listed on the care plan were reviewed and she reported that they were generalized interventions that had not been customized for the specific resident. When asked if she was responsible for updating the care plan, she reported updates were done by the care plan team. An interview on 7/2/26 at 10:58 AM with ADON #11 revealed she was part of the care plan team. She stated she was responsible for reviewing the resident's care plans, goals, and interventions to prepare for the quarterly care plan meetings. She could not recall when the facility identified Resident #1's hoarding behaviors or when the resident's van showed up. The Director of Nursing (DON) reported on 6/30/26 at 2:00 PM that she took a stand off approach to the concerns with Resident #1's hoarding behavior. Further reporting that she had not wanted any nursing staff involved, but the Nursing Home Administrator (NHA) kept asking the floor nurse, who was frequently assigned to the resident, to help intervene. She stated that she felt it was more of a safety issue and not a clinical issue.An interview with the Social Services Director Staff #16 on 6/26/26 at 12:06 PM revealed she was unaware as to whether Resident #1 had been diagnosed with hoarding or not. She reported she thought that Psychiatric Nurse Practitioner #12 was working with the resident regarding the hoarding behaviors. She stated she does not provide counseling to the residents because they have a contractual Licensed Certified Social Worker (LCSW). When asked about the incident that occurred on 5/18/26, when staff attempted to clean out the resident's room and the resident was crying and screaming, according to multiple written statements from staff. She reported she was not there to support the resident in a social services capacity, but to act as a witness for administration. Furthermore, prior to the 5/18/26 incident and after, the Social Services Director failed to report the hoarding behaviors and the resident's responses to staff when they tried to intervene to Psychiatric Nurse Practitioner #12 or to the LCSW to ensure the resident's mental illness/behavioral health concerns were addressed. During an interview with the Nursing Home Administrator (NHA) on 6/30/26 at 2:25 PM, he reported that some staff had gone to the resident's room on 5/18/26 to help the resident clean out the unsafe things that were in the room. He reported that some people thought the resident was a hoarder. He stated that when the resident did not allow staff to throw away spoiled food, he went in to intervene. During which time he reported the resident was yelling and screaming and a back and forth occurred over a bag of spoiled food. He stated that he was aware the resident had capacity to make his/her own decisions, but told them he was not going to allow them to consume spoiled food. An interview with Psychiatric Nurse Practitioner Staff #12 on 7/2/26 at 8:55 AM revealed that he relied on information provided by facility staff when they requested a consult from him. He reported that he was able to diagnose residents with mental disorders. He stated that he was asked once to see Resident #1 for hoarding behaviors. At that time, he noticed the resident had boxes piled to the ceiling, however, because the resident denied that s/he was hoarding he did not offer treatment. He admitted that people with hoarding often deny that they have an issue. He reported that staff had not informed him that the resident often had meltdowns with screaming and yelling when staff attempted to remove items from his/her room. He was informed of the incident that occurred on 5/18/26, when staff attempted to throw out spoiled food and described the resident as becoming belligerent and refusing to allow them to continue and ultimately resulted in the resident screaming and crying and trying to take a bag of food back. He stated with this information he would have diagnosed the resident with hoarding, prescribed a serotonin reuptake inhibitor (a psychotropic medication that will help the resident's underlying condition causing the hoarding) and prescribe cognitive behavioral therapy.During a subsequent interview with the DON on 7/6/26 at 1:47 PM she was asked why nursing staff failed to document the hoarding behavior. She was informed of the locations the surveyor had reviewed in the medical record. She stated that she was unaware that the certified nursing assistants behavior charting included a code for hoarding behavior. She stated that her expectation was for nursing staff to document the behaviors on the medication or treatment administration record or write a progress note. She reported that they will add a resident's name to a hot charting list, which meant the nurse was to document behaviors every shift for 72 hours. She agreed this information was vital to help medical providers make diagnoses and provide treatment as needed. In addition, she reported that nurses assigned to the residents were expected to update care plans, however, she thought there was a lack of training on how to access and update them. She reported this may be the reason staff failed to update the resident's care plan with behaviors and create interventions to help the resident.An interview with the Administrator in Training (AIT) revealed she was aware of the hoarding and that it had been going on for a long time. She stated that when the NHA asked staff to intervene she thought she would assist with the process and formed a team to go to the resident's room and help the resident clean out. She reported on 5/18/26 when they went to the resident's room to help clean up, the resident had spoiled food stored in bags in the room. She stated the resident became belligerent and upset when they tried to get rid of the food, even though it was not safe to keep it. She reported that there was a bag of food that was moldy and the resident insisted that s/he bought the food that morning at the hospital. The resident tried to pull the bag away from the NHA and was screaming and yelling at him. However, the 5 staff members (AIT, NHA, ADON, RN, and Social Services Director) who were present during the 5/18/26 incident failed to report this information to the Psychiatric Nurse Practitioner Staff #12 when he was asked to see the resident after the incident.

Based on observation, record review, and interview, it was determined that facility staff failed to follow the physician's ordered therapeutic diet for their residents. This was evident for 1 (#5) of 1 resident reviewed for dietary services.The findings include:On 6/26/26 at 8:35 AM an observation of Resident #5 revealed the resident was sitting in a chair in his/her room and the aid was setting up the resident's breakfast tray. The resident had pureed cereal with milk, a pureed biscuit, and regular scrambled eggs. A medical record review for Resident #5 on 6/26/26 at 8:51 AM revealed in the orders tab a physician's order that stated, Consistent Carbohydrates diet, Dysphagia Mechanical Soft texture, Regular consistency and no bread or crunchy foods. The order was dated 2/20/26.A review of the meal tickets for 2 weeks prior to 6/29/26 for Resident #5 on 7/1/26 at 12:48 PM revealed the resident's diet was listed at the top of the slip, however, the instructions for no bread or crunchy food were not included. Further review revealed there were meals that had pureed breads or bread-like products included on the meal ticket. However, on 6/26/26, the day the surveyor observed the resident breakfast tray, the resident's meal ticket showed s/he was to be served a cup of fresh fruit and no biscuit.On 7/1/26 at 9:20 AM an interview with the contracted dietary company's Regional Dietitian revealed that when a resident's orders state no bread or crunchy foods then there should be no breads to include pureed breads. She stated that these types of directives usually were from a speech therapist and were to be followed.The Dietary Manager was interviewed on 7/2/26 at 2:01 PM with the Administrator in Training (AIT) present. He reported that he was not sure why it did not show up on the ticket that there should be no bread or crunchy foods for the resident. He stated that sometimes with meal tracker he will mark no breads, but some breads would still show up on the meal tickets. The AIT was made aware of the concerns at this time.

Based on observations and interviews, it was determined that the facility failed to post nursing staffing for the entire building. This was observed during the survey.The findings include: On 6/26/26, at approximately 8:04 AM, an observation of the facility's main lobby was conducted. There was no observed staffing posted at the time. Continued tour and observations of the facility revealed that there was construction in progress where the main desk in the front entrance was no longer present and makeshift tables were in place where the nurses would sit throughout the day to document. There was no observed staffing posted at this time, nor were there any noted posted throughout the remainder of the facility. The survey team, upon entrance and meeting with the facility DON and NHA, requested staffing schedules for 06/26/26 and the following week. A review of these schedules revealed that the rooms assigned to the staff are not always filled in. Additionally, the print on the schedule included the entire day's schedule, day, evening and night on the front of the page, equating to over 40 lines of staff to sift through to determine who is caring for which resident. A normal sheet of notebook paper that is college ruled has a max of 34 lines, while wide ruled paper has a max of 24 lines for reference. On 6/30/2026 at 10:20 AM a staff schedule was observed posted in the lobby area by the makeshift nurse desks on a cart where the medical charts were stored. It was the same type of schedule provided to the survey team, secondary to the small font, the schedule remained illegible from regulatory standpoints. Continued observations of the nursing stations at the back of the facility failed to display any type of schedule. GNA #18 was interviewed on 6/30/26 at 10:35 AM regarding the lack of posted staff schedules and assignments. He stated that there used to be a board on the wall, where there are now two pictures of boats. So now they just lay it down at the nurse's station. During this time the maintenance director was walking by. GNA #18 asked him, 'what happened to the boards.' The maintenance director replied that they must have come down during all the renovations. The facility ADON was then interviewed at 10:37 AM. She stated that the form the surveyors were shown at this moment was for the in-house staff to use and she was not sure if that was for posting for the residents/visitors/families to use but did say the boards were ordered. This surveyor spoke with The Regional Nurse Consultant at 10:45 AM on 6/30/26 regarding the observations and findings. She verbalized understanding and referred this surveyor to the posting on the cart with the resident medical charts. The identified concerns with the legibility for all, as well as the concern of the lack of posting in all required locations was reviewed at this time and again during exit.

Based on observations and interviews it was determined that the facility failed to maintain a safe/clean/comfortable/homelike environment for Residents. This finding was found to be evident in 2 (Resident rooms [ROOM NUMBERS]) out of 15 Resident rooms and in review of an adequate supply of linen which has the potential to affect all Residents in the facility. The findings include: On 3/23/2026 at 10:45 AM the surveyor observed that the call light panel cracked in the Resident shared bathroom of room [ROOM NUMBER]. In the Resident shared bathroom of room [ROOM NUMBER] at 10:55 AM on 3/23/2026 the surveyor observed a large crack in the cover to the ceiling light. In an interview with the Regional Maintenance Director at 9:20 AM on 3/26/2026, the surveyor conveyed that the call light panel and the ceiling light cover were cracked in Resident shared bathrooms on the 300 hall. The Maintenance Director toured the 300 hall with the surveyor and observed the cracked call light panel in room [ROOM NUMBER], and the cracked ceiling light cover in room [ROOM NUMBER]. The Maintenance Director stated that he would get right on fixing these items. In a follow up interview with the Regional Maintenance Director at 10:08 AM on 3/26/2026 he stated that the ceiling light cover was replaced and that he had to order the call light panel. No additional information was provided by the facility at the time of survey exit. On 03/26/2026 at 7:11 AM, GNA #13 and GNA #18, told the surveyor that the facility never had enough washcloths to bathe residents. The surveyor observed that the supply closet contained no washcloths. The surveyor interviewed Staff #30 on 03/26/2026 8:40 AM. Staff #30 confirmed a shortage of washcloths, and stated the facility ordered 600 per month, which was never enough. The surveyor observed that the emergency linen supply did not have any washcloths. During an interview on 03/26/2026 8:53 AM, the Licensed Nursing Home Administrator stated they were aware of the linen shortage and were increasing the supply for daily use and for emergency linen.

Based on observations, interviews and record reviews, it was determined that the facility failed to follow appropriate respiratory care and services. This was found to be evident in 4 (Resident #2, 3, 8 and #11) out of 5 Residents reviewed for respiratory care.The findings include: On 03/23/2026 at 12:06 PM Resident #8 was observed in bed with an oxygen concentrator in use. The oxygen tubing was not labeled and dated and there was no oxygen in use signage on the Resident room door.At 1:02 PM on 3/23/2026 the surveyor observed Resident #2 in his/her room with an oxygen concentrator in use. There was no oxygen signage on the Resident room door. Additionally, the oxygen tubing was not labeled and dated.In an interview with staff nurse #9 at 1:10 PM on 3/23/2026 the surveyor asked what the expectation was for oxygen in use signage on Resident room doors when the Resident was using oxygen. Staff nurse #9 stated that there should be an oxygen sign on the Resident room doors and that he/she would look for oxygen signs.At 1:26 PM on 3/23/2026 the surveyor observed Resident #11 in bed with an oxygen concentrator in use. There was not an oxygen sign posted on the Resident room door/door frame and the oxygen tubing and humidifier bottle were not labeled and dated. The surveyor observed Resident #3 in his/her room with an oxygen concentrator in use at 3:04 PM on 3/23/2026. There was no oxygen signage posted on the Resident room door.In an interview with the Director of Nursing at 3:30 PM on 3/23/2026 the surveyor conveyed that there were several Residents who had oxygen in use in the facility and that there was no oxygen in use signage on the Resident room doors/doorframes. In addition, oxygen tubing and humidifier bottles were not labeled and dated. DON acknowledged surveyor.On 3/23/2026 at 4:15 PM the surveyor reviewed the facility's oxygen policy titled Oxygen Administration dated February 2026, and the policy revealed to place a No Smoking / Oxygen in Use sign on the outside of the room entrance door and in a designated place on or over the Resident's bed.Additionally, the surveyor reviewed the physician orders for Resident #2, #3, #8, and #11 on 3/24/2026 at 7:30 AM and all 4 Residents had physician orders for continuous oxygen by nasal cannula tubing, and to change tubing, mask and/or nasal cannula weekly, may change sooner as needed.No additional information was provided by the facility at the time of survey exit.

Based on record review and interviews it was determined that the facility failed to provide a resident with reasonable accommodation of need. This was found evident in 1 (for Resident # 42) of 6 facility-reported incidents reviewed on the survey. The findings include: On 3/26/26 at 7:18 AM, the surveyor reviewed the facility's investigation file in regard to an allegation of abuse/neglect of Resident #42 by a staff member on 3/7/26. On further review a statement was written by Geriatric Nursing Assistant (GNA) #32 that stated while attempting to assist Resident #42 to the bathroom it was noted that his/her bathroom was under construction so a bed pan was given. Next the surveyor reviewed Resident #42's care plan. A care plan was created on 3/9/26 that stated, Resident #42 has Activities of Daily Life (ADL) self-care deficit. One of the interventions listed was to assist to the toilet/commode. Additionally, it stated Resident 42 needed maximum assistance of 1 staff for toileting. On 3/36/26 at 10:59 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON stated when Resident #42 was admitted to the facility, his/her bathroom was out of order due to the floor needing time to set as it was newly renovated. She further stated that a commode should have been available for Resident #42 to utilize while the bathroom was out of commission.

Based on record review and interviews, it was determined that the facility failed to ensure that a Resident's Responsible Party (RP) was notified of changes in a resident's condition. This was evident for 1 (Resident #96) of 3 residents reviewed for wound care during the survey. The findings include: On 3/24/26 at 10:48 AM, the surveyor reviewed a complaint and a facility reported incident into allegations that Resident #96 did not receive appropriate care. Next the surveyor reviewed Resident #96's medical record. The review revealed that on 12/5/25 the attending physician determined that Resident # 96 was unable to comprehend and make medical treatment decisions. On further review it was noted that Resident #96 had an Advanced Directive that named a healthcare power of attorney. In the progress notes the surveyor noted a wound provider documented seeing Resident #96 on 12/10/25 and addressed a new wound found on Resident #96 {genitalia}. The surveyor also noted a change of condition note written by Registered Nurse (RN) #34 on 12/10/25 regarding the new wound found on Resident #96's {genitalia}. In the section that documents that the Resident Representative (Responsible Party) was notified, RN #34 wrote, Resident is alert and oriented-refused to have family notified said thats (sic) my {genitalia} and I don't want to tell them. On 3/25/26 at 8:09 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that Resident #96's RP was not notified of the new skin conditions for Resident #96 and the PR had concerns about the treatment of wounds. The DON confirmed that the RP should have been notified when the new skin condition was found and the treatment that were needed.

Based on observations and interviews it was determined that the facility failed to ensure the personal privacy of a Resident. This finding was found to be evident in 1 (Resident #11) out of 2 Residents reviewed for urinary catheters.The findings include:Urinary Drainage Bag collects urine from a catheter designed to be kept below bladder level to present backflow and infections. Urinary drainage bags hang on the bedframe or wheelchair.At 1:23 PM on 3/23/2026 the surveyor observed Resident #11 in bed with a yellow substance in the urinary drainage bag hanging on the bedframe. On 3/24/2026 the surveyor observed Resident #11 on a stretcher in the hall outside of room [ROOM NUMBER] with the urinary drainage bag in view.Care Plan is a personalized comprehensive roadmap addressing an individual's health, social, and functional needs. It covers activities of daily living (ADL), assessment of needs, safety modifications, health and medical care, including diagnoses. Care plan must be reviewed regularly and updated to reflect changes in health status or care needs. The care plan includes problems, goals, interventions and evaluations.The surveyor conducted a record review of Resident #11's medical record on 3/26/2026 at 7:15 AM. Review of the medical record revealed that Resident had a physician order dated 1/1/2026 for catheter bag to gravity drainage below level of bladder and catheter care every shift. Further review of the medical record revealed that Resident #11 had a care plan for a catheter with an intervention to position catheter bag and tubing below the level of the bladder with privacy bag.In an interview with the Director of Nursing (DON) at 10:30 AM on 3/26/2026 surveyor conveyed that Resident #11 had a catheter and urinary drainage bag, but there was not a privacy bag on the urinary drainage bag. The DON accompanied the surveyor to Resident #11's room where Resident was observed in bed with the urinary drainage bag hanging on the bedframe without a privacy bag. The surveyor asked the DON what the expectation was for privacy bag coverings on urinary drainage bags, and the DON stated that the urinary drainage bag should be in a blue colored privacy bag that covered the urinary drainage bag. The DON acknowledged that the urinary drainage bag for Resident #11 was not covered with the blue privacy bag.No additional information was provided by the facility at the time of survey exit.

Based on review of the facility's investigation report, record review, and interviews, it was determined that the facility failed to protect a resident from verbal abuse and neglect from an employee. This was found evident on 1 (Resident #42) of 4 Residents reviewed for abuse and neglect. The findings include:On 3/26/26 at 7:18 AM, the surveyor reviewed the facility's investigation file into the allegation that Geriatric Nursing Assistant (GNA) #31 verbally abused and refused to provide care to Resident #42. The conclusion to the investigation stated that the allegation was verified by evidence collected during the investigation.Next the surveyor reviewed the statement given by GNA #32. GNA #32 reported she was asked to help pull Resident 42 up in bed with GNA #31 on the morning of March 7th, 2026. While entering Resident #42's room, GNA #32 heard Resident #42 state It's been a long time since I have been asking you to help me use the toilet. Please, I need to pee, otherwise, I am going to pee myself and the bed. GNA #32 reported the response of GNA #31 was, And I told you that I am serving breakfast trays, so go ahead and pee the bed, I will clean you up. GNA #32 reported returning to her assignment and later returning to Resident #42's room to pick up breakfast trays. GNA #32 asked if #42 was done with his/her tray and he/she stated, I still need help to use the bathroom, I badly need to be, I think I started to wet myself.Further review of the investigation file had statements from Resident #6, Resident #49 and Resident #13, whom all stated they had concerns with how GNA #31 provided care and/or spoke to them. Resident #42 was not able to recall the incident.On 3/26/26 at 8:12 AM, the surveyor interviewed Resident #42 and confirmed that he/she would not remember the allegation on 3/7/36.On 3/26/26 at 8:21 AM, the surveyor interviewed Resident #13. During the interview Resident #13 stated that if he/she had ask GNA #31 for anything and he/she was in a bad mood GNA #31 would get upset and say, I hate my job. Resident #31 stated that he/she was scared to ask for help because he/she did not want to get GNA #31 all worked up.On 3/26/26 at 8:26 AM, the surveyor interviewed Resident # 6. During the interview Resident #6 stated that GNA #31 would offer to give a bath and stated that he/she would come back and would not return until the afternoon. Resident #6 also stated that GNA #31 would tell Resident #6 that he/she did not have time to change him/her and would do it when he/she came back. Resident #6 stated that he/she was scared to ask for things because he/she would be told no.On 3/26/26 at 8:32 AM, the Surveyor interviewed Resident #49. During the interview Resident #49 stated the GNA #31 would often tell him/her that he/she would be right back after checking in with Resident #49 in the morning and wound not come back until after lunch, even though he/she was wet and was dependent on staff for help. Resident #49 also stated that he/she heard Resident #13 yell in pain while being bathed by GNA #31 and heard GNA #31 tell Resident #13, I can't bathe you if you are like that. I don't have to bathe you. I can be taken off your assignment.On 3/26/26 at 9:35 AM, the surveyor interviewed GNA #32. During the interview GNA #32 confirmed that her statement was true.On 3/26/26 at 10:59 AM, the surveyor conducted an interview with The Director of Nursing (DON). During the interview the surveyor relayed the concerns that that GNA #31 verbally abused Resident #42 and walked away from providing cares. The DON stated that after the allegation GNA #31 was suspended and after the concerns were validated, fired. She also stated that GNA #31 was reported to the Board of Nursing and the abuse prevention education was completed by the staff after the investigation.

Based on record review and interview, it was determined that the facility failed to obtain a qualifying diagnosis prior to prescribing a psychotropic medication. This was found to be evident in 1 (#97) out of 5 residents reviewed for unnecessary medications.The findings include:Psychotropic medications are used to treat mental health disorders and are considered any drug that affects behavior, mood, thoughts, or perception. There are five main types of psychotropic medications, and each type has its own specific uses, benefits, and side effects. The five main types are: antidepressants, anti-anxiety, stimulants, antipsychotics and mood stabilizers.The surveyor noted during a record review on 03/24/2026 at 11:24 AM, that a prescriber ordered, SEROquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 25 mg by mouth every morning and at bedtime for Agitation -Start Date03/19/2026 1900 for Resident #97. The Director of Nursing (DON) stated Resident #97 was a new admission and the facility was trying to obtain records and learn a diagnosis for the antipsychotic medication. On 3/24/2026 at 1:30 PM the DON provided the clinical pharmacist Unnecessary Medication Review, dated 3/23/26, that stated the facility was administering antipsychotic pharmacotherapy to Resident #97 without a qualifying diagnosis. The DON stated the facility had a call out to the physician about it. On 03/26/2026 at 10:30 AM, the Psychiatric Nurse Practitioner (PNP) #25 stated he started Seroquel due to Resident #97's restlessness, yelling and delusional behaviors. PNP #25 tried the medication to see if it would help Resident #97, as the behaviors were disturbing other residents. PNP #25 stated it was too soon to give Resident #97 a diagnosis of delusional disorder since they were just admitted . The surveyor interviewed the Medical Director on 03/26/2026 10:35 AM. The Medical Director stated they were familiar with Resident #97 from before they were admitted . Resident # 97 had been having behavior issues, hallucinations and psychotic behaviors, but the prescriber should have had a diagnosis attestation before ordering Seroquel.

Based on interviews and record reviews it was determined that the facility failed to code Minimum Data Set (MDS) assessments accurately. This finding was found to be evident in 2 (Resident #2 and #16) out 8 Residents reviewed for accurate MDS assessments.The findings include:Minimum Data Set (MDS) assessment is a federally mandated standardized assessment tool used in Medicare/Medicaid certified nursing homes to evaluate a Resident's functional, cognitive, and physical health. It guides care planning, improves clinical accuracy, and determines reimbursement rates. Assessments occur at admission, discharge, quarterly, and upon significant changes. The MDS assessments are completed by trained staff in the nursing home.The surveyor conducted a record review of Resident #16's medical record on 3/24/2026 at 3:50 PM. Review of the 1/27/2026 Admission/Medicare-5 Day MDS assessment revealed that Resident #16 was coded No for Ostomy and Not rated for bowel continence.In an interview with the Director of Nursing (DON) at 4:15 PM on 3/24/2026 the surveyor asked the DON if Resident #16 had an ostomy, and she stated that Resident did not have an ostomy. The surveyor conveyed that the 1/27/2026 Admission/Medicare-5 Day MDS assessment for Resident #16 was coded Not rated for bowel continence. The DON stated she would review with the MDS Coordinator.In a follow up interview with the DON on 3/25/2026 at 8:07 AM, she stated that the 1/27/2026 Admission/Medicare-5 Day MDS assessment for Resident #16 was inaccurately coded for bowel continence and that the MDS Coordinator was doing a Modification of Admission/Medicare-5 Day MDS assessment dated [DATE].On 3/25/2026 at 9:25 AM the surveyor reviewed Resident #16's 1/27/2026 Modification of Admission/Medicare-5 Day MDS assessment. Review revealed that the MDS Coordinator made a correction on 3/24/2026 at 4:32 PM to the 1/27/2026 Admission/Medicare-5 Day MDS assessment which was coded Always continent for bowel continence.At 9:25 AM on 3/25/2026 the surveyor conducted a record review of Resident #2's medical record. Review of the 2/18/2026 Admission/Medicare-5 Day MDS assessment was not coded for IV Access, Central.In an interview with the Director of Nursing (DON) at 3:15 PM on 3/25/2026 the surveyor asked DON if Resident #2 had a central line and she stated that the Resident had a central line (chest port) for dialysis. The surveyor conveyed that the 2/18/2026 admission Medicare-5 Day MDS assessment was not coded that Resident #2 had a central line. The DON stated that she would follow up with the MDS Coordinator.In a follow-up interview with the Director of Nursing at 5:35 PM on 3/25/2026 she stated that the 2/18/2026 Admission/Medicare-5 Day MDS assessment for Resident #2 was inaccurately coded for IV Access, Central and that the MDS Coordinator was doing a Modification of Admission/Medicare-5 Day MDS assessment dated [DATE].On 3/26/2026 at 7:25 AM the surveyor reviewed Resident #2's 2/18/2026 Modification of Admission/Medicare-5 Day MDS assessment. Review revealed that the MDS Coordinator made a correction on 3/25/2026 at 3:24 PM to the 2/18/2026 Admission/Medicare-5 Day MDS assessment which was coded Yes for IV Access, Central.No additional information was provided by the facility at the time of survey exit.

Based on interviews and record review, it was determined that the facility failed to ensure residents were provided with summaries of their baseline care plans. This was found to be evident for 1 (#99) out of 8 residents reviewed for care planning during the recertification survey.The findings include:During a record review on 03/24/2026 at 1:02 PM, the surveyor found no documentation that the facility obtained a baseline care plan signature or provided a copy to Resident #99 or their representative. The surveyor requested documentation from the facility. The surveyor interviewed the Director of Nursing (DON) on 03/25/2026 at 7:13 AM. The DON stated the facility lacked documentation showing that a copy of the baseline care planned was signed by, and provided to Resident #99. The social worker gave Resident #99 a copy but did not document it. The facility will work on that process.

Number of residents sampled: Number of residents cited: Based on observations, interviews and record reviews it was determined that the facility failed to develop and implement comprehensive care plans for Residents. This finding was found to be evident for 3 (Resident #2, 5 and 11) out of 8 Residents reviewed for care plans. The findings include:Hemodialysis is a life-sustaining treatment for kidney failure that filters waste, toxins, and excess fluid from the blood using a machine and a dialyzer (artificial kidney). Typically performed three times a week for 3-5 hours, it reduces symptoms of kidney failure. Blood is removed from the body through a vascular access point (fistula, graft, or catheter). Care plan is a written document that outlines a person's care needs and how they will be met. It's a key tool for health and social care professionals to ensure a Resident receives the right level of care. Care plan includes medical history, current treatments, and medications. Care plans should be reviewed regularly to monitor their effectiveness, and the Resident should be involved in the process. The care plan includes assessment, diagnoses, goals, interventions and outcomes.During the entrance conference on 3/23/2026 at 8:45 AM with the Licensed Nursing Home Administrator (LNHA), Administrator in Training (AIT) and the Director of Nursing (DON), they stated that dialysis treatments were performed at UPMC - Regional Dialysis Center (University of Pennsylvania Medical Center) in Western Maryland.The surveyor conducted a record review of Resident #2's medical record on 3/25/2026 at 9:25 AM. Review of the medical record revealed that Resident #2 had a physician order for dialysis treatment scheduled Tuesdays, Thursdays and Saturdays. Further review of the medical record revealed that Resident #2 did not have a comprehensive care plan for hemodialysis.The surveyor reviewed the facility's policy for Care of a Resident with End-Stage Renal Disease (ESRD) dated February 2026. The policy indicated that the Resident's comprehensive care plan will reflect the Resident's needs related to ESRD/dialysis care.In an interview with the Director of Nursing and Regional Clinical Consultant at 9:45 AM on 3/25/2026 the surveyor conveyed that Resident #2 received dialysis treatments at UPMC and that review of the comprehensive care plan did not reveal a comprehensive care plan for hemodialysis. The DON acknowledged the surveyor and confirmed that Resident #2 did not have a hemodialysis care plan.At 11:20 AM on 3/25/2026 the LNHA provided the surveyor with a hemodialysis care plan for Resident #2 that was completed on 3/25/2026 by the DON, after surveyor intervention.At 1:24 PM on 3/23/2026 the surveyor observed Resident #11 in bed with 2 steri-strips to the right side of forehead. Resident #11 stated that he/she recently fell out of bed.The surveyor conducted a record review of Resident #11's medical record at 7:15 AM on 3/26/2026. Review of the progress notes revealed that Resident #11 had a fall on 3/17/2026 and sustained a laceration on the right side of forehead. Further review of the medical record revealed that there was a care plan for at-risk for falls but there was not a comprehensive care plan for actual fall. In an interview with the Director of Nursing (DON) at 10:30 AM on 3/26/2026 the surveyor conveyed that Resident #11 had a fall on 3/17/2026 with minor injury and that the Resident had a care plan for at-risk for falls but there was not a care plan for actual fall with injury. The DON stated that there should have been a care plan done for the actual fall with injury.At 3:09 PM on 3/23/2026 the surveyor observed on Resident #5's Resident room door signage which indicated that Resident was on isolation. The surveyor conducted a record review at 8:25 AM on 3/24/2026 of Resident #5's medical record and this review revealed that Resident had a physician order dated 3/19/2026 for COVID-19 isolation for 10 days. Further review of the medical record revealed that Resident #5's comprehensive care plan did not have a problem, goal or inventions for isolation and COVID-19. In an interview with the Director of Nursing and Regional Clinical Consultant at 9:20 AM on 3/24/2026 the surveyor conveyed that the comprehensive care plan for Resident #5 did not address the isolation precautions and the COVID-19 diagnoses. DON acknowledged the surveyor and confirmed that there was not a care plan for active COVID-19 and isolation precautions.No additional information was provided by the facility at the time of exit.

Based on observation, interviews and record reviews it was determined that the facility failed to review, update and revise Resident's care plans after Resident's changes in conditions. This finding was found to be evident in 2 (Resident #11 and #95) out of 13 Residents reviewed for care plan timing and revision. The findings include:Care plans are a written document that outlines a person's care needs and how they will be met. It's a key tool for health and social care professionals to ensure a Resident receives the right level of care. Care plan includes medical history, current treatments, and medications. Care plans should be reviewed regularly to monitor their effectiveness, and the Resident should be involved in the process. Additionally, care plans should be developed, revised and updated as necessary to reflect the Resident's condition by the interdisciplinary team. The care plan includes assessment, diagnoses, goals, interventions and outcomes. Care Plans are required to be developed within 7 days of completion of a Resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The surveyor observed Resident #11 in bed on 3/23/2026 at 1:26 PM with oxygen in use. Resident #11 was alert and oriented to person, place and time. A record review of Resident #11's medical record was conducted by the surveyor at 9:05 AM on 3/25/2026. Record review revealed that Resident #11 had a physician order for oxygen at 2 Liters/minute via nasal cannula every 24 hours as needed for shortness of breath dated 2/19/2026, and continuous oxygen every shift dated 3/5/2026. Further review of the medical record revealed that oxygen usage was not indicated on Resident #11's care plan. In an Interview with the Director of Nursing (DON) at 10:30 AM on 3/26/2026 the surveyor conveyed that Resident #11 had orders for as needed and continuous oxygen, but review of the care plan did not reveal that oxygen usage was addressed on any of the Resident's care plans. DON stated that Resident #11 was new to the usage of oxygen. The surveyor asked what the expectation for the care plan update and revision was when a Resident had a new order for oxygen, and the DON stated that the care plan should have been updated for oxygen usage. No additional information was provided by the facility at the time of survey exit. On 3/25/26 at 9AM, the surveyor reviewed Resident #95's medical record. The review revealed Resident #95 was admitted to the facility in early February of 2026 and transferred to a hospital after a fall on 2/12/26. On further review a progress note written by Registered Nurse (RN) #33 stated, Resident #95 was found on the floor after falling out of bed on 2/9/26. The note stated that fall protocol was initiated. Next the survey reviewed Resident #95's care plan. A care plan initiated on 2/5/26 stated Resident #95 was at risk for falls. After the fall on 2/9/26 an additional intervention was updated on 2/10/26 and stated, to monitor side effects of medication. On further review of Resident #95's care plan, the surveyor noted a care plan initiated on 2/16/26 that stated, Resident #95 was at risk for falls related to history of falls, gait and transfer dysfunctions, fatigue or weakness, new environment, impaired safety awareness/cognition loss and unsteady gait. This was entered after the 2nd fall. On 3/25/26 at 3:12 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked what steps were completed after a resident fall. The DON stated that after a fall the facility investigates the reason for the fall and addresses the issues. She further stated that care plans are updated as needed. The surveyor reviewed the care plan with the DON and pointed out that the care plan written after the second fall had the same conditions present after the first fall, however, it was written only after the 2nd fall. The DON agreed that the actual fall was not captured in the resident's fall care plan revised on 2/10/26.

Based on observations, record reviews, and interviews, it was determined that the facility failed to administer medications according to professional standards procedure. This was evident for 1 (Resident #69) out of 5 residents reviewed for medication administration. The findings included: Multi-dose insulin pens are handheld devices that contain a prefilled insulin cartridge for multiple injections combined with a needle. This pen allows users to dial specific dosages. A new needle is used for each dose given and the pen is designed for single-person use. The new needle is primed before every injection to remove air bubbles and ensure the needle allows the flow of insulin. Standard priming dose is 2 units of insulin. On 3/24/26 at 8:24 AM, the surveyor observed License Practical Nurse (LPN) #4 prepare insulin for Resident #69. The surveyor watched LPN 4 place the needle onto the top of the insulin pen and then dialed the insulin pen to 20 units. LPN #4 went into Resident #69's room to give the insulin to the Resident. After returning to the medication cart the surveyor asked LPN #4 if she administered the medications. LPN #4 confirmed the she had given 20 units of Resident #69's long acting insulin (glargine) to the Resident. The surveyor asked if she was supposed to disinfect the top of the pen before placing the needle on. LPN #4 stated that she only disinfects the multi dose vials. Next the surveyor asked if she primed the needle after application before dialing in the 20 units. LPN #4 confirmed that she had not and stated that it was not part of her practice to prime the insulin needle. On 3/24/26 at 11:05 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the observations with the DON. The DON confirmed that it was the expectation to have the inulin pen sanitized before application of the needle as well as having the needle primed to ensure accurate dosing.

Based on record reviews and interviews it was determined that the facility failed to provide treatments according to a Resident's plan of care. This was found evident of 1 (Resident #96) out of 3 residents reviewed for wound care. The findings include: On 3/24/26 at 10:48 AM, the surveyor reviewed Resident #96's medical records. A review of Resident #96's December Treatment Administration Record revealed that on 12/10/25 an order was written that stated, apply skin guard ointment to {genital area} and coccyx every day and evening shift for skin healing. The order was documented as completed on the evening of 12/10/25 and morning and afternoon on 12/11/25. The order was discontinued on 12/11/25. A new order was written to start on 12/12/25 that stated apply skin guard to {genital area} every day and evening shift for wound healing. However the new order did not include the orders to apply the treatment to the coccyx. A new order for the coccyx wound was written to start on 12/17/25 and stated, to cleanse with wound cleaner, apply medi-honey to the wound bed and cover with a border foam dressing as needed for wound care. On 3/24/26 at 1:50 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that would care for Resident #96's coccyx wound was not ordered or documented as provided 12/12/25-12/17/25 until a new order was written on 12/17/25. The DON stated she would look for wound care documentation. At the time of exit no additional documentation was provided to the surveyor.

Based on observation, interview and medical record review, it was determined the facility failed to prevent the development of a stage 4 pressure ulcer, failed to notify the physician when a weekly wound assessment began to indicate potential signs of infection, failed to implement a physician order for a surgical consult, and failed to ensure that a physician or nurse practitioner assessed the pressure ulcer from the time it was first identified as a stage 2 in January of 2022 until May of 2022, at which time the wound specialist assessed the wound as stage 4 ulcer. This was found to be evident for 1 (Resident #51) out of 5 residents reviewed for pressure ulcers. As a result of this failure, actual harm was identified for Resident # 51. The findings include: On 3/21/23, review of Resident #51's medical record revealed the resident was originally admitted to the facility in 2020 and whose diagnoses included, but were not limited to hemiplegia. Hemiplegia is a severe or complete loss of strength in the arm and leg of one side of the body. On 3/21/23, review of the Minimum Data Set (MDS) assessment, with an assessment reference date (ARD)of 12/12/21, revealed that the resident had a range of motion impairment on one side for both upper and lower extremities and required extensive assist of one person for bed mobility, dressing and personal hygiene. The resident was totally dependent on staff for bathing and toilet use. This assessment also revealed the resident was incontinent (unable to control) bowel and bladder. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 3/21/23, review of the care plans revealed that a plan was in effect since 1/22/2020 to address risk for pressure ulcer due to poor mobility and incontinence. The resident also had an order, in effect since 1/27/2020, to turn and reposition every 2-4 hours. This order was being reviewed with documentation by nursing staff every shift on the Treatment Administration Record, except for 1/5/22, which was noted to be blank. Further review of the 12/12/21 MDS assessment revealed the resident did not have a current diagnosis of cancer or anemia and did not have any pressure, arterial or venous ulcers in December 2021. Review of the Geriatric Nursing Assistant (GNA) documentation of bed mobility, and the support provided by staff, for January - March 2022 revealed that the resident was totally dependent on staff assistance for moving in bed for the majority of the shifts that staff documented. No documentation was found to indicate that GNA staff provided assistance with bed mobility on 1/5/22, 1/6/22, 1/24/22, 1/25/22 or 3/30/22. On 1/5/22 at 4:22 AM, 2/21/22 at 1:57 PM, and on 2/22/22 at 2:39 PM, the GNA documented Activity did not occur. Further review of the GNA documentation revealed multiple days when staff only documented that bed mobility assistance was provided during one shift. These included: 1/9/22, 1/11/22, 1/14/22, 1/15/22, 1/23/22, 1/27/22, 2/9/22, 2/13/22, 2/17/22, 3/1/22, 3/3/22, 3/7/22, 3/9/22, 3/10/22, 3/13/22, 3/15/22, 3/16/22, 3/26/22. Review of a nursing progress note, dated 1/11/22, revealed that, while the resident was receiving a bath, a stage 2 pressure ulcer was identified on the resident's coccyx. The responsible family and the physician were notified, and a dressing order was implemented. Review of the Treatment Administration Record (TAR) revealed that the initial treatment order, in effect from 1/11/22-1/19/22, was for dcd [dry clean dressing], with Aquacel and Mepilex daily on right coccyx. The coccyx, or tailbone, is located at the base of the spine. Review of the medical record failed to reveal documentation of weekly skin checks during the 6 weeks prior to 1/11/22. On 3/21/23 at 2:00 PM, the Director of Nursing (DON) confirmed that there were no routine weekly skin checks in the weeks prior to the identification of the pressure ulcer on 1/11/22. Review of the Weekly Skin Measurement assessment, dated 1/11/22, revealed that the stage 2 pressure ulcer was 2 cm in length and 1 cm in width with no depth, the wound bed was red with no exudate (drainage) or pain. It also documented that the wound was facility acquired. This initial assessment was documented by Nurse #46, a licensed practical nurse (LPN). A classification of Stage 2 Pressure for a pressure ulcer indicates there was partial-thickness skin loss with exposed dermis (second layer of skin) presenting as a shallow open ulcer. The wound bed was viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Further review of the medical record revealed that the resident was seen by the primary care physician on 1/14/22. Review of this note revealed the following documentation under Physical Examination: SKIN: Decubitus Ulcer None. No documentation was found in the assessment or plan sections of the note related to the recently identified stage two pressure ulcer. The DON reported on 3/22/23 at 1:25 PM, that prior to a wound consultant starting in May of 2022, the facility did not have a wound specialist, and indicated they just had a wound team of nursing staff. Review of the Weekly Skin Measurements that were completed for Resident #51's right coccyx pressure ulcer between 1/21/22 and April 2022 revealed they were completed by Nurse #10, a registered nurse (RN). On 3/22/23 at 2:05 PM, the DON reported that Nurse #10 had some additional training in wound care a while back, but had no certification or other credentials in wound care. Review of the 1/21/22 Weekly Skin Measurement assessment revealed that the Stage 2 right coccyx pressure ulcer was 0.4 cm in length and 0.2 cm in width with superficial depth, pink wound bed with scant brown exudate. The treatment was documented on this form as: Clean with NS. Apply Aquacel and Mepilix every other day and prn [as needed]. Review of the orders revealed the treatment order was changed from daily to every other day on 1/20/22. Further review of the TAR revealed that the dressing treatment order was changed on 1/20/22 to dcd (dry clean dressing), with Aquacel and Mepilex every other day on r coccyx until healed. This order was in effect until 3/4/22. No documentation was found in the order or on the Treatment Administration Record (TAR) to indicate what was to be used to clean the wound. Also, although the order was for every other day, it was put into the electronic health record TAR with a frequency of once a day. There was no separate area to document or distinguish between regularly scheduled every other day changes, and any additional as needed dressing changes. On 3/21/23 at approximately 2:30 PM, surveyor reviewed the concern with the Director of Nursing (DON) that the treatment recorded on the Weekly Skin Measurement assessments did not correspond to the actual orders. Further review of the treatment administration record (TAR) revealed that staff were documenting changing the dressing every day from 1/20/22 thru 3/4/22, except on 1/28/22 which had no documentation, and on 2/15/22, when the nurse documented that the dressing change was not completed because it was ordered every other day and it had been completed the day before. Review of the Weekly Skin Measurement assessment, with an observation date of 1/28/23, and a recorded date of 2/3/23, revealed the presence of the stage two pressure ulcer on the right coccyx with a length of 0.4 cm and width of 0.2 cm with scant brown exudate. Interview with Nurse #10 on 3/21/23 at 2:55 PM, revealed that the observation date was the date she made the observations, but that the recorded/completed date reflected the date that the information was entered into the electronic health record. Review of the Weekly Skin Measurement assessment, with an observation date of 2/3/23 revealed the presence of the stage two pressure ulcer on the right coccyx with a length of 1.0 cm and width of 0.5 cm with scant brown exudate. Further review of the medical record revealed that the primary care physician #47 saw the resident on 2/4/22. Review of the progress note for this visit revealed the following documentation under the section titled Physical Examination: SKIN: Decubitus Ulcer None. Review of the Plan section of the note failed to reveal documentation specific to the current treatment for the pressure ulcer. Review of the Weekly Skin Measurement assessment with an observation date of 2/11/22 revealed the presence of the stage two pressure ulcer on the right coccyx with a length of 1.5 cm and width of 1 cm with scant brown exudate. Review of the Weekly Skin Measurement assessment, with an observation date of 2/18/22, revealed the presence of the stage two pressure ulcer on the right coccyx with a length of 1.5 cm and width of 1.5 cm with a small amount of brown exudate. Episodic pain with cleaning is also documented in this assessment. Review of the Weekly Skin Measurement assessment with an observation date of 2/25/22 revealed the presence of the stage two pressure ulcer on the right coccyx with a length of 3.0 cm and width of 3.0 cm with a small amount of brown exudate. Episodic pain with cleaning was also documented in this assessment. Review of the MDS with an ARD of 2/28/22 revealed documentation that the resident had one unhealed stage 2 pressure ulcer. On 3/21/23, further review of the care plan for risk for pressure ulcer failed to reveal documentation to indicate the addition of interventions since the plan's initiation in January 2020. A care plan addressing the impaired skin integrity related to the pressure ulcer to the coccyx was not initiated until 4/21/22. On 3/21/23 at 2:00 PM, the surveyor reviewed the concern with the DON that a care plan addressing the presence of the pressure ulcer was not initiated until April 2022. This was three months after the pressure ulcer was first identified. Other than the order for the dressing changes, no other interventions were put in place to promote the healing of the pressure ulcer until March 2022. Review of the Weekly Skin Measurement assessment, with an observation date of 3/4/22, revealed that the coccyx pressure ulcer was 4 cm in length and 3 cm in width and the wound bed was black/moist/necrotic (dead tissue). The Stage of the ulcer was assessed as unable to stage. A wound is determined to be unstageable when the extent of the tissue damage within the ulcer cannot be confirmed because the wound bed is obscured (not fully visible) by slough or eschar. Eschar is dry, hard necrotic tissue. Slough is dead tissue that is usually yellow or cream in color. If slough or eschar is removed a Stage 3 or Stage 4 pressure ulcer will be revealed. During an interview with Nurse #10 on 3/21/23 at 2:55 PM, surveyor reviewed that the Weekly Skin Measurement assessment revealed that the wound had become unstageable. Nurse #10 indicated she would have informed the physician. Surveyor reviewed the concern that no documentation was found in the progress notes to indicate this notification had occurred. Further review of the medical record revealed an order, on 3/4/22, for an Alternating Pressure Mattress. Further review of the medical record revealed the physician visited the resident on 3/5/22. Review of the corresponding progress note revealed the following documentation: Physical Examination: SKIN: Decubitus Ulcer stage II on sacral area. No documentation was found regarding the size or presentation of the pressure ulcer. Review of the Plan section of the note failed to reveal documentation specific to the current treatment for the pressure ulcer. Pressure ulcer, decubitus and bedsore all refer to the same thing. The sacrum, or sacral area, is located just above the coccyx. Further review of the medical record revealed that, on 3/5/22, there was a new order for the treatment to the coccyx: Clean coccyx with NS [normal saline]; Apply Aquacel AG and cover with Mepilex every day. This treatment order was in effect until 6/2/22. On 3/22/23 at 9:37 AM, the primary care physician #47 was interviewed about his process when a resident had a pressure ulcer. The physician reported that they have a wound team and that he follows their recommendations. When asked if he observed the wounds himself, he replied sometimes. He went on to report that he normally rounds with a nurse and that if the wound is dressed then he does not open it, but if not dressed, he will look at the wound. He indicated the documentation is no different on occasions when he visualizes the wound vs when he does not look at the wound. He reported he would not document the size or the dimensions of the wound. He was unable to recall if he had observed Resident #51's wound last year or not. The physician reported that the facility has had a wound team for a couple of years, and the expectation is that the nurse who identifies a wound would alert the wound team. On 3/22/23 at 10:50 AM, the surveyor asked the DON if there was any wound specialist or wound team at the facility in Jan-April 2022. The DON reported that she had been informed that there was not. After review of the physician documentation about depending on the wound team recommendations, the DON indicated that possibly the physician was referencing the wound team of the nurses and registered dietitian here at the facility. On 3/22/23 at 11:34 AM, the DON confirmed that there was no wound team in Jan-April of 2022, reporting that it was just Nurse #10. Review of the physician orders revealed that, on 3/9/22, there was an order for ProSource (a protein supplement) to be administered twice a day for healing. However, review of the 3/14/22 progress note completed by registered dietitian #28 revealed the following: No current pressure areas noted and failed to reveal documentation regarding the ProSource order. Review of the Weekly Skin Measurement assessment with an observation date of 3/11/22, revealed the unstageable coccyx pressure ulcer was 2.8 cm in length and 3 cm in width and 0.1 cm in depth. The appearance of the wound bed was yellow moist slough. There was a small amount of brown, malodorous (bad smelling) exudate. And episodic pain was noted. Further review of the medical record failed to reveal documentation to indicate the physician was made aware of the malodorous exudate (drainage) that was documented on 3/11/22. Review of the Weekly Skin Measurement assessment, with an observation date of 3/19/22, revealed the unstageable coccyx pressure ulcer was 3 cm in length and 3 cm in width and 0.6 cm in depth. The appearance of the wound bed was black/moist/necrotic. There was a small amount of brown, malodorous (bad smelling) exudate, with episodic pain. Further review of the medical record failed to reveal documentation to indicate that the physician was made aware of the malodorous exudate (drainage) that was documented on 3/19/22. Review of the Weekly Skin Measurement assessment, with an observation date of 3/25/22, revealed that the unstageable coccyx pressure ulcer was 3 cm in length and 3 cm in width and 1.0 cm in depth. The appearance of the wound bed was black/yellow/moist/slough. There was a small amount of brown, malodorous (bad smelling) exudate. And episodic pain was again noted. Further review of the medical record failed to reveal documentation to indicate the physician was made aware of the malodorous exudate (drainage) that was documented on 3/25/22. Review of the Weekly Skin Measurement assessment, with an observation date of 4/1/22, revealed that the unstageable coccyx pressure ulcer was 3 cm in length and 3 cm in width and 1.4 cm in depth. The appearance of the wound bed was red/moist with areas of yellow slough. There was a moderate amount of brown, malodorous (bad smelling) exudate. And episodic pain was noted. Further review of the medical record failed to reveal documentation to indicate the physician was made aware of the malodorous exudate (drainage) or that the wound now had a depth of 1.4 cm that was documented on 4/1/22. Further review of the medical record revealed the following progress note, written by Nurse #19 and dated 4/3/22 at 11:11 PM: Family at bedside early in shift. POA/Sponsor wanted to speak to the nurse regarding the smell from the resident's coccyx. Stated, 'I was in the room when they turned and changed [him/her] and the smell from the wound was terrible.' Stated he had a close family member who was a nurse. Wants to have a surgical consult to see if wound can be debrided and requested that an antibiotic be ordered for foul smelling wound. Faxed [name of primary care physician #47] the family members requests. Will report to next shift. Review of the resident's paper chart revealed a corresponding fax communication form, dated 4/3/22 at 7:00 PM, that included the following: Sponsor (POA) noticed the smell from [his/her] coccyx wound. He would like a surgical consult to see if wound can be debrided. Also wants to know if [s/he] should be on an antibiotic. Debridement is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. Debridement methods may include a range of treatments such as the use of enzymatic dressings to surgical debridement in order to remove tissue or matter from a wound to promote healing. No documentation was found to indicate Nurse #19 had assessed the resident's wound herself prior to sending the fax to the primary care physician. Further review of the 4/3/22 fax communication form revealed it was returned by the primary care physician on 4/4/22 and include the following documentation: Keflex [an antibiotic] 500 tid [three times a day] and surgery consult. During an interview with the primary care physician #47 on 3/22/23 at 9:37 AM, when asked about the process when staff fax a communication form to him, the physician reported that sometimes he writes on the form and returns it to the facility and confirmed that he considers that to be his orders. Further review of the medical record revealed an order in effect from 4/4/22 until 4/10/22 for Cephalexin (generic for Keflex) 500 mg three times a day for 7 days for wound to coccyx. Review of the medication administration record revealed that the resident received the antibiotic as ordered. Further review of the medical record revealed that the resident was seen by the primary care physician on 4/9/22. Review of the corresponding progress note revealed: SKIN: Decubitus Ulcer sacral area. No documentation was found regarding the size, appearance or stage of the ulcer. No documentation was found regarding the recently prescribed antibiotic to treat the wound or the recent order for a surgical consult for possible debridement. Further review of the medical record failed to reveal documentation to indicate the surgical consult was entered into the electronic health record as indicated in the 4/4/22 fax from the primary care physician. No documentation was found to indicate a physician or nurse practitioner observed/assessed the wound prior to the initial assessment by the wound specialist NP on 5/5/22. On 4/13/22, Arginade, a nutritional supplement, was ordered by the primary care physician. Further review of the medical record revealed that on 4/21/22 a care plan was initiated to address the presence of the pressure ulcer. This was 3 months after the wound was initially identified and almost two months after the pressure ulcer was identified in the 2/28/22 MDS assessment. Review of the 5/5/22 wound specialist note revealed that the wound was assessed as a stage 4 wound. The length was 3.03 cm, width 2.34 cm, L x W 7.09 cm; depth 1 cm. There was 80% granulation and 20% slough/eschar and exposed muscle. A stage 4 pressure ulcer represents full-thickness skin and tissue loss with exposed or directly palpable (can feel) muscle, tendon, ligament, cartilage, or bone in the ulcer. Further review of the medical record failed to reveal documentation to indicate the resident was hospitalized or had another leave of absence between January and May 2022. On 3/21/23 further review of the medical record revealed the resident continues to be seen weekly by the wound specialist. The current wound treatment order, since 2/9/23, is to clean the stage 4 sacral pressure ulcer with wound cleanser and pack with collagen matrix and then hydrofera blue. And cover with bordered foam dressing, every other day for wound care. On 3/21/23 at 10:52 AM surveyor observed Nurse #13 complete the resident ' s dressing change. This observation revealed the nurse placed the collagen matrix over the opening of the wound, but did not pack it in the wound as indicated in the current orders. During an interview with Nurse #13 at 11:48 AM she confirmed the wound has depth but stated it is kind of hard to pack right now. She went on to indicate that she would speak with the wound nurse (ADON) about updating the order. On 3/21/23 at 12:25 PM surveyor discussed with the Director of Nursing (DON) the concern that based on observation the nurse did not pack the wound as ordered, just placed the collagen on top of the wound. Additionally, on 3/21/23 at 12:25 PM, surveyor reviewed the concern with the DON that the resident developed an avoidable stage 4 pressure ulcer. This concern was also reviewed with the Administrator at time of exit on 3/22/23 at 6:00 PM.

Based on observation, record review, and staff interview it was determined that the facility failed to prevent abuse of residents from other residents who exhibited behaviors triggering resident-to-resident physical altercations. This was evident for 4 (#8, #9, #10, and #11) of 5 residents reviewed for abuse. Because of these findings, an Immediate Jeopardy(IJ) was called on 1/10/22 at 1:25 PM, related to the facility's failure to prevent abuse of residents from other residents who exhibited behaviors triggering resident to resident altercations. The facility submitted three plans of removal. The first removal plan was submitted on 1/10/22 at 4:25 PM, but was not accepted. The second removal plan was submitted on 1/10/22 at 6:17 PM, but was not accepted. The third removal plan was submitted on 1/10/22 at 7:50 PM. The removal plan was accepted on 1/10/22 at 8:00 PM, by the Office of Health Care Quality. On 1/13/22 at 7:09 AM, after validation the accepted removal plan had been implemented the IJ was removed. The Administrator was made aware the IJ was removed on 1/13/22. After the removal of the immediacy, the deficient practice remained with the potential for more than minimal harm for all the remaining residents at a scope and severity of E. The findings include: MDS (Minimum Data Set) - A core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. (MDS 3.0 Manual) BIMS (Brief Interview of Mental Status) - a standardized cognitive test. (MDS 3.0 Manual) A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. During an initial tour of the facility on 12/28/21 at 8:57 AM, Resident #9 was observed leaving room [ROOM NUMBER] drying his/her hands with a paper towel. room [ROOM NUMBER] was not the room assigned to Resident #9. A medical record review for Resident #9 was completed on 1/5/22 at 12:31 PM and revealed Attending Physician #6 had documented Resident #9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a MDS assessment with an ARD of 10/30/21, revealed Resident #9 had a BIMS score of 3/15, indicating severe cognitive impairment. Staff had initiated a care plan on 5/13/20, to address Resident #9's wandering with a goal to wander safely in the facility without elopement. The care plan interventions implemented had not addressed Resident #9's intrusive wandering that led to multiple resident-to-resident altercations. Further review revealed a behavior care plan initiated on 5/22/20, to address Resident #9's aggressive behaviors towards staff and other residents with a goal that Resident #9 would not harm other residents during the review period. The interventions had not included an increase in supervision of Resident #9 to ensure the safety of other residents. Resident #9, had been known to wander in and out of other resident's rooms and engage in physical altercations with other residents. Multiple observations had been made during the onsite survey activities of Resident #10 wandering in the hallways in his/her wheelchair and sitting in the common area with other residents. A medical record review for Resident #10 on 1/10/22 at 12:58 PM, revealed an MDS assessment with an ARD of 12/24/21, that documented a BIMS score of 5/15, which indicated severe cognitive impairment. Further review revealed a behavioral care plan that had been initiated on 11/10/19, to address Resident #10's altered thought processes related to depression, anxiety, agitation, and dementia as evidenced by wandering, confusion, and combative behaviors and making inappropriate sexual remarks to staff and residents. The goal had read that [Resident #10] would not harm self or others through the next review. However, there had been no documented interventions implemented to increase supervision of Resident #10, who had been known to wander and hit other residents, to ensure an environment that had been free of abuse for other residents. In addition, there had been no care plan to address Resident #10's aggressive behaviors towards other residents in response to the 5 resident-to-resident physical altercations Resident #10 had engaged in over the past year. Multiple observations had been made during onsite survey activities of Resident #11 wandering in the hallways and sitting in the common areas. A medical record review for Resident #11 on 1/6/22 at 1:23 PM, revealed a MDS assessment with the ARD of 1/6/22, that documented a BIMS score of 3/15, which indicated severe cognitive impairment. Further review of the medical record revealed in the physician's progress notes that Resident #11 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff failed to include interventions that provided supervision for Resident #11. In addition, Resident #11 had a care plan, initiated on 8/17/20, for altered thought processes related to dementia and [CONDITION(S)] as evidenced by delusions and aggressive behaviors towards staff and other residents. The goal had been for Resident #11 not to have aggressive behaviors towards staff and residents. An intervention had been initiated on 8/17/20, for staff to be aware of factors that escalate behaviors; however, the intervention had not documented what these factors were and what actions staff were to take had they recognized them. A review on 1/11/22 at 1:00 PM, of the facility's documentation for a resident-to-resident abuse incident on 1/5/21, revealed a statement from Resident #8. The statement read that Resident #8 had been lying in his/her bed at 5:00 AM watching television when Resident #8 felt something touch his/her arm. When Resident #8 looked up, Resident #9 was standing beside his/her bed. Resident #8 started screaming and Resident #9 grabbed Resident #8's elbow. Continued review of the facility's documentation revealed a self-report that read staff determined that Resident #9 had gone into Resident #8's room accidently, although Resident #9 had documented behaviors of wandering aimlessly in and out of other residents' rooms. Staff implemented the following measures to prevent further incidents of a similar nature; offer a room change to Resident #8 and post pictures on Resident #9 room door to remind Resident #9 which room was his/hers. In addition, local law enforcement had not been notified and there was no evidence that a thorough investigation had been conducted to determine if the measures had been appropriate interventions to avoid future occurrences. On 1/11/22 at 1:00 PM, a review of the facility's documentation for a facility reported incident of resident-to-resident abuse on 3/5/21 at 8:30 PM, revealed Geriatric Nursing Assistant (GNA) #20 witnessed the incident. GNA #20's statement read that, while she was sitting at the nurses' station, Resident #10 and Resident #11 were talking in the hallway. Resident #10 told Resident #11 to shut up and then Resident #11 hit Resident #10 with his/her pocketbook, and then Resident #10 hit Resident #11 back. Further review of the documentation revealed a self report that documented the measures to prevent further incidents of a similar nature were to separate Resident #10 and Resident #11, however there was no evidence of a thorough investigation of the incident to determine the appropriate intervention needed to ensure that resident-to-resident abuse was prevented in the future. There was no evidence that GNA #20, who had witnessed the incident, had been interviewed to find when he/she responded to the incident, how he/she responded and if additional staff training had been needed. In addition, local law enforcement had not been notified. Furthermore, a continued review of the documentation revealed that Resident #10 was seen by Psychiatrist #12 on a regular basis. A progress note written for 3/23/21, documented that staff reported that Resident #10 had increasing restlessness and depression, however failed to mention that Resident #10 had a resident-to-resident physical altercation with Resident #11 on 3/5/21. On 1/11/22 at 1:00 PM, a review of the facility's documentation for the self-reported incident on 3/30/21 at 6:25 PM, revealed a statement from Registered Nurse (RN) #21. Review of the statement revealed that RN #21 heard a resident screaming, get out to someone and when she went to investigate RN #21 observed Resident #15 hit Resident #10. According to the statement Resident #15 was escorted out of the room and both residents were assessed for injuries. Further review revealed the facility's self report that documented an interview with Resident #10 revealed that Resident #10 went into Resident #15's room to look at a stuffed animal on a bedside table and when Resident #10 picked it up Resident #15 started screaming, so Resident #10 smacked Resident #15 on the arm. The measures taken to prevent further incidents of a similar nature was to separate the two residents and encourage Resident #10 and Resident #15 not to interact with each other. There was no evidence that RN #21 had been interviewed to determine the discrepancies between her statement and Resident #10's interview. Staff failed to address the intrusive wandering behaviors that Resident #10 exhibited therefore, did not implement interventions to reduce the likelihood of this type of incident occurring in the future. Furthemore, there was no evidence that a thorough investigation had been conducted. Local law enforcement had not been notified of the incident. A medical record review for Resident #15 on 1/11/22, revealed Resident #15 had an unspecified mood disorder as evidenced by aggressive behaviors. During a review on 1/6/22 at 9:00 AM, of the facility's documentation for the facility reported incident dated 5/22/21, for a resident-to-resident abuse, it was revealed that 3 statements from the following staff; Housekeeper #15, Registered Nurse (RN) #16, and Geriatric Nursing Assistant (GNA) #3 were collected. The 3 statements documented a similar recollection of the events of the incident; that Resident #11 was telling Resident #9 to leave him/her alone and Resident #9 started hitting Resident #11 with both of his/her fists. Resident #11 had to put up his/her arms to protect themselves. Each of the staff members writing a statement failed to document if and when they had attempted to intervene to prevent the resident-to-resident abuse and protect Resident #11 from Resident #9's physical attack. Further review of the documentation revealed a self-report which documented that the intervention taken was to separate Resident #9 and Resident #11. However, there had been no evidence a thorough investigation had been conducted to determine the appropriate interventions to prevent further resident-to-resident abuse from occurring and local law enforcement had not been notified. In addition, there was no evidence that Resident #11 wss assessed for injuries and offered treatment, if needed. Resident #9's Attending Physician #6 was notified, however there had been no documentation as to whether new orders were obtained. On 1/6/22 at 9:00 AM, a review of the facility's documentation for the self-reported resident-to-resident abuse incident dated 5/23/21, revealed a statement from Licensed Practical Nurse (LPN) #14. In the statement, LPN #14 reported that she heard a sound like someone was smacking a book against an object. LPN #14 documented that when she had gone to investigate, LPN #14 had found Resident #9 standing in the doorway of Resident #10's room. Resident #10 reported to LPN #14 that Resident #9 had hit him/her on the face and arms with a book. LPN #14 reported that Resident #10 had some pinkness on his/her arm. Further review revealed a self-report that documented the measures taken to prevent further incidents of a similar nature was to separate Resident #10 and Resident #9. There was no evidence that an investigation was conducted to determine the appropriate interventions needed to ensure that resident-to-resident abuse did not continue. In addition, local law enforcement had not been notified. A continued review revealed, Resident #9's Attending Physician #6 was notified and had given orders to increase Resident #9's antipsychotic medications, order laboratory testing, and consulted with Psychiatrist #12, who had agreed with the treatment plan. A concurrent review had been completed by LPN #14 for Resident #10, however there was no evidence in the medical record that facility staff assessed Resident #10's arm and face and provided treatment. Furthermore, there was no evidence that social work staff and/or psychiatric services had been offered to Resident #10 following the incident of abuse. On 1/11/22 at 1:00 PM, during a review of the facility's documentation for the self reported incident on 8/11/21 at 1:30 PM, it was revealed on the self report form that Resident #21 and the Activities Director witnessed an event between Resident #10 and Resident #19. A statement was obtained from Resident #21 which documented that Resident #21 observed Resident #10 come up to the front and Resident #10 squeezed his/her way into a spot that had been facing Resident #19. When Resident #10 was attempting to leave the spot, Resident #10 asked Resident #19 to move, when Resident #19 stated he/she was not afraid of Resident #10, that was when Resident #10 balled up his/her fist and hit Resident #19 in the face. Although the incident had been witnessed by the Activities Director, facility staff failed to obtain a statement from her. According to the self-report form, it was after Resident #10 hit Resident #19, that facility staff moved Resident #10 from the common area. Further review of the self report revealed that Resident #10 was known to impulsively lash out when frustrated, however staff failed to intervene before Resident #10 hit another resident. There was no evidence that a thorough investigation was conducted to determine interventions that needed to be implemented to ensure that Resident #10 did not continue to abuse other residents. In addition, local law enforcement had not been notified of the incident. A medical record review for Resident #19 on 1/11/22 at 1:50 PM, revealed Resident #19 had a care plan to address Resident #19's altered thought process due to dementia as evidenced by Resident #19 exhibiting agitation/annoyance towards other residents. The goal had been noted to ensure Resident #19 had not harmed another resident during the review period. However, the interventions had not addressed the need for increased supervision to avoid resident-to-resident altercations. On 1/6/22 at 9:30 AM, a review of the facility's documentation for a self- reported incident of resident-to-resident abuse that occurred on 9/5/21, revealed a statement from Geriatric Nursing Assistant (GNA) #9. The statement read that on 9/5/21 at 10:15 AM, GNA #9 and Housekeeper #10 were redirecting Resident #9 down the center hall when Resident #10 came out of his/her room and punched Resident #9 in the shoulder. Further review of the documentation revealed a self-report form that stated Resident #9 and Resident #10 had been separated. There had been no documented investigation, therefore it had been unclear how this incident occurred with 2 staff members in close proximity to Resident #9. In addition, staff failed to implement further interventions to ensure that resident-to-resident abuse by Resident #10 did not continue, as this had been the 4th self-reported incident of resident-to-resident abuse involving Resident #10 since 3/21/21. Furthermore, local law enforcement had not been notified. A medical record review on 1/6/22 at 12:19 PM, revealed facility staff had failed to offer Social work services for Resident #9. Psychiatric services were not provided until 9/30/21, 25 days after the incident. A review of psychiatric notes on 1/6/21 at 9:30 AM, revealed Psychiatrist #7 made some changes to Resident #9's medications. Further review revealed a concurrent review for Resident #9, dated 9/5/21, that staff failed to document an assessment of Resident #9's possible injuries. During a review on 1/6/22 at 9:30 AM of the facility's documentation for a self-reported incident of resident-to-resident abuse that occurred between Resident #10 and Resident #9 on 10/3/21, revealed that Receptionist #11 witnessed the event. Receptionist #11 provided a statement which documented that Receptionist #11 and Resident #10 were sitting in the Activities' office talking when Resident #9 entered the office and started talking to Receptionist #11. Receptionist #11 reported that Resident #10 interrupted Resident #9 telling him/her that nobody wanted to hear Resident #9. Then Resident #10 started using hand gestures towards Resident #9 to go away. Resident #10 pushed Resident #9 and then Resident #9 and Resident #10 started hitting each other and it escalated to Resident #10 grabbing Resident #9 by the throat. At that point, Resident #9 started yelling for help and Receptionist #11 started yelling for help as well. Receptionist #11 failed to report what measures she had taken when this incident started to ensure the safety of each resident. Review of the self report revealed the intervention was to separate Resident #9 and Resident #10 and there was no documentation that facility staff had investigated further if, when and/or how Receptionist #11 had intervened before the altercation between Resident #10 and Resident #9 became physical. Local law enforcement was not notified. In addition, the facility staff failed to conduct and document a thorough investigation to determine the appropriate interventions needed to prevent further abuse perpetrated by Resident #10 on vulnerable residents in the facility. There had been no documented assessment for Resident #9 for possible injuries and no referral for Social Work services or psychiatric services for Resident #9 or Resident #10. A review of the medical record on 1/6/22 at 1:50 PM, revealed that Resident #9 was seen by Attending Physician #6 who documented a visit with Resident #9 on 10/21/21 (18 days after the 10/3/21 incident), and in the note stated that there was not much more that could be done for Resident #9 due to the progression of Alzheimer's disease and staff were to continue supportive care and referred to the medication adjustment on 9/30/21. On 1/11/22 at 1:00 PM, a review of the facility's documentation for the facility reported incident on 11/3/21 at 2:45 PM, revealed a statement from Activites Aid #22 that read that Activities Aid #22 overheard a confrontation between Resident #10 and Resident #11 and when she went to check on them, Activities Aid #22 observed Resident #10 hit Resident #11 on the back of the head and then grab Resident #11's arm. The Activity Aid #22 documented that another Activity staff member had intervened and separated the residents; however, facility staff failed to obtain a statement from the other Activity staff member. During a review of the self report form it was revealed that Resident #10 and Resident #11 had been separated and redirected. However, in the section marked, measures taken to prevent further incidents of a similar nature staff had documented that the facility had been unable to keep Resident #10 and Resident #11 separated as they had been friends and staff will continue to encourage them to sit in separate areas and watch for escalating behaviors. Although these two interventions had been implemented previously for Resident #10 and Resident #11 via care plans and had not been effective. A documented investigation had not been completed to determine the appropriate interventions to implement to prevent further resident-to-resident abuse. In addition, local law enforcement had not been notified. On 1/6/22 at 9:00 AM, a review of the facility's documentation for the self reported incident of resident-to-resident abuse on 11/10/21, revealed a self report form that documented that Resident #9 wandered into Resident #8's room and staff responded due to Resident #8 yelling and screaming. Resident #8 was observed poking Resident #9 with his/her grabber device. Resident #9 had laid down on Resident #8's bed and covered his/her face with their hands. The Director of Nursing (DON) noted that she had a conversation with Resident #8 regarding how to stay calm when Resident #9 comes into Resident #8's room and to call for staff assistance. Also the DON informed Resident #8 that the facility staff cannot keep wandering residents out of Resident #8's room. Local law enforcement had not been notified and no documented interventions had been implemented to ensure the safety of Resident #9 and other vulnerable residents who may have wandered into Resident #8's room. An interview with Resident #8, who was alert and oriented to person, place, and time, on 12/31/21, revealed that Resident #8 had reported to facility staff, to include the DON, that he/she had not wanted Resident #9 in his/her room and rummaging through his/her belongings. An interview with Activities Staff #11 on 1/6/22 at 9:33 AM, revealed that she had worked with Resident #9, at least three to five times a week. Activities Staff #11 stated that she had to redirect Resident #9 out of the other resident's rooms frequently. During an interview with Activities Staff #4 on 1/6/22 at 9:54 AM, it was revealed that they had activities that Resident #9 enjoyed in the common area on a table, however it had not stopped Resident #9 from intrusive wandering behaviors. An interview with Assistant Director of Nursing (ADON) #8 on 1/6/22 at 9:25 AM, revealed there had been no consistent interventions to provide supervision for Resident #9 when he/she had been wandering in and out of other residents' rooms. An interview with the Director of Nursing on 1/6/21 at 10:11 AM, revealed that she had been responsible for reporting and investigating resident-to-resident abuse incidents for the facility. The DON reported that she had not contacted local law enforcement because both residents involved had cognitive impairments. Furthermore, the DON reported that she had investigated the incidents, but failed to document the investigation. During a discussion regarding the incidents that occurred between Resident #8 and Resident #9, the DON reported that she informed Resident #8 that she could not keep Resident #9 from wandering in and out of rooms. The DON reported that the facility had not known what else to do to keep the residents from wandering and having contact with each other due to the cognitive impairment and resident rights. Administrator and DON were notified of surveyor concerns on 1/10/22 at 1:25 PM. Based on these findings, on 1/10/22 at 1:25 PM, an Immediate Jeopardy (IJ) was called related to the facility's failure to prevent abuse of residents from other residents who exhibited behaviors triggering resident-to-resident altercations. The facility submitted three plans of removal. The first removal plan was submitted on 1/10/22 at 4:25 PM, but was not accepted. The second removal plan was submitted on 1/10/22 at 6:17 PM, but was not accepted. The third removal plan was submitted on 1/10/22 at 7:50 PM, and was accepted at 8:00 PM. The removal plan was accepted on 1/10/22 at 8:00 PM, by the Office of Health Care Quality. On 1/13/22 at 7:09 AM, after validation the accepted removal plan had been implemented the IJ was removed. The Administrator was made aware the IJ was removed on 1/13/22. After removal of the immediacy, the deficient practice remained with the potential for more than minimal harm for all the remaining residents at a scope and severity of E. The facility's removal plan included the following provisions: 1. On 1/7/22, Resident #9 was transferred to a facility with a specialized unit. 2. On 1/10/22, Resident #8, Resident #10, and Resident #11 have been assessed for behaviors and found no aggressive or agitated behaviors. Assessment noted in EMR (Electronic Medical Record). 3. Facility Abuse Prevention/Protection/Investigation and Reporting policies have been updated on 1/10/22 to ensure compliance. The facility will develop and educate staff on strategies to identify and de-escalate aggressive resident behavior interventions. 4. Staff will be educated by January 12, 2022. Scheduled staff will be educated onsite and prn (as needed) staff will be contacted via electronic communication. Staff development coordinator will lead the education of interventions and updated policies.

Based on observation, record review, resident and staff interview, it had been determined that the facility failed to provide adequate supervision for residents with intrusive behavior that wander throughout the facility. This was evident for 3 (#9, #10, and #11) of 11 residents reviewed for wandering. Because of these findings, an Immediate Jeopardy was called on 1/6/22 at 5:03 PM, regarding the facility's failure to provide adequate supervision for residents with intrusive wandering behaviors to ensure their safety and the safety of other residents in the facility. The facility submitted three plans of removal. The first removal plan that was submitted on 1/6/22 at 5:50 PM, was not accepted. The second removal plan that was submitted on 1/6/22 at 6:45 PM, was not accepted. The third removal plan that was submitted on 1/6/22 at 7:12 PM was accepted at 7:13 PM, by the Office of Health Care Quality. On 1/12/22 at 10:58 AM, after validation the accepted removal plan had been implemented the IJ was removed. The Administrator was made aware the IJ had been removed on 1/12/22. After removal of the immediacy, the deficient practice remained with potential for more than minimal harm for all remaining residents at a scope and severity of E. The findings include: MDS (Minimum Data Set) - A core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. (MDS 3.0 Manual) BIMS (Brief Interview of Mental Status) - a standardized cognitive test. (MDS 3.0 Manual) A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. During an initial tour of the facility on 12/28/21 at 8:57 AM, Resident #9 was observed leaving Room 101 drying his/her hands with a paper towel. Room 101 was not the room assigned to Resident #9 and was not in the same hallway as Resident #9's room was located. On 1/5/22 at 12:31 PM, a medical record review for Resident #9 revealed a History and Physical (H&P) dated 4/26/20, written by Attending Physician #6 which documented Resident #9 had, but was not limited to the following diagnosis of Alzheimer's dementia. Further review of the medical record revealed a progress note dated 4/23/20, written by Licensed Practical Nurse (LPN) #23 that documented Resident #9 was wandering in the hallways and needed redirection. On 4/24/20, LPN #23 documented Resident #9 was wandering in hallways and in and out of other resident's rooms. According to the progress notes these behaviors continued and a progress note written by LPN #24, dated 10/04/21, stated that Resident #9 frequently wandered throughout the hallways and in and out of other resident's rooms. A care plan quarterly review note on 11/10/21, stated that Resident #9 wandered aimlessly in the hallways, however failed to mention that Resident #9 wandered into other residents' rooms and was engaged in resident-to-resident altercations. A review of Resident #9's MDS with an Assessment Reference Date (ARD) of 10/30/21 documented Resident #9 had a BIMS score of 3/15, which indicated severe cognitive impairment. A continued review of Resident #9's wandering care plan initiated on 5/13/20, revealed staff addressed Resident #9's wandering due to the diagnosis of Alzheimer's dementia, however staff failed to include Resident's intrusive behaviors of wandering in and out of other resident's rooms and implement interventions that addressed adequate supervision for Resident #9's intrusive wandering behaviors. Further review revealed a behavior care plan, initiated on 5/22/20, for Resident #9 for, Altered thought processes related to Alzheimer's disease and adjustment disorder as evidenced by confusion, agitation, and aggressive behaviors towards staff and other residents. Staff failed to include interventions to address the identified behavioral care plan problems for Resident #9. Multiple observations had been made during the onsite survey activities of Resident #10 wandering in the hallways in his/her wheelchair and sitting in the common area with other residents. A medical record review for Resident #10 on 1/10/22 at 12:58 PM, revealed Resident #10 had a MDS assessment with an ARD of 12/24/21, that documented a BIMS score of 5/15, indicating severe cognitive impairment. Further review of the medical record revealed a behavioral care plan initiated on 10/11/19 listed, Altered thought processes r/t (related to) Dx (diagnosis) depression, anxiety, agitation, and dementia aeb (as evidenced by) feeling down or depressed, wandering, confusion resulting in several attempts of reorientation, combative behaviors, yelling at staff and making inappropriate sexual comments to residents and staff. However, there were no interventions implemented to address the identified behavioral care plan problems, for Resident #10, related to the level of supervision needed to keep Resident #10 and/or other residents in the facility safe. Multiple observations had been made during the onsite survey activities of Resident #11 wandering in the hallways and sitting in the common areas. A medical record review for Resident #11 on 1/6/22 at 1:23 PM, revealed a MDS assessment with the ARD of 1/6/22, that documented a BIMS score of 3/15, which indicated severe cognitive impairment. Further review of the medical record revealed in the physician's progress notes that Resident #11 had a diagnosis of unspecified dementia with behavioral disturbances. Further review revealed a care plan initiated on 1/15/20, for potential for wandering with risk of elopement related to the diagnosis of dementia, with a goal to wander safely within the facility without elopement. Staff failed to include interventions that provided supervision for Resident #11. In addition, Resident #11 had a care plan, initiated on 8/17/20, for altered thought processes related to dementia and [CONDITION(S)] as evidenced by delusions and aggressive behaviors towards staff and other residents. The goal was for Resident #11 not to have aggressive behaviors towards staff and residents. An intervention had been initiated on 8/17/20, for staff to be aware of factors that escalate behaviors; however, the intervention had not documented what these factors were and what actions staff were to take had they recognized them. On 1/11/22 at 1:00 PM, a review of the facility's documentation for a resident-to-resident abuse incident on 1/5/21, revealed a statement from Resident #8. In the statement, Resident #8 reported that he/she was lying in bed when Resident #8 felt something on his/her arm and when Resident #8 looked up Resident #9 was standing beside Resident #8's bed. Resident #8 started screaming and yelling and Resident #9 grabbed Resident #8 by the elbow. Continued review of the facility's self-report revealed that the incident occurred on 1/5/21 at 5:00 AM. Resident #8's room was next to Resident #9's room, so staff documented that Resident #8 was offered a room change and declined. The measures taken to prevent further incidents of a similar nature were to post pictures of Resident #9 and of Resident #9's husband on his/her room door. The results of the investigation had been left blank as no investigation had been conducted. The facility staff failed to document any interventions such as increased supervision to address the safety of Resident #9 and other residents. On 1/11/22 at 1:00 PM, a review of the facility's documentation for a facility reported incident of resident-to-resident abuse on 3/5/21 at 8:30 PM, revealed a statement from Geriatric Nursing Assistant (GNA) #20 that read that Resident #10 and Resident #11 were talking in the hallway, when Resident #10 told Resident #11 to shut up then Resident #11 hit Resident #10 and Resident #10 hit Resident #11 back. Review of the self report, revealed the residents were separated by staff. There were no measures taken to prevent further incidents of a similar nature. Local law enforcement was not notified, there was no documented evidence that a thorough investigation had been completed. The residents were separated however, staff failed to implement escalated interventions to ensure the safety of Resident #10 and Resident #11. Furthermore, Resident #10 was seen by Psychiatrist #12 on a regular basis. A progress note written for 3/23/21, documented that staff reported that Resident #10 had increasing restlessness and depression, however failed to mention that Resident #10 had a resident-to-resident altercation on 3/5/21. On 1/11/22 at 1:00 PM, a review of the facility's documentation for the facility reported incident on 3/30/21 at 6:25 PM, revealed a statement from Registered Nurse (RN) #21 that read RN #21 heard a resident screaming to get out and when she went to investigate RN #21 observed Resident #15 hit Resident #10. According to the statement Resident #15 was escorted out of the room and both residents were assessed for injuries. Further review revealed the facility's self report documented an interview with Resident #10 where Resident #10 stated they had went into Resident #15's room to look at a stuffed animal on a bedside table and when Resident #10 picked it up Resident #15 started screaming, so Resident #10 smacked Resident #15 on the arm. The measures taken to prevent further incidents of a similar nature was to encourage Resident #10 and Resident #15 not to interact with each other. However, no interventions were implemented to ensure adequate supervision of Resident #10 for wandering and intrusive behaviors. Furthemore, a thorough investigation was not conducted as evidenced by the RN #21's statement and the interview with Resident #10 had conflicting information about which resident hit the other resident. In addition, local law enforcement had not been notified. A medical record review for Resident #15 on 1/11/22, revealed Resident #15 had an unspecified mood disorder as evidenced by aggressive behaviors. On 1/6/22 at 9:00 AM, a review of the facility's documentation for the facility reported incident dated 5/22/21, for a resident-to-resident abuse, revealed three statements from the following staff: Housekeeper #15, Registered Nurse (RN) #16, and Geriatric Nursing Assistant (GNA) #3. The statements documented that Resident #11 told Resident #9 to leave him/her alone and Resident #9 was hitting Resident #11 with both of his/her fists. Resident #11 had to put up his/her arms to protect themselves. However, staff failed to document when and how they intervened to ensure the safety of the residents. Further review of the investigation file revealed the self-report which documented that the residents were separated by staff. The police had not been notified of the incident. The attending physician #6 was notified, however there was no documentation as to whether new orders were obtained. There were no documented interventions to ensure the safety of Resident #11 and other vulnerable residents in the facility. Resident #9 was not evaluated by a physician after the incident and there were no documented physician progress notes. In addition, there was no documented evidence that Resident #11 was assessed for injuries and treatment provided if needed. There was no documented evidence that Resident #11 was offered social work or psychiatric services following the incident. A review of the facility's documentation for the self-reported Resident-to-Resident abuse incident dated 5/23/21, revealed a statement from Licensed Practical Nurse (LPN) #14, indicating she was passing medications and heard a sound like someone was smacking a book against an object. LPN #14 documented that when she had gone to investigate LPN #14 found Resident #9 standing in the doorway of Resident #10's room. Resident #10, had a BIMS of 4/15, indicating severe cognitive impairment. Resident #10 reported that Resident #9 hit him/her on the face and arms with a book. LPN #14 reported that Resident #10 had some pinkness on his/her arm. The self-report form reported that the residents were separated by staff. The police had not been notified. There was no documented evidence that staff had implemented any interventions to ensure immediate safety of Resident #10 and other vulnerable residents in the facility. The attending physician #6 was notified and gave orders to increase Resident #9's antipsychotic medications, order laboratory testing, and consult with Psychiatrist #12, who agreed with the treatment plan. A concurrent review was completed by LPN #14 for Resident #10, however there was no documented evidence in the medical record that staff assessed Resident #10's arm and face and provided treatment. Furthermore, there was no documented evidence that social work or psychiatric services were offered to Resident #10 following the incident. On 1/11/22 at 1:00 PM, during a review of the facility's documentation for the self reported incident on 8/11/21 at 1:30 PM, it was revealed on the self report form that Resident #21 and the Activities Director witnessed an event between Resident #10 and Resident #19. Resident #21 provided a statement that read that Resident #21 observed Resident #10 came up front and squeezed his/her way into a spot that was facing Resident #19. When Resident #10 attempted to leave the spot, Resident #10 asked Resident #19 to move, when Resident #19 stated he/she was not afraid of Resident #10, that was when Resident #10 balled up his/her fist and hit Resident #19 in the face. The facility staff failed to collect a statement from the Activity Director. Further review of the self-report form revealed, facility staff did not remove Resident #10 from the common area until after Resident #10 punched Resident #19 in the face. Further review of the self report revealed that Resident #10 was known to impulsively lash out when frustrated, however staff failed to document why staff did not intervene before Resident #10 hit another resident. After the incident local law enforcement was not notified. There was no intervention implemented regarding the level of supervision needed to ensure Resident #10, who had been involved in 3 resident to resident altercations since 3/21/21, did not continue to physically lash out at other residents. A review of the facility reported incident documentation on 1/6/22 at 9:30 AM, of a facility reported incident involving resident-to-resident abuse that occured on 9/5/21, revealed a statement from Geriatric Nursing Assistant (GNA) #9. The statement revealed that on 9/5/21 at 10:15 AM, GNA #9 and Housekeeper #10 were redirecting Resident #9 down the center hall when Resident #10 came out of his/her room and punched Resident #9 in the shoulder and then Resident #10 stated to Resident #9 to stay out of his/her room. There was no documented investigation, therefore it was unclear as to when and how the staff intervened. The self-report stated that the residents were separated. Local law enforcement had not been notified. There was no documented evidence that staff implemented interventions to ensure the safety of Resident #9 and other vulnerable residents in the facility. In addition, staff had failed to offer Social work services for Resident #9. Psychiatric services were not offered until 9/30/21, 25 days after the incident. A review of the psychiatric notes on 1/6/21 at 9:30 AM, revealed Psychiatrist #7 made some changes to Resident #9's medications. Further review revealed a concurrent review for Resident #9, dated 9/5/21, that failed to document an assessment of possible injuries to Resident #9. Review on 1/6/22 at 9:30 AM, of the facility's documentation for the facility reported incident on 10/3/21, of resident-to-resident abuse revealed a statement written by Receptionist #11. Receptionist #11 reported that she and Resident #10 were sitting in the Activities office talking when Resident #9 entered and started talking to Receptionist #11. She reported that Resident #10 interrupted Resident #9 telling him/her that nobody wanted to hear Resident #9. Then Resident #10 started using hand gestures towards Resident #9 to go away. Then Resident #9 and Resident #10 started hitting each other and it escalated to Resident #10 grabbed Resident #9 by the throat. At that point Resident #9 started yelling and Receptionist #11 started yelling for help. Review of the self report revealed that the residents were separated however local law enforcement was not notified. There was no documented evidence that interventions were implemented to protect Resident #9 and Resident #10 from each other. In addition, there was no documented evidence that an investigation was conducted. There was no documented assessment for Resident #9 for possible injuries,and no documented referral for Social Work services or psychiatric services. There was no documented assessment for Resident #10 for possible injuries, and no documented referral for Social Work services or psychiatric services. A review of the medical record on 1/6/22 revealed that Resident #9 was seen by Attending Physician #6 who documented a visit with Resident #9 on 10/21/21 (18 days after the 10/3/21 incident), to continue support care and referred to the medication adjustment that was initiated on 9/30/21. On 1/11/22 at 1:00 PM, a review of the facility's documentation for the facility reported incident on 11/3/21 at 2:45 PM, revealed a statement from Activites Aid #22 that read that Activities Aid #22 overheard a confrontation between Resident #10 and Resident #11 and when she went to check on them, Activities Aid #22 observed Resident #10 hit Resident #11 on the back of the head and then grab Resident #11's arm. The statement stated that another Activity staff member intervened and separated them; however, staff failed to obtain a statement from that staff member. Review of the self report form revealed Resident #10 and Resident #11 were separated and redirected. However, measures taken to prevent further incidents of a similar nature documented that the facility was unable to keep Resident #10 and Resident #11 separated as they were friends and staff would continue to encourage them to sit in separate areas and watch for escalating behaviors. This was the 3rd documented resident-to-resident altercation between Resident #10 and Resident #11 since 3/21/21, and the facility failed to implement interventions that included supervision of the residents to ensure their safety. On 1/6/22 at 9:00 AM, a review of the facility's documentation for the self reported incident on 11/10/21, revealed a self report form that documented that Resident #9 wandered into Resident #8's room and staff responded due to Resident #8 yelling and screaming. Resident #8 was observed poking Resident #9 with his/her grabber device. Resident #9 laid down on Resident #8's bed and covered his/her face with their hands. Local law enforcement was not notified and no interventions were implemented to ensure the safety of Resident #9 and other vulnerable residents who may have wandered into Resident #8's room. An interview with Activities Staff #11 on 1/6/22 at 9:33 AM, revealed that she worked with Resident #9 usually 3-5 times a week. Activities Staff #11 stated that she had to redirect Resident #9 out of the other resident's rooms frequently. During an interview with Activities Staff #4 on 1/6/22 at 9:54 AM, it was revealed that they had activities that Resident #9 enjoyed in the common area on a table, however it had not stopped Resident #9 from intrusive wandering behaviors. An interview with Assistant Director of Nursing (ADON) staff #8 on 1/6/22 at 9:25 AM, revealed there were no consistent interventions to provide supervision for Resident #9 when he/she had been wandering in and out of other residents' rooms. An interview with the Director of Nursing on 1/6/21 at 10:11 AM, revealed that she was responsible for reporting and investigating resident-to-resident incidents for the facility. The DON reported that she did not contacted local law enforcement because both residents involved had cognitive impairment. The DON reported that she had discussions with Resident #8 about the fact that the facility could not keep Resident #9 from wandering in Resident #8's room and that Resident #8 should not yell and scream at Resident #9, but call for staff to come and get Resident #9. In addition, the DON stated that incidents were investigated but due to prioritization she did not document the findings. Resident #9, Resident #10, and Resident #11 had multiple incidents of wandering and aggressive behaviors towards each other and towards other residents from 1/21/21 to the time of the survey. However, the facility failed to provide adequate supervision of each resident to ensure their safety and the safety of other residents in the facility. Administrator and DON had been notified of concerns on 1/6/22 at 2:19 PM. Because of these findings, an Immediate Jeopardy was called on 1/6/22 at 5:03 PM, regarding the facility's failure to provide adequate supervision for residents with intrusive wandering behaviors to ensure their safety and the safety of other residents in the facility. The facility submitted three plans of removal. The first removal plan that was submitted on 1/6/22 at 5:50 PM, was not accepted. The second removal plan that was submitted on 1/6/22 at 6:45 PM, was not accepted. The third removal plan that was submitted on 1/6/22 at 7:12 PM was accepted at 7:13 PM, by the Office of Health Care Quality. On 1/12/22 at 10:58 AM, after validation the accepted removal plan had been implemented the IJ was removed. The Administrator was made aware the IJ had been removed on 1/12/22. After removal of the immediacy, the deficient practice remained with potential for more than minimal harm for all remaining residents at a scope and severity of E. The facility's removal plan included the following provisions: 1. Facility arranged direct supervision for Resident #9 that included staff were to remain at arms length of Resident #9 at all times when Resident #9 had been out of bed. 2. While Resident #9 was sleeping the designated staff member was to sit outside Resident #9's room door. 3. Resident #9 was to be transferred to another facility. 4. Date of compliance was 1/6/22.

Based on observation, staff interview and record review, it was determined that the facility failed to prevent a resident from eloping the facility multiple times on 8/12/20, 9/5/20, 10/11/20, 11/3/20 and 11/4/20. This was evident for 1 (Resident #3) of 10 residents reviewed during the survey. The findings include: On 11/5/2020, facility reported incident MD 173 was investigated, which involved Resident #3 being found outside the building in their wheelchair at 4:10 PM on 8/12/2020. Review of Resident #3 ' s record on 11/5/2020 at 11:05 AM revealed that Resident #3 [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment completed 1/17/2020 revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3 which indicates a severe cognitive impact. A BIMS test is used to provide a snapshot of a resident's cognitive ability and is scored out of 15. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care such as cognition, behavior, mobility, activities of daily living, accidents, activities, etc. to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. Resident #3's Elopement Risk Assessment on 1/3/2020 was scored as a 10 and as interventions for a score over 8, the facility notified resident's family and physician. An Elopement Risk Assessment completed 1/13/2020 specified that Resident #3's score increased to 11 and that as an intervention for a score of 8 or higher an order would be obtained from a physician for a Roam Alert Bracelet which was started on 1/13/2020. A Roam Alert Bracelet is a wireless device worn by residents that helps to prevent residents at risk of elopement from leaving the facility while still providing some freedom of movement within the facility. In this case the facility's Roam Alert system activates an audible alarm any time a resident wearing a Roam Alert approaches or opens an exit door, as confirmed by the Director of Environmental Services in an interview on 11/5/2020 at 1:15 PM. Review of Resident #3's Care Plan on 11/5/20 revealed that the interventions for Resident #3's wandering and elopement behaviors had not been updated since 1/15/20. These interventions included testing the resident's Roam Alert Bracelet monthly, ensuring the resident is able to move freely, monitoring the resident for distress, assisting the resident with their basic needs when observed wandering, offering diversional activities, assisting the resident with toileting regularly and providing visual checks as ordered. In an interview with the Director of Nursing (DON) concerning Resident #3's elopements on 11/5/20 at 2:00 PM, the DON stated that the facility had not explored other interventions such as relocating the resident to a facility with a locked unit. Review of Resident #3's medical record on 11/6/20 at 9:00 AM revealed multiple progress notes describing instances where Resident #3 had eloped or attempted to elope from the facility, including on 8/12/20 as reported to the state by the facility in MD 173. In a statement from the Human Resources Scheduling Coordinator (Staff #30), it was revealed that, at approximately 4:10 PM on 8/12/20, Staff #30 observed Resident #3 sitting in their wheelchair outside the front hall fire escape door as they were walking to their car to leave for the day. Staff #30 immediately called the facility and had a staff member open the fire escape door to get Resident #3 back into the building. In a statement written by Maintenance Staff #31, it was revealed that, on 8/12/20, they were informed that the alarm on the front hall exit was not on. Upon checking the Nurse's station alarm switches, Maintenance Staff #31 noted that the alarm was in the off position and proceeded to turn it back on. According to a statement from the Director of Maintenance, the alarm had been checked the morning of 8/12/20 at approximately 7:15 AM, and was in the on position. Further review of Resident #3's medical record on 11/6/2020 revealed that Resident #3 had eloped from the facility or made it through the facility doors thresholds on 9/5/20, 9/13/20, 10/11/20, 11/3/20 and 11/4/20 as confirmed by nursing progress notes. On 9/5/20, LPN #11 stated in a progress note that Resident #3 Had opened door at far end of front hallway and had his/her front wheels out of doorway when the nurse was able to catch him/her. Redirection is ineffective. On 9/13/20, RN #28 stated in a progress note Resident #3 has been eloping out the door numerous times this shift. On 10/11/20, LPN #27 wrote in a progress note that Resident #3 made 2 attempts to elope facility prior to bed and one successful elope to outside and was assisted back in from staff. In a progress note dated 11/3/20, LPN #26 stated that Resident #3 was opening outside doors and getting out of a wheelchair and walking outside. Staff gets him/her to go back inside to sit in a wheelchair. Once he/she got back inside, Resident #3 went to another exit and opened the door. Lastly, on 11/5/20, RN #25 stated in a progress note that Resident #3 was relentlessly attempting to elope multiple times last evening's shift and attempted to make it as far as the blacktop road, abandoning his/her wheelchair on the road and walking. Record review confirmed that, after each of these elopement events, the facility did not order supervision, care plan review or offer new interventions. The Centers for Medicare & Medicaid Services defines Immediate Jeopardy as Immediate Jeopardy (IJ) represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. As a result of the above findings, the Maryland Office of Health Care Quality determined an immediate jeopardy situation existed and the facility was notified of this on 11/6/20 at 9:56 AM. The facility submitted multiple plans to remove immediacy that did not meet minimum standards. On 11/6/20 at 2:52 PM, the facility submitted a revised plan that was reviewed and accepted by the survey team and OHCQ. The provisions of the plan to remove the immediacy included the following: 1. Installation of a Linear e3 Elite Series 36 Access control system to supplement the current Roam Alert system and allow for electromagnetic locks to control resident egress. 2. Resident #3 will be monitored and remain with activities staff from 8 AM to 10 PM to provide monitoring, until the maglock system is operational. All other residents who are elopement risks will be evaluated and any resident who has attempted elopement will also be assigned a staff member to monitor them. 3. Resident #3's care plan will be updated to reflect the intervention. All other residents who have been assessed as active elopement risks will also have their care plans updated. 4. All staff will be educated on the new systems operation and the use of swipe cards and keypads. Staff will also be educated on the overall functionality of the system in daily and emergency operations and attendance will be documented. 5. All education and installation will be completed by 11/12/20. The Immediate Jeopardy was removed on 11/12/20 at 3:38 PM after on-site confirmation of the facility's plan of removal. Cross reference F 657.

Based on record review and staff interview, it was determined the facility failed to follow a resident's care plan by failing to approach the resident at a later time when the resident, who was aggravated and irritable at the time, expressed a desire to not get dressed or get out of bed. Staff nonetheless willfully persisted against the resident's wishes resulting in an interaction where staff pushed the resident's arm away, causing a fracture and requiring treatment. This was evident for 1 (#5) of 10 residents reviewed during a complaint survey. The findings include: The Centers for Medicare and Medicaid Services (CMS) defines abuse as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Facility reported incident MD 742 was reviewed on 11/5/2020 at 9:00 AM and documented that, during a shower on 8/5/19, Resident #5 dug his/her nails into Geriatric Nursing Assistant (GNA) #6's arm, drew blood and tore the skin. The GNA, who was approximately 10 weeks pregnant at that time, pushed Resident #5's arm away and the resident immediately screamed out in pain. The resident was transported to the emergency room where an x-ray was taken and revealed a fractured right humerus. The humerus is the long bone in the arm that runs from the shoulder to the elbow. The humerus connects the scapula and the two bones of the lower arm, the radius, and the ulna. Resident #5's medical record was reviewed on 11/5/2020 at 9:05 AM. A 5/17/19 physician's history and physical documented that the [AGE] year old resident had clinical [DIAGNOSES REDACTED]. Addressing these concerns, the resident care plans indicated that the resident was dependent on staff for activities of daily living, except for feeding as the resident could feed her/him self. Resident #5's care plan related to, altered thought processes and anxiety indicated for staff to be aware of factors that escalate (name) behaviors and remove factors if possible; explain all care to (name) as it is given; have a different staff member offer care to (name) if needed; and if (name) is combative or aggressive, approach at a later time. The facility obtained a statement from GNA #6 on 8/5/19 which stated, I was bathing resident when he/she started to slap me and dig his/her nails into me and I asked him/her to please stop because I'm pregnant and did not want to be hit in the stomach. He/She called me a [***] and continued to dig his/her nails into me. I shoved his/her hand away from me because I was starting to bleed. When I shoved his/her hand away he/she let out a scream and started yelling his/her arm hurt so I ran out of the room and got the other aide and nurse, then I called (name) (ADON) (Assistant Director of Nursing) because I was afraid I had hurt him/her. An interview was conducted with GNA #6 on 11/6/2020 at 12:18 PM: GNA #6 stated, I went in to get Resident #5 ready for the day. Resident #5 had been aggravated, irritated, not in his/her usual mood. I didn't know if there had been a med (medication) change. I tried to get Resident #5 out of bed and get dressed. Resident #5 said, No get the (expletive) out of here. It was not like him/her too much. Resident #5 tried to hit me. I was about 12 weeks pregnant at the time and he/she tried to hit me in the stomach when I was at an angle next to the bed. I swatted his/her arm away and when I did, I heard a crunch, I can't describe it. Resident #5 started screaming that his/her arm hurt. I went to the nurse's station and called the ADON. We were not in the shower at the time. We were in his/her bedroom. I did not use very much force because I know how fragile their arms are when they are older. I didn't want to hurt him/her at all. The DON (Director of Nursing) had a meeting with me after my suspension and told me I should have walked away to give Resident #5 time to cool down, which is what I should have done. GNA #6 failed to follow the crafted care plan to ensure resident safety by continuing attempts to provide care after Resident #5 began to escalate in a manner known, understood and planned for, but GNA #6 did not follow the care plan to stop and approach at a later time. Though no intent was evident the action was deliberate and therefore met the Federal definition for abuse. Review of the emergency room physician's note on 11/5/2020 at 2:30 PM documented, presents to the ED (emergency department) via EMS from the nursing home with complaints of right elbow pain which began this morning. Patient also complains of right shoulder pain. His/Her symptoms are noted to be moderate in severity. An x-ray of the right shoulder on 8/5/19 at 1454 (2:54 PM) documented, comminuted distal humerus fracture. An x-ray of the right humerus on 8/5/19 at 1454 documented, comminuted distal humerus fracture. The emergency room physician documented that a long-arm posterior splint was placed on the resident. The emergency room physician documented that the hospital's orthopedics felt they would not be able to repair the fracture and the resident was transferred to another acute care facility for orthopedic treatment and repair.

Based on staff interview, review of the medical record and resident interview, it was determined that the facility failed to ensure an effective system to manage resident pain when pain medications were ordered but unavailable, pain assessments were consistently not completed in accordance with standards of practice, as-needed pain medications were given with insufficient assessment, effectiveness of pain medication was consistently not reassessed, resident ongoing pain was not reported to the physician, and the care plan for pain management was not followed. This was evident for 1 (#137) of 35 residents reviewed during stage 2 of the Quality Indicator Survey and left Resident #137 in pain they described as severe. The failure to provide necessary services to meet the individualized needs of Resident #137 resulted in harm and constituted neglect as defined in the regulations. The findings include: Resident #137 was admitted to the facility on [DATE] at 2:20 PM from home after a recent hospitalization for pneumonia. Review of the medical record found a hospital consultation report, dated 6/17/15, which noted the resident had other [DIAGNOSES REDACTED]. An admission progress note of 6/22/15 at 4:19 PM noted that the resident was alert and oriented to person, place and time. It also revealed that their home medications were verified, physician orders [REDACTED]. A pain assessment was completed for this resident on 6/22/15 at 3:47 PM and under the caption Observation Details under Location Of Pain, no pain was documented. Review of the admitting physician orders [REDACTED]. moderate pain every 6 hours as needed and sublingual (under the tongue) [MEDICATION NAME] as needed for chest pain. A hospital Consultation Report dated 5/3/13 (in the resident medical record) noted that the resident was receiving the same dosage of [MEDICATION NAME] and [MEDICATION NAME] ER at that time. Review of the resident's Medication Administration Record [REDACTED]. No assessment of the resident related to pain was found in the medical record when his scheduled pain medication was ordered to be administered and was unavailable, and no physician notification was made. (Cross reference F 157) On 6/23/15 at 8:21 AM, the resident was administered 650 mg of [MEDICATION NAME] as needed for back pain, but no pain assessment was found in the medical record related to the characteristics or intensity of the pain. He had been assessed as pain free on admission. The effectiveness of the [MEDICATION NAME] was also not documented. During an interview of Resident #137 on 6/23/15 at 9:20 AM, he stated he was in a lot of pain all over his body. Documentation on the MAR indicated [REDACTED]. The physician returned the call and ordered [MEDICATION NAME] IR (Immediate Release) 10 mg by mouth one time for chronic pai[DIAGNOSES REDACTED] which the resident received at 10 AM on 6/23/15. The verbal physician's orders [REDACTED]. [MEDICATION NAME] IR is a short acting medication and its effects typically do not last 12 hours like the extended release medication does. Again, no assessment of the resident's pain was found in the medical record at 10 AM when the [MEDICATION NAME] IR was administered and no documentation was found in the medical record about the effectiveness of the medication after administration. Review of the June MAR for 2015 revealed that the resident had received [MEDICATION NAME] 650 mg by mouth on 6/23/15 at 2:32 PM for generalized pain. Generalized pain does not constitute a pain assessment and no other documentation of a pain assessment was found in the medical record. At 3 PM, Resident #137 told the surveyor he was still having pain and at 3:47 PM, the MAR indicated [REDACTED]. Interview of RN #4, on 6/23/15 at 4:20 PM, revealed that she marked the [MEDICATION NAME] as not effective because the resident asked for pain medication again. RN #4 stated she had just administered his routine [MEDICATION NAME], that was also administered for pain. When asked during the same interview if his [MEDICATION NAME] ER had arrived from the pharmacy yet, RN #4 responded no, it's not due until 9 PM tonight. RN #4 failed to follow the resident's plan of care for pain which lists as an approach to Notify physician if pain medication is not effective (cross reference F 282). Thus, per facility documentation, the resident had pain since 2:32 PM and no additional interventions were put in place when the medication was not effective at 3:47 PM. No complete assessment of the resident's pain was found in the medical record. Surveyor informed the Assistant Director of Nursing (ADON) at 4:30 PM on 6/23/15 of the resident complaint, ineffectiveness of medication documented at 3:47 PM, the [MEDICATION NAME] ER still not available from the pharmacy and the interview of RN #4. The ADON stated at that time she would look into it. Review of the MAR indicated [REDACTED]. On the MAR under Special Instructions is written until [MEDICATION NAME] ER is delivered from pharmacy. No assessment of the resident's pain was found in the medical record such as intensity, description or location. No effectiveness of the medication was documented in the medical record. A note on 6/23/15 at 6:44 PM documented no signs or symptoms of distress. Resident #137's [MEDICATION NAME] ER for pain was not available from the pharmacy over 24 hours after admission. (Cross reference F 425) Resident #137's physician visited the resident the evening of 6/23/15 and noted in the Admission History and Physical under musculoskeletal is Joint pain multiple esp (especially) back. Under the Treatment section number 6. Spinal stenosis, Notes: Pain control. Meds adjusted. Resident #137's [MEDICATION NAME] was decreased to twice a day, the [MEDICATION NAME] ER was discontinued, and [MEDICATION NAME] IR 10 mg by mouth as needed for moderate to severe pain every 4 hours was ordered. On 6/23/15 at 8:43 PM, staff administered [MEDICATION NAME] IR 10 mg by mouth to the resident for general pain. The medication was ordered for moderate to severe pain. No assessment of the resident's pain is found in the medical record to know the intensity of the pain at the time the medication was administered. The effectiveness was noted on the MAR, 3 hours later at 11:45 PM to be effective. Further review of the MAR indicated [REDACTED]. No documentation was found in the medical record related to the resident's behavior requiring medication for anxiety. The [MEDICATION NAME] was administered a little over 1 hour after the resident was medicated for pain and no indication was found in the medical record regarding the pain medication effectiveness. Resident #137 had just had his long standing three times a day [MEDICATION NAME] decreased to twice a day and had not received his long acting pain medication, [MEDICATION NAME] ER 20 mg twice a day for over 24 hours, which by way of history he has been on for years, and was discontinued also on 6/23/15. Further review of the medical record revealed that again on 6/24/15 at 6:12 AM, the resident received [MEDICATION NAME] IR, 10 mg by mouth for back pain with no description of the pain or intensity noted. And again, the effectiveness of the medication was not found in the medical record. (Cross Reference F 514) Another Admission- Pain Observation was completed on 6/24/15 at 10:40 PM, and noted that the resident is achy, all over all the time. It also notes that on a scale of 1-10 where less than 1 is none (no Pain), his pain is a 7 at its least and a 9 at its worst. Part of a progress Note, dated 6/24/15 at 5:15 PM, in the medical record written by MDS Coordinator #2 reads as follows: During pain assessment section of resident interview resident answered questions about pain over the last 5 days. He answered that; he has pain constantly, the pain makes it hard for him to sleep at night, the pain has not changed his daily activities, he rated his pain over the last 5 days as being a 9 and severe. At the time of the interview while answering the interview questions resident was calm and relaxed without any signs or symptoms of pain. The facility failed to accurately assess a resident's pain, have prescribed pain medication available timely from the pharmacy, document the effectiveness of pain medications, follow a resident's plan of care for pain, and notify the resident' s physician when pain medication was not available.

Based reviews of a medical record, administrative records, and staff interview, it was determined that the facility staff failed to adequately supervise and protect a resident from an accident with injury. This was evident for 2 of 2 residents reviewed during a complaint survey. The findings include: 1) Resident #1 suffers from advanced dementia and Parkinson's disease and is totally dependent upon the nursing staff for all aspects of her care. Review of resident #1's medical record, on 06/27/2013, revealed nursing documentation dated 04/12/2013, indicating that resident #1 rolled out of bed during care which resulted in a laceration to the back of resident #1's head. Resident #1 was sent to the hospital and received 14 staples. In an interview with GNA #1 on 06/27/2013 at 9:05 am, GNA #1 stated that he/she raised resident #1's bed to provide morning care on 04/12/2013 at approximately 9 am. GNA #1 stated he/she turned resident #1 away from him/her and then turned away from resident #1 to grab a resident care item, that was sitting on the bedside table, and that is when resident #1 rolled out of bed to the ground. 2) Resident #2 suffers from dementia and is totally dependent upon the nursing staff for all aspects of her care. Review of resident #2's fall incident report, dated 04/16/2013 at 6:30 am, revealed that resident #2 slid out of his/her bed during care. In an interview with GNA #4, on 06/26/2013 at 7:28 pm, GNA #4 stated he/she was preparing to weigh resident #2 by turning resident #2 away from him/her to place a Hoyer sling underneath resident #2 and that is when resident #2 slid out of bed to the floor. GNA #4 stated the bed was in a low position at the time and resident #2 did not receive any injuries. In conclusion, the facility staff failed to adequately supervise and protect resident #1 from rolling out of bed and injuring her scalp which required a trip to the hospital for 14 staples, and also failed to adequately supervise resident #2 from rolling out of bed which could have potentially injured resident #2.