Every finding on record at Ludlowe Center for Health & Rehabilitation

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #2) reviewed for accidents, the facility failed to ensure adequate supervisor for a resident with dementia to prevent leaving the facility without staff knowledge. The findings include:Resident #2 had a diagnosis of history of falls, vascular dementia, auditory hallucinations, and parkinsonism (neurological deficit). The admission Minimum Data Set (MDS) dated [DATE] identified Resident #2 had a Brief Interview Mental Status (BIMS) score of 9 indicating moderately impaired cognition, had no behaviors, and required maximal assistance with transfers. The Resident Care Plan (RCP) dated 12/12/25 identified a self-care deficit, deficit in functional mobility, and potential for falls. Interventions directed to note any changes in gait, assist of one (1) with transfers, and ambulation with rehabilitation department only. Facility Elopement evaluation dated 12/1/25 identified Resident #1 was not a risk for elopement. Nursing note dated 1/11/26 at 2:34 PM identified Resident #2 had left the building at 1:44 PM; Resident #2 told the Receptionist he/she was a visitor and left the building with a walker.Record review failed to identify any exit seeking behaviors since admission on [DATE]. Nursing note dated 1/11/26 at 6:11 PM identified she observed Resident #2 seated in a chair and calm in his/her room at approximately 12:03 PM. Facility Reportable Event (RE) dated 1/16/26 identified on 1/11/26 Resident #2 was observed leaving the facility at 12:45 PM and at 1:40 PM a neighbor notified the facility that Resident #2 was home. Upon notification, the nursing supervisor checked the unit and confirmed that Resident #2 was not in the facility, and notified the attending physician, and the local police department and requested a wellness check. The local police department conducted a wellness check and reported back to the facility that Resident #2 was home and safe with his/her live-in caregiver. Facility RE summary dated 1/16/25 identified the wellness check identified Resident #2 was safe and did not want to return. The police reported Resident #2 walked to a nearby church where he/she was a member and obtained a ride home from a church member. The facility confirmed Resident #2 had the necessary medications and supplies to meet his/her needs. The facility identified Resident #2 was last observed by staff at approximately 12 PM during lunch, and was wearing jeans, turtleneck and sweatshirt, and appeared calm with no expressed desire to leave. Facility surveillance footage showed Resident #2 left the building at 12:17 PM through the atrium door (opened the door him/herself). The receptionist got up from the desk and looked out the window, and exited the facility to approach Resident #2. Facility interview identified the receptionist asked Resident #2 if he/she was okay and if he/she was a resident. Resident #2 responded he/she was okay and stated he/she was not a resident, was only visiting. Resident #2 proceeded to walk down the driveway to the sidewalk and toward the traffic light and the receptionist returned to the building. Facility interviews identified the receptionist did not observe any nametag or markings on the walker. Review of facility camera footage revealed the following timeline: Resident #2 entered the elevator at approximately 12:15 PM. Resident #2 entered the lobby through the atrium door at approximately 12:17 PM. The atrium door was equipped with a locking mechanism requiring simultaneous activation of a wall-mounted button and door handle; video indicated Resident #2 successfully opened the door after three attempts. Resident #2 exited the front door at approximately 12:19 PM. The receptionist got up from the desk and looked out the window with visual on the resident and at approximately 12:21 PM the receptionist exited the facility to approach the resident. Facility written statement from Receptionist #1 dated 1/11/26 identified she was sitting at the front desk when she observed an older person with a light blue sweater walk past the reception desk with a walker. Receptionist #1 stood up to see where he/she was going and thought they were waiting for a ride because a car had pulled up to the front door. the person did not get in the car and turned left and started walking on the sidewalk toward the street. Receptionist #1 then went out the front door and approached him/her and asked if they were okay, and the person stated yes. Receptionist #1 asked if he/she was a resident and he/she stated no, and that they came to visit. Receptionist #1 then asked if he/she knew where they were going and the person said yes, for a walk. Receptionist #1 noted there was no identification wrist band on and then the person turned left out of the driveway of the facility toward the traffic light (on the sidewalk) and continued walking. Interview with the Director of Rehabilitation on 7/21/26 at 11:23 AM identified Resident #1 ambulation and transfer status was with a walker and supervision. The Director of Rehabilitation further stated although Resident #2 should not transfer or ambulate without supervision, it would be possible for Resident #2 to transfer and ambulate off the unit without supervision. Interview with the Director of Nursing (DNS) and Administrator on 7/21/26 at 1:26 PM identified the Receptionist #1 did not tell staff about the person she observed outside because she thought the person was a visitor and she did not observe any ID bracelet on the person, so she did not think to tell anyone else. However, facility upon investigation identified that Resident #1 did have their identification bracelet on during medication pass on 1/11/26 and that Resident #2 may have taken it off at some point before exiting the facility. Resident #2 had no prior exit seeking behaviors, and was not an elopement or wander risk. Interview failed to identify why staff did not notice Resident #2 walking to the elevator and exiting the unit, and why Resident #2 was able to exit the facility without staff knowledge. Review of facility Elopement Policy dated December 2025 directed that an elopement was defined as the unauthorized absence of a resident from the facility who was unable to make decisions due to mental capacity. Facility documentation review identified staff education was initiated on 1/11/2026 and included review of the elopement policy, and the facility conducted elopement drills starting on 1/15/26. A QAPI meeting was held on 1/11/26 and 1/13/26. Based on review of facility documentation, past non-compliance was identified.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #3) reviewed for accidents, the facility failed to ensure a resident with known grabbing behaviors was free from injury related to side rail use. The findings include:Resident #3 had diagnoses that included dementia with behavioral disturbance, anxiety, depression, reduced mobility, and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15) indicative of severely impaired cognition, exhibited physical and verbal behavioral symptoms directed toward others, was dependent on staff for all ADLs, including bed mobility and transfers, was non-ambulatory and was dependent for wheelchair mobility. The Resident Care Plan (RCP) dated 7/10/2025 identified Resident #3 had a potential for altered mood and behavior due to dementia, had the potential to be physically and verbally aggressive and had repeated movements that included hitting, kicking, pushing, grabbing, pinching, biting, and threatening behaviors, yelled/screamed, and used abusive language. Interventions directed to monitor behaviors, and to intervene before agitation escalates, guide away from source of distress, engage calmy in conversation, if response is aggressive, directed staff to walk away calmly and reapproach later. Review of Resident #3's side rail evaluation dated 8/27/2024 identified Resident #3 had a self-care deficit, and side rails were used to promote independence. The side rail evaluation directed the use of half (1/2) rails/mobility bars for assistance with bed mobility, not to exceed 28 inches in length from the head of the bed. A physician order dated 8/13/2025 directed side rails: half rails up to enable bed mobility every shift. Review of the task/monitor behavior symptoms sheets identified from 9/9/2025 to 9/23/2025, Resident #3 exhibited grabbing behaviors daily except on 9/14/2025 and 9/15/2025. Facility reportable event dated 9/23/2025 at 11:00 A.M. identified Resident #3 presented with right hand edema, discomfort, and erythema (redness). Resident #3 was unable to explain what occurred. X-ray results identified an acute nondisplaced fracture of the proximal phalanx (finger bone closest to the palm) of the fifth digit (finger). APRN #4's note dated 9/23/2025 identified Resident #3 was seen for reported bruising and swelling of the right outer hand. Resident #3 was unable to provide information regarding the injury due to cognitive impairment. A STAT (immediate) x-ray identified an acute nondisplaced fracture in the proximal phalanx of the fifth digit of the right hand. Review of the facility summary dated 9/26/2025 identified Resident #3 had grabbing behaviors with care and during transfers, and extends his/her right arm with the hand lying in between the lower bar openings of the side rail. The summary identified the discoloration noted on the right hand aligns with the side rail. The summary further indicated the fracture was sustained when Resident #3 placed his/her hand in the lower open portion of the side rail. The summary indicated the side rails were discontinued and a perimeter (raised edge) mattress was placed on the bed. Interview with NA #11 on 10/6/2025 at 9:18 A.M. identified she last provided care for Resident #3 on 9/20/2025, and when providing care, Resident #3 always grabs the side rails. Further, NA #11 stated before she provides care to Resident #3, she places a pillow between Resident #3 and the side rails to prevent Resident #3 from grabbing hold of the side rails. Interview and written statement review with NA #7 on 10/3/2025 at 11:07 A.M. identified Resident #3 always grabbed and attempted to grab the side rails or Hoyer lift during care. NA #7 stated she provided care and transferred Resident #3 on 9/22/2025 during the 7 A.M. to 3 P.M. shift, and Resident #3 was yelling and reaching out during care and Hoyer transfer, and she redirected Resident #3 and folded Resident #3's arms onto his/her lap during the transfer. Interview and review of NA written statement with NA #8 on 10/3/2025 at 9:41 A.M. identified she provided care for Resident #3 on 9/22/2025 during the 3 to 11 P.M. shift. NA #8 stated Resident #3 required assistance of one with bed mobility, and during care Resident #3 grabs the side rails. NA #8 further stated when providing care on 9/22/2025, Resident #3 got his/her right hand stuck in between the upper and lower bars on the side rails, and she did not notify the nurse because he/she always grabs the side rail and gets his/her right hand intertwined between the railing. Interview with NA #3 on 10/3/2025 at 11:22 A.M. identified she provided care on the morning of 9/23/2025, and her shift ended at 7 A.M. NA #3 stated Resident #3 always grabs the side rails during care and before she provides care to Resident #3, she places a pillow between Resident #3 and the side rails to prevent Resident #3 from getting injured. NA #3 stated she did not observe any injury, redness or swelling on the right hand during her shift. Interview, record review and review of written statement with LPN #7 on 10/3/2025 at 11:11 A.M. identified she last provided care for Resident #3 on 9/22/2025 during the night shift that ended at 7 A.M. on 9/23/2025. LPN #7 stated she was aware Resident #3 had a history of being resistive to care and grabbing the side rails and was not aware of any behaviors during her shift. Interview and review of written statement with NA #9 on 10/3/2025 at 11:50 A.M. identified her shift started on 9/23/2025 at 7 A.M. and she provided care for Resident #3. NA #9 stated when she gave morning care, she observed a bruise and swelling on the right hand and finger, and she notified the nurse. NA #9 further stated Resident #3 required one staff to reposition in bed, and during care, Resident #3 grabs on to clothing, grabs on to staff, and when turned on his/her side, grabs on to the side rails. NA #9 stated she did not transfer Resident #3 out of bed on 9/23/2025 because of the injury noted to the hand. Interview, record review and written statement review with RN #3 on 10/3/2025 at 10:48 A.M. identified at times Resident #3 was resistant to care and would grab the side rails on the bed. On 9/23/2025, NA #9 reported Resident #3 had discoloration on his/her right hand and fingers. RN #3 stated Resident #3's right hand and last 2 fingers were swollen with purple bruises, and Resident #3 said ouch when she touched the areas. Interview, record review and facility documentation review with the Assistant Director of Nurses (ADON) on 10/6/2025 at 9:56 A.M. identified Resident #3 had agitation at times and extends his/her right arm into the lower opening of the side rails. The ADON stated on 9/22/2025, on the overnight shift (11 P.M.-7 A.M.), Resident #3's right hand and right fingers impacted with the side rails because the bruising lined up with the side rails, causing the fracture. Although the ADON stated the care plan had interventions that directed staff to redirect or deescalate if the resident was agitated, she was unable to explain why there was no intervention to prevent contact with (grabbing) or prevent injury from the side rail use. Interview with MD #2/Radiologist on 10/6/2025 at 11:19 A.M. identified that Resident #3's fracture was likely caused by banging into something, and if Resident #3 was swinging his/her right hand and hit the side rail, it could have caused the fracture. Interview with orthopedic Physician Assistant (PA) #1 on 10/6/2025 at 11:30 A.M. identified Resident #3's fracture was caused by Resident #3 hitting an object. Interview with the Director of Nurses (DNS) on 10/6/2025 at 11:45 A.M. identified she was aware Resident #3 had grabbing behaviors prior to the fracture. The DNS was unable to explain why interventions were not included in the plan of care to direct staff to prevent Resident #3 from hitting his/her hand/arm on the side rails, such as use of a pillow or padding. The DNS stated Resident #3's side rails should have been padded or removed before 9/23/2025 to prevent an injury. The DNS stated on the day the fracture was identified (9/23/2025) the side rails were zip tied to the bed to prevent use, and on 9/24/2025 the side rails were removed from the bed and a perimeter mattress was placed on the bed. The DNS was unable to explain why Resident #3's side rails were not padded or removed prior to the fracture identified on 9/23/2025. Review of facility Behavior Management Program Policy dated 10/2022, directed in part, the behavioral management program will provide the necessary healthcare and services to residents with dementia. The Policy further directed to provided care that maintains a safe environment.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #3) reviewed for accidents, the facility failed to develop and implement a comprehensive a comprehensive care plan was implemented with person-centered interventions for a resident with known grabbing behaviors. The findings include: Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #3) reviewed for accidents, the facility failed to develop and implement a comprehensive comprehensive care plan was implemented with person-centered interventions for a resident with known grabbing behaviors. The findings include: Resident #3 had diagnoses that included dementia with behavioral disturbance, anxiety, depression, reduced mobility, and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15) indicative of severely impaired cognition, exhibited physical and verbal behavioral symptoms directed toward others, was dependent on staff for all ADLs, including bed mobility and transfers, was non-ambulatory and was dependent for wheelchair mobility. The Resident Care Plan (RCP) dated 7/10/2025 identified Resident #3 had a potential for altered mood and behavior due to dementia, had the potential to be physically and verbally aggressive and had repeated movements that included hitting, kicking, pushing, grabbing, pinching, biting, and threatening behaviors, yelled/screamed, and used abusive language. Interventions directed to monitor behaviors, and to intervene before agitation escalates, guide away from source of distress, engage calmy in conversation, if response is aggressive, directed staff to walk away calmly and reapproach later. A physician order dated 8/13/2025 directed side rails: half rails up to enable bed mobility every shift. Review of Resident #3's side rail evaluation dated 8/27/2024 identified Resident #3 had a self-care deficit, and side rails were used as an enabler to promote independence. The side rail evaluation directed the use of half (1/2) rails/mobility bars for assistance with bed mobility, not to exceed 28 inches in length from the head of the bed. Review of the task/monitor behavior symptoms sheets identified from 9/9 to 9/23/2025, Resident #3 exhibited grabbing behaviors daily except on 9/14 and 9/15/2025. Facility reportable event dated 9/23/2025 at 11:00 A.M. identified Resident #3 had a history of striking and hitting behaviors, and presented with right hand edema, discomfort, and erythema (redness). Resident #3 was unable to explain what occurred. X-ray results identified an acute nondisplaced fracture of the proximal phalanx (finger bone closest to the palm) of the fifth digit (finger). APRN #4's note dated 9/23/2025 identified Resident #3 was seen for reported bruising and swelling of the right outer hand. A STAT (immediate) x-ray identified an acute nondisplaced fracture in the proximal phalanx of the fifth digit of the right hand. Review of the facility summary dated 9/26/2025 identified Resident #3 had grabbing behaviors with care and during transfers, and extends his/her right arm with the hand lying in between the lower bar openings of the siderail. The summary identified the discoloration noted on the right hand aligns with the siderail. The summary further indicated the fracture was sustained when Resident #3 placed his/her hand in the lower open portion of the siderail. The summary indicated the siderails were discontinued and a perimeter (raised edge) mattress was placed on the bed. Review of facility investigation identified the following staff statements: LPN #8's written statement dated 9/24/2025 identified Resident #3 had grabbing behaviors. NA #10's written statement dated 9/25/2025 identified Resident #3 had sudden movements and grabbing behaviors, and during Hoyer lift transfers, Resident #3 always swings his/her arms and grabs. Further, NA #10 indicated she uses a pillow to position Resident #3's arms during Hoyer lift transfers and Resident #3 also grabs at the pillow. Interview with NA #11 on 10/6/2025 at 9:18 A.M. identified Resident #3 always grabs the side rails. Further, NA #11 stated before she provides care to Resident #3, she places a pillow between Resident #3 and the siderails to prevent Resident #3 from grabbing hold of the siderails. Interview and review of NA written statement with NA #8 on 10/3/2025 at 9:41 A.M. identified during care Resident #3 grabs the siderails. Interview, record review and written statement review with RN #3 on 10/3/2025 at 10:48 A.M. identified at times Resident #3 was resistant to care and would grab the siderails on the bed. Interview and written statement review with NA #7 on 10/3/2025 at 11:07 A.M. identified Resident #3 always grabbed and attempted to grab the side rails or Hoyer lift during care. Interview, record review and review of written statement with LPN #7 on 10/3/2025 at 11:11 A.M. identified she was aware Resident #3 had a history of being resistive to care and grabbing the siderails. Interview with NA #3 on 10/3/2025 at 11:22 A.M. identified Resident #3 always grabs the side rails during care and before she provides care to Resident #3, she places a pillow between Resident #3 and the siderails to prevent Resident #3 from getting injured. Interview and review of written statement with NA #9 on 10/3/2025 at 11:50 A.M. identified Resident #3 had a history of grabbing on to clothing, grabbing on to staff, and when turned on his/her side, grabbing the siderails. Record review failed to identify a plan of care that directed interventions to prevent an injury from grabbing onto the side rails. Interview, record review and facility documentation review with the Assistant Director of Nurses (ADON) on 10/6/2025 at 9:56 A.M. identified Resident #3 had agitation at times and had a history of extending his/her right arm into the lower opening of the side rails. Although the ADON stated the care plan had interventions that directed staff to redirect or deescalate if the resident was agitated, she was unable to explain why there was no intervention to prevent contact with (grabbing) or prevent injury from the siderail use. Interview with the Director of Nurses (DNS) on 10/6/2025 at 11:45 A.M. identified she was aware Resident #3 had grabbing behaviors prior to the fracture. The DNS was unable to explain why interventions were not included in the plan of care to direct staff to prevent Resident #3 from hitting his/her hand/arm on the side rails, such as use of a pillow or padding. The DNS stated Resident #3's siderails should have been padded or removed before 9/23/2025 to prevent an injury, and the care plan should have included interventions to protect Resident #1 from grabbing the side rails. The DNS was unable to explain why Resident #3's side rails were not padded or removed prior to the fracture identified on 9/23/202 Review of facility Care Plan Baseline/Comprehensive Person Center Care Plan Policy dated 3/2023, directed in part, the interdisciplinary team will observe the resident and obtain additional input from staff to identify high risk factors requiring intervention for potential improvement or prevention and initiate the comprehensive person center care plan to include the problems, goals, and interventions.

Based on review of the clinical record, facility documentation, facility policy, and interview, for the resident (Resident #12) reviewed for accidents, the facility failed to provide adequate supervision for a resident at risk to fall, who was placed in a common area to be closely watched and fell, sustaining an acute fracture at the base of the femoral neck. Additionally, the facility failed to maintain supervision during shift changes, ensure staff assignment/accountability, timely identify and report significant changes in condition, and implement care plan interventions.The findings include:Resident #12's diagnosis included Alzheimer's Disease and dementia. The care plan dated 05/2/2025 indicated Resident #12 was at risk for falls due to poor communication/comprehension, impaired mobility, impaired cognition, resistance to care and the use of psychiatric and cardiac medications. Interventions included to provide non-skid footwear when ambulating or mobilizing in the wheelchair, encourage Resident #12 to be out of the bedroom when awake for socialization and/or recreational activities, offer diversional activities such as music, snacks, toileting, ambulating, fluids, puzzles, therapy evaluation and treat as indicated and to check the medication regimen with the pharmacist regarding medications that increase risk for falls. The care plan dated 05/05/2025 indicated Resident #12 had a deficit in functional mobility with interventions including 2-person assistance for transfers and bed mobility and ambulation only with the rehab/therapy department. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #12 was severely cognitively impaired, used a walker and a wheelchair, required maximum assistance for sit to stand and transfers, was dependent on staff for ambulating 10 feet and had no signs of pain. The MDS further indicated Resident #12 had no falls in the last 6 months prior to admission, had no falls since admission to the facility and was receiving physical and occupational therapy. A nursing note dated 05/09/2025 at 4:23 AM indicated Resident #12 was resistive with hands-on care, confused and had no complaints of pain. An SBAR Summary (standard format for organizing and conveying information) dated 05/09/2025 completed by the charge nurse (LPN #5) at 11:00 PM indicated Resident #12 had a fall which occurred at the change of shift resulting in a skin tear and no evidence of pain. The Reportable Event Form completed by LPN #5 dated 05/09/2025 indicated Resident #12 had an unwitnessed fall at 10:57 PM while in the dining room and sustained a skin tear to the right elbow. Resident #12 was alert, restless, agitated and confused at times, had poor safety awareness and made several attempts to ambulate unassisted. Resident #12 required assistance of 2 for transfer and bed mobility, assist of 1 person for activities of daily living and ambulates only with therapy. Further, no change in mental status or physical status was noted except for a skin tear of the right elbow for which treatment was provided. The APRN and family member was notified. Range of motion (ROM) was within normal limits, no internal or external rotation of limb per the Registered Nurse The form was signed by the Administrator dated 05/20/2025. A Nursing Pain Tool evaluation dated 05/09/2025 at 11:00 PM indicated Resident #12 had no pain at the present time or during the last 5 days. An order note dated effective 05/10/2025 at 2:02 AM written by the second shift Nursing Supervisor, (RN #5), indicated on 05/09/2025 at 10:57 PM Resident #12 was sitting in the dining room in a wheelchair, stood up and was on the floor with a skin tear on the right outer elbow. The APRN was notified and a treatment order for the elbow skin tear was obtained at 11:16 PM. After a body audit was conducted, including range of motion (ROM) and neurological checks Resident #12 required 3 staff members to stand and transfer to the wheelchair. The resident representative was notified of the incident by the charge nurse at 11:16 PM. A Change in Condition (CIC) follow-up note dated 05/10/2025 at 07:02 AM by the 11:00 PM - 7:00 AM charge nurse (LPN #4) indicated Resident #12 had no complaints of pain or distress, neurological evaluation continues in progress with no attempts to get out of bed and slept well. A Medication Administration Note dated 05/10/2025 at 08:04 PM indicated Tylenol 325mg, 3 tablets were given to Resident #12 orally for moderate pain. Tylenol was effective with no pain on reevaluation. A late entry note for 05/10/2025 at 08:04 PM indicated LPN #4 was present with nurse aide NA #8 providing incontinent care. Resident #12 was at his/her baseline confusion with pushing staff away with his/her hands and kicking both legs while in bed. Resident #12 indicated his/her leg hurts. LPN #4 indicated Resident #12 was independently, actively, moving both legs up and down without difficulty, noting no observable abnormalities including changes in skin color, bruising, redness or swelling. Tylenol was given for stated leg pain with positive effect, and the resident was observed in bed resting and slept the remainder of the shift. A Physical Therapy Treatment Encounter Note dated 05/11/2025 at 11:17 AM indicated Resident #12 had dementia and was a fall risk. The note indicated Standing at the Rolling walker 2 times for 1 minute and 1 time for 45 seconds was completed with minimum assistance of the therapist. Sit to stand to the rolling walker with minimum to moderate assistance of the therapist and verbal cues for proper sequencing was completed. The note further indicated Resident #12 was resistant to therapy saying, I can't and refused walking. A Change in Condition Follow-Up Note dated 05/11/2025 at 06:02 PM indicated no changes in range of motion or immobility. A Change in Condition Follow-up Note dated 05/12/2025 at 07:37 AM indicated in Resident #12 was post fall day #3 with a skin tear to the right elbow, no signs or symptoms of pain, agitation noted only when providing care and slept well. A Health Status Note Dated 05/12/2025 at 12:15 PM written by RN #6 indicated she notified the APRN that Resident #12 had right leg pain and would not allow her to touch the leg to assess. A late entry note dated 05/12/2025 at 3:11 PM by RN #6 indicated she was notified by the nurse aide that Resident #12 had right leg pain and on assessment of the right leg and hip Resident #12 flinched. The APRN was notified. A Progress Note Dated 05/12/2025 at 1:42 PM written by APRN #1 indicated the reason for the visit to Resident #12 was for complaints of right leg/hip pain. The assessment identified Resident #12 was complaining of right leg pain (s/p fall 05/09/2025, 3 days ago) but due to dementia was unable to articulate the exact location of the pain but pain was noted to the right hip on palpation and the resident had difficulty lifting the right lower extremity. As a result, x-rays to rule out a fracture and Tylenol 1000mg orally 3 times a day for pain control was ordered. A Health Status Note dated 05/13/2025 at 11:49AM indicated the x-ray provider called to report Resident #12 had an acute right hip fracture. The nursing supervisor and APRN were updated and orders were obtained to send Resident #12 to the hospital emergency room for further evaluation. After the responsible family member was notified, the resident was transferred to the hospital via ambulance leaving the facility at 11:50 AM. A reportable event form, event first known to the facility dated 05/13/2025 at 12:00 PM resulted in a serious injury. It further indicated Resident #12 had an unwitnessed fall on 05/09/2025 at 11:00 PM and on 05/12/2025 Resident #12 was noted to be guarding the right lower extremity and complaining of leg pain. Subsequently Resident #12 was evaluated by APRN #1 and scheduled Tylenol for pain was ordered along with x-rays. The x-rays indicated an acute nondisplaced fracture at the base of the femoral neck (hip fracture) and Resident #12 was transferred to the hospital. A statement from LPN #5, who worked on 5/9/2025, dated 05/15/2025 (6 days after the fall) indicated she was monitoring Resident #12 and other residents in the common area and when the oncoming shift nurse arrived LPN #5 left to complete the narcotic count. LPN #5 indicated she did not see the resident fall but found the resident on their right side on the floor complaining of pain to the right elbow where a skin tear was noted. A facility interview with LPN #4 completed during their investigation dated 05/15/2025 (6 days after the fall) indicated on 05/10/2025 s/he assisted NA #8 to provide incontinent care as the nurse aide indicated the resident was being combative with care. During care Resident #12 complained of right leg pain and remembering the fall on 05/09/2025, LPN #5 administered Tylenol for the pain and upon reevaluation the resident indicated no further pain. The Reportable Event Summary dated 05/19/2025 indicated during Resident #12's hospitalization the resident underwent open reduction and internal fixation (ORIF) surgery to repair the right hip fracture and was readmitted to the facility on [DATE].An interview, facility document and clinical record review with RN #3, the regional RN, on 09/12/2025 at 10:45 AM indicated upon further investigation after the fracture was discovered, s/he noted on 05/10/2025 at 08:04 PM, Resident #12 had complained of right leg pain, the nurse administered Tylenol but did not report the pain to the supervisor or the physician. RN #3 identified staff had moved Resident #12 to the dining room for falls with other residents at risk to be closely watched, but at the change of shift no one was watching Resident #12 while the charge nurses were counting the narcotics. RN #3 stated the facility does not provide 1:1 supervision. Interview with the Director of Nursing Services (DNS) on 09/15/2025 at 01:50 PM indicated on 9/16/2025 at 11:05 AM interview with LPN #5 (charge nurse for Resident #12 at the time of the fall on 05/09/2025) indicated Resident #12 had already been toileted and provided care, was sitting close to the nurse's station in the dining room. LPN #5 indicated residents who were seated in the dining room are those who are restless or cannot sleep and are brought to the dining room so staff can keep an eye on them. The nurse aides are assigned a half hour at a time during the shift. LPN #5 indicated she was not aware of which staff member was scheduled to watch Resident #12 at the change of shift when the fall occurred. LPN #5 indicated she did not tell the nurse aides to be sure someone was watching the residents in the dining room while the two charge nurses were counting the narcotic medications. LPN #5 indicated other staff were at the nursing station due to change of shift but could not remember who. LPN #5 indicated NA #12 had most likely left the unit before 11:00 PM to report to another unit s/he was scheduled to start working at 11:00 PM stating the nurse aides give each other report at the change of shift and if they are leaving the unit they report to staff before doing so. An interview with RN #5 on 09/16/2025 at 11:38 AM who worked as the 3:00 PM - 11:00 PM nursing supervisor on 05/09/2025 indicated s/he was called to the unit due to a resident fall. After assessing Resident #12's range of motion, there were no leg length changes, no external rotation, no pain or abnormalities. There was a skin tear on the elbow. The on-call APRN service was called, the fall and resident condition was reported, a treatment order obtained, and the charge nurse called the family member. An interview on 09/16/2025 at 11:58 AM with NA #10 who worked the 3:00 PM - 11:00 PM shift on 5/9/2025 indicated s/he was coming back from a resident room and when passing the dining room was asked by the nurses to come help them as Resident #12 was on the floor. NA #10 indicated there were assignments indicating who and when each staff member was assigned to watch the residents in the dining room area further indicting not knowing who was assigned and added it was the change of shift, and everyone was getting ready to leave. An interview on 09/16/2025 at 12:16 PM with LPN #4 who worked second shift (3:00 PM - 11:00 PM) on 5/10/2025 and first and second shifts (7:00 AM - 3:00 PM and 3:00 PM- 11:00 PM) on 05/11/2025 indicated the nurse aide asked him/her to assist with Resident #12 due to the resident being combative while trying to provide incontinent care. While assisting NA #8 with providing care to Resident #12, NA #8 indicated to LPN #4 that Resident #12 was having leg pain. LPN #4 indicated Tylenol was given for pain and was effective later when the resident was reevaluated and the resident slept the remainder of the shift. LPN #8 indicated the 3:00 PM - 11:00 PM supervisor did not come to the unit to obtain report at the end of the shift and LPN #8 indicated she did not call the supervisor to report the pain because it was relieved with the Tylenol provided. Further, the resident was moving his/her legs and was not screaming in pain and the supervisor would only be notified when the pain medication does not work. LPN #4 who worked the next day (5/11/2025) indicated Resident #12 was already up in the wheelchair when seen and had no complaints of pain or discomfort and had visitors who stayed for quite some time and offered no concerns. Attempts were made on 09/16/2025 at 12:48 PM to contact NA #8, the third nurse aide who worked 05/09/2025 3:00 PM - 11:00PM (second shift) and worked second shift on 05/10/2025 who provided incontinent care to Resident #12 and reported Resident #12 had complained of leg pain, were unsuccessful. An interview on 09/16/2025 at 01:02 PM with RN #6 who worked first shift on 05/12/2025 indicated noticing Resident #12 had pain and flinched when touched and notified the APRN who was in the facility and ordered x rays.An interview on 9/17/2025 at 7:23 AM with NA #12 who worked 5/9/25 second shift (3:00 PM -11:00 PM) and was assigned to provide care for Resident #12 indicated Resident #12 was always on the move further indicating care and toileting had been provided around 09:45 PM then the resident was brought to the dining room/lounge area to be watched. NA #12 identified Resident #12 cannot be placed in bed until later when the resident shows signs of being tired because he/she would try to get out of bed unassisted and could fall. NA #12 indicated not knowing who was assigned to watch the residents in the dining room/lounge area at the time. NA #12 left the unit at about 10:53 PM to report for duty for the 3rd shift on another unit at the facility. NA #12 further indicated about 10 minutes after leaving the unit, a nurse aide came to find her on the new assigned unit to provide an investigation statement to be completed by NA #12 as Resident #12 had a fall. NA#12 indicated not being able to remember where the staff were on the unit when s/he reported to them s/he was leaving the unit for the next shift but did indicate staff would have been at the nurse's station or the Kiosk at the end of the shift preparing to leave. The facility policy Labeled Fall Prevention Program indicated that all residents would be evaluated for risk for falls on admission, readmission, and with a change of condition. Residents at high risk for falls would have interventions initiated to prevent falls.

Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 4 residents (Resident #98) reviewed for respiratory care, the facility failed to determine if it was clinically appropriate for the resident to self-administered oxygen. The findings include:Resident #98 was admitted to the facility in April 2025 with diagnoses that included atherosclerotic heart disease (plaque buildup inside the arteries that supply blood to the heart), chronic kidney disease, and heart failure.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #98 was cognitively intact and required moderate assistance (helper does less than half the effort) with toileting hygiene, showering, upper and lower body dressing, and transfers. The Resident Care Plan (RCP) dated 7/31/25 identified Resident #98 had altered respiratory status, difficulty breathing and hypoxemia (low levels of oxygen in the blood). Interventions included position resident with proper body alignment for optimal breathing and administer oxygen 2 at liters per minute via nasal cannula.Observations on 9/8/25 at 12:41 PM and at 2:20 PM identified Resident #98 seated in wheelchair inside in his/her room with oxygen at 2 liters via nasal cannula. Observation on 9/9/25 at 11:30 AM identified Resident #98 seated up in bed with oxygen at 2 liters via nasal cannula. Interview with LPN #1 on 9/10/25 at 10:02 AM identified Resident #98 puts the oxygen on when he/she feels short of breath and the physician is not aware.Interview with Assistant Director of Nurses (ADNS) on 9/10/25 at 10:39 AM identified if Resident #98 puts oxygen on when he/she feels short of breath, there should be a physician's order for it and Resident #98 should be evaluated to ensure he/she is able to self-administer oxygen.Interview with the Director of Nurses on 9/15/25 at 9:23 AM identified that an evaluation is needed to determine the resident's ability to safely self-administer oxygen.Review of the Self-Administration Policy dated 10/2024 directed a Self-Administration Evaluation is completed by the licensed nurse to evaluate the resident's safety and understanding of their medication/treatments. If evaluation determines it is safe for the resident to self-administer, the licensed nurse will obtain an order from the Healthcare Provider for self- administration for the specific medication/treatment. The licensed nurse is responsible to account for every medication/treatment on the EMAR and TAR. The licensed nurse will periodically review for continued cognitive and physical ability to self-administer.

Based on review of the clinical record, facility documentation, facility policy and interviews for the only resident (Resident #44), reviewed for missing clothing, the facility failed to acknowledge the resident's complaint of missing clothing and actively work toward resolution of that complaint. The findings include: Resident #44 was admitted with diagnoses that included chronic pain. The quarterly MDS dated [DATE] identified Resident #44 was cognitively intact. The MDS further indicated that Resident #44 required set-up or clean-up assistance for upper-body dressing and supervision or touching assistance for lower-body dressing. A care plan dated 7/11/2025 indicated that Resident #44 had a self-care deficit with interventions that included to provide supervision, such as verbal cues or touch assist for dressing. Interview with Resident #44 on 9/8/2025 at 12:44 PM identified that he/she was missing 2 to 3 pairs of pants, 2 shirts, and a sweater that had been taken to the laundry 3 weeks ago. Resident #44 indicated he/she was particularly concerned about the sweater, as it was a sweater he/she frequently used to go to appointments in the mornings. Resident #44 indicated he/she had told NA #7 and Laundry Aide #1, but could not recall the date. Resident #44 could not recall if his/her clothes were labelled. Further, Resident #44 indicated he/she did not know if anything was being done about the missing clothes and that, since the incident, he/she has family do the laundry. A review of nursing notes from 8/25/2025 to 9/10/2025 and review of social work documentation from 1/24/2025 to 9/15/2025 failed to identify documentation related to missing belongings. A review of the clical record failed to identify a Personal Belongings Checklist. Interview with NA #7 on 9/10/2025 at 10:58 AM identified that laundry was usually placed in personal laundry hampers that are labelled with the resident's room and bed number. The laundry department collects the hampers and returns the clothes a few days later. NA #7 indicated that Resident #44 had told her, a while back, that he/she was missing clothes from the laundry. Further, NA #7 indicated she had found a pajama suit belonging to Resident #44 in another resident's room and returned it to Resident #44. NA #7 identified that Laundry Aide #1 and LPN #1 were aware of the missing belongings. Interview with LPN #1 on 9/10/2025 at 12:00 PM identified that she was aware that Resident #44 was missing clothes and further indicated that laundry was aware, however, LPN #1 could not identify what had been done or what was being done regarding the missing clothes. Additionally, a record review with LPN #1 failed to identify a Personal Belongings Checklist in the paper chart or the electronic medical record. Interview with the Director of Housekeeping on 9/10/2025 at 1:32 PM, who also oversaw the laundry department indicated that laundry that was collected on Tuesdays and Wednesdays was returned the following Monday, and laundry collected on Saturday and Sunday was returned on the following Thursday. The Director of Housekeeping indicated it's a [NAME] turnaround time for personal laundry to be returned from the day it was collected to the day it gets dropped off the by the laundry aide. The Director of Housekeeping indicated that the facility has a tracking system for missing belongings, and when belongings are missing, the facility tells the resident to give the facility a few weeks to look for the belongings. The Director of Laundry indicated he was not aware of any missing belongings for Resident #44. Interview with Social Worker #1 on 9/10/2025 at 2:31 PM indicated she was not aware Resident #44 had any missing belongings. Social Worker #1 indicated that when clothing is reported missing to social services, they work with the laundry department, notify the family or resident of what is being done, and then do a last follow-up once missing belongings are resolved or are unable to be resolved. Social Worker #1 indicated that social services gets notified of missing belongings by residents, family, or the nurse aides. Additionally, nurse aides, family, or residents can fill out a grievance form. Once social services receives the grievance, the social worker will follow up with the resident to obtain a list of belongings that are missing. Interview with the Director of Housekeeping on 9/10/2025 at 3:22 PM identified there was no other tracking system for missing belongings and that he used the grievance forms to track missing belongings. Additionally, the Director of Housekeeping indicated that he did not think Resident #44's clothes were labelled; however, the Director of Housekeeping further indicated that whether clothes are labelled or not, the facility would still follow the grievance process. The Director of Housekeeping indicated that Resident#44 must have been overlooked, and therefore, there was no grievance written for regarding the missing laundry, and that he had spoken to Resident #44 on 9/10/2025 to obtain details of the missing clothing. Interview with Laundry Aide #1 on 9/10/2025 at 3:25 PM identified that she was aware of Resident #44's missing belongings and that the resident had been complaining to her about missing laundry for a while but could not recall the exact dates but indicated the resident complained to her about the same belongings 3 or 4 times. Laundry Aide #1 indicated that once Resident #44 was crying about his/her missing sweater, which had a hood. Laundry Aide #1 indicated she went through the clothes in the laundry room but was unable to locate any, and that she told the Director of Housekeeping of Resident #44's missing laundry on several occasions but was unaware of what had been done. The facility policy for Resident Lost Property indicated that upon report by a resident of lost property, the facility would document the report as a grievance pursuant to the facility's Grievance Policy and conduct a thorough search for the missing property. The facility's Grievance Policy indicated that facility staff are encouraged to attempt to resolve the verbal grievance/concern at the time it is brought forward, when possible, and that in the case that a concern cannot be resolved promptly, the staff member would complete the grievance form or give it to the person with the concern to complete. The form would then be forwarded to the social service department.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #76), reviewed for abuse, the facility failed to ensure the resident was free from abuse. The findings include: Resident #76's diagnoses included Dementia, anxiety disorder and adjustment disorder. The revised care plan dated 4/6/24 identified prior resident to resident incident. Interventions included providing emotional support, monitoring changes in mood or behavior, psychiatric follow up etc. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #76 was cognitively impaired, required set-up assistance with bed mobility and was independent in chair to bed mobility and sit to stand. Review of a facility statement dated 11/30/24 at 2:50 PM by Recreation #1 identified as she was charting; Resident #64 began yelling at Resident #76 telling him/her (no) then proceeded to slap Resident 76 in the face on the right side. A progress note dated 11/30/24 at 5:02 PM identified it was mentioned to this social worker that Resident #76 was hit by Resident #64. Both residents have a diagnosis of dementia. Social worker will continue to follow up to monitor mood and behavior. A progress note dated 11/30/24 at 6:59 PM identified Resident #76 was in the recreation room on the 2nd floor when Resident #64 slapped him/her on the right side of the face. Resident #76 did not provoke Resident #64. Both residents have dementia. No injury. Resident #76 denied pain. Observation on 9/8/25 at 12:53 PM identified Resident #76 and Resident #64 were observed in the dining area sitting at separate tables. Interview on 9/12/2025 at 10:03 AM with Recreation #1 indicated Resident #64 assaulted Resident #76. Recreation #1 reported nothing happened prior to agitate the resident and indicated Resident #76 and Resident #64 were separated following the incident. Further, Recreation #1 indicated to her knowledge there were no previous altercations involving Resident #64 and Resident #76. Review of the Abuse Policy indicates each resident has the right to be free from abuse.

Based on review of the clinical record and interviews for 1 of 2 residents (Resident #154) reviewed for discharge, the facility failed to ensure complete information regarding the discharge was documented in the resident's medical record and complete information was communicated to the receiving health care institution or provider. The findings include:Resident #154's diagnosis included pneumonia and dysphagia.The care plan dated 07/3/2025 indicated Resident #154 was in need of a safe and appropriate discharge plan with interventions including to assess discharge needs, at admission and throughout stay, involve the resident, family, and/or responsible party in discharge planning, providing education, regarding medications and/or treatments and therapy home evaluations if needed.The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #154 had a moderate cognitive impairment.A Discharge Summary Guide-V4 dated 07/25/2025 at 1:35 PM was incomplete with sections not completed by nursing, physical/occupational/speech therapy, and dietary. The social service section indicated Resident #154 was to receive home care services and would have a private duty nurse aide. The form indicated oxygen, and a transport chair were ordered through a supplier and indicated the need to follow up with the primary physician for an appointment. The retained discharge information also include an 8-page form labeled NAC: Functional Abilities Summary-discharge and NPE-V5 (an assessment of Resident #154's functional abilities during the last 3 days of his/her stay at the facility), functional status was blank on the first 7 1/2 pages, and there was no staff signature.An interview with the DNS on 09/15/2025 at 1:10 PM indicated she was not able to locate the W-10 or a physician order for discharge home with services.An interview and record review on 09/15/2025 at 2:05 PM with SW #2 identified the interdisciplinary discharge summary was not completed or signed by the complete interdisciplinary team and no physician order was found. The W-10 would have been completed by nursing, and SW #2 would obtain a copy to fax to the home care agency and nursing would retain a copy for the chart. SW #2 indicated s/he only retains the W-10 faxed to the agencies for about 2 weeks then discards and does not retain a copy of fax receipt.The facility policy labeled Clinical Services Subject: Admission, Discharge Policy section, Discharge Process indicated in part, the interdisciplinary team would complete all necessary discharge paperwork including the Discharge Summary guide, the Transfer/Discharge Report the forms are then placed in the discharge folder and given to the resident or the responsible party at the time of discharge. The policy further indicated the licensed nurse would be responsible for reviewing the Discharge Summary guide and the transfer/discharge report including the me with the resident/responsible party and once completed the patient/responsible party signs the form and the health care provider signs the document then uploads the document into the electronic health care record.

Based on observation, review of the clinical record, facility documentation, and interviews for 1 of 2 residents (Resident #102) reviewed for indwelling catheter, the facility failed to develop a care plan with interventions to care for the catheter and for 1 resident (Resident #13) reviewed for skin, the facility failed to ensure the care plan was updated to include noncompliance with geri sleeves. The findings include: Resident #102‘s diagnoses included retention of urine. A physician's order dated 7/31/25 directed to irrigate the indwelling catheter with 60cc of sterile saline. The admission Minimum Data Set assessment dated [DATE] identified Resident #102 was cognitively intact, dependent with toilet hygiene and max assistance with bed mobility. The care plan dated 8/7/25 failed to reflect the indwelling catheter. Interview with Resident #102 on 09/08/2025 at 12:07 PM indicated ongoing pain due to catheter. The resident indicated he/she has reported the pain to staff; however, they have not been able to give him/her an answer. Interview with the DNS on 9/15/2025 at 10:32 AM indicated that a care plan should identify focus areas and the nursing team is responsible for ensuring this is done. The DNS is unsure why the care plan was not updated to reflect residents' indwelling catheter. The policy Baseline/Comprehensive Person-Centered Care plan indicates the Comprehensive Person-Centered Care plan will be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating the care plan. 2. Resident #13 was admitted on [DATE] with diagnoses that included dementia, diabetes, and nonthrombocytopenic purpura (small purple or red spots on the skin from bleeding under the skin). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was severely cognitively impaired and required moderate assistance (helper does less than half the effort) with toileting hygiene, upper and lower body dressing, personal hygiene and maximal assistance (helper does more than half the effort) with transfers. The Resident Care Plan (RCP) dated 8/7/25 identified Resident #13 had potential for skin breakdown due to muscle weakness. Interventions included to perform skin checks with care for changes, report changes to the nurse and treatments as ordered. A physician's order dated 8/17/25 directed bilateral upper extremity (both arms) geri sleeves (soft fabric sleeves used to protect skin) every shift for fragile skin related to nonthrombocytopenic purpura. Check placement every shift. May remove for care. Observations on 9/8/25 at 1:23 PM and on 9/15/25 at 9:56 AM identified Resident #13 dressed in long sleeve top without the benefit of geri sleeves. Interview with LPN #2 on 9/15/25 at 9:58 AM identified Resident #13 refused to wear geri sleeves on both upper arms, did not currently have them on, has a history of skin tears to both arms and is non-complaint with the geri sleeves. Interview with Assistant Director of Nurses (ADNS) on 9/15/25 at 10:13 AM identified if Resident #13 refused to wear geri sleeves, staff should re-approach Resident #13 to wear them and if refused, family and physician should be notified, and a care plan should be developed to address the noncompliance. Subsequent to surveyor inquiry, on 9/15/25 the RCP was revised with interventions that included to apply house moisturizer to both upper arms and long sleeve shirts and long sleeve sweaters to be placed. Although requested, a facility policy for skin protective devices was not provided.

Based on review of the clinical record, facility documentation, facility policy and interview for the only resident (Resident #12) reviewed for accidents the facility failed to ensure staff transferred the resident with the assistance of 2 per the plan of care, and for 1 resident (Resident #13) reviewed for skin, the facility failed to ensure geri sleeves were applied per the physician's order. The findings include: Resident #12's diagnosis included Alzheimer's Disease. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #12 was severely cognitively impaired, used a walker and a wheelchair, required maximum assistance for transferring from sitting to a standing position and for transfers to a chair, and had no signs or symptoms of pain. The care plan dated 05/5/2025 indicated Resident #12 had a deficit in functional mobility with interventions that included the need for the assistance of 2 staff members for transfers and bed mobility. The Reportable Event Form completed by LPN #5 dated 05/09/2025 indicated Resident #12 had an unwitnessed fall on 05/09/2025 at 10:57 PM and sustained a skin tear to the right elbow. The resident was alert, restless, agitated and confused at times, had poor safety awareness and several attempts to ambulate unassisted. Resident #12 required assistance of 2 for transfer. A facility Investigation Statement form (no date) indicated NA #9 had worked 3rd shift (11:00 PM - 07:00 AM) on Resident #12's unit and assisted Resident #12 back to bed around 11:20 PM after the resident sustained a fall with injury at the change of shift. NA #9 indicated she transferred Resident #12 from the wheelchair to the bed alone without a second staff member by standing the resident who then turned and sat on the side of the bed. NA #9 further indicated Resident #12 had no complaints of pain at that time, was in bed the remainder of the shift and had no complaints of pain. An interview and clinical record review with RN #3 indicated after further investigation once the fracture was known, a nurse aide identified she had independently transferred Resident #12 to bed after the fall but should have transferred Resident #12 with 2 staff members assistance per the plan of care. An interview on 09/12/2025 at 01:48 PM with NA#9 who worked 3rd shift (11:00 PM - 07:00 AM) identified she assisted Resident #12 back to bed from the wheelchair alone without another staff assist. NA #9 did not offer a reason why she did not ask for another staff member to assist with the transfer as Resident #12's care plan indicated 2 staff assistance. A policy regarding resident transfers was not provided. The Facility policy labeled Change in Condition Notification indicated in part the purpose of the policy is to ensure a resident's change of condition is evaluated, documented, and reported to the healthcare provider. 2. Resident #13 was admitted on [DATE] with diagnoses that included dementia, diabetes, and nonthrombocytopenic purpura (small purple or red spots on the skin from bleeding under the skin). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was severely cognitively impaired and required moderate assistance (helper does less than half the effort) with toileting hygiene, upper and lower body dressing, personal hygiene and maximal assistance (helper does more than half the effort) with transfers. The Resident Care Plan (RCP) dated 8/7/25 identified Resident #13 had potential for skin breakdown due to muscle weakness. Interventions included to perform skin checks with care for changes, report changes to the nurse and treatments as ordered. A physician's order dated 8/17/25 directed bilateral upper extremity (both arms) geri sleeves (soft fabric sleeves used to protect skin) every shift for fragile skin related to nonthrombocytopenic purpura. Check placement every shift. May remove for care. Observations on 9/8/25 at 1:23 PM and on 9/15/25 at 9:56 AM identified Resident #13 dressed in long sleeve top without the benefit of geri sleeves. Interview with LPN #2 on 9/15/25 at 9:58 AM identified Resident #13 refused to wear geri sleeves on both upper arms, did not currently have them on, has a history of skin tears to both arms and is non-complaint with the geri sleeves. Interview with Assistant Director of Nurses (ADNS) on 9/15/25 at 10:13 AM identified if Resident #13 refused to wear geri sleeves, staff should re-approach Resident #13 to wear them and if refused, family and physician should be notified, and a care plan should be developed to address the noncompliance. Interview with ADNS on 9/15/25 at 11:45 AM identified the physician's order for application of geri sleeves daily should be followed, and if Resident #13 is non-compliant, the physician should be notified. Although requested, a facility policy for skin protective devices was not provided.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #98) reviewed for respiratory care, the facility failed to obtain a physician's order for oxygen for a resident who was using oxygen as needed and failed to ensure the oxygen tubing was dated when changed. The findings include: Resident #98 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (plaque build up inside the arteries that supply blood to the heart), chronic kidney disease, and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #98 was cognitively intact and required moderate assistance (helper does less than half the effort) with toileting hygiene, showering, upper and lower body dressing, and transfers. The Resident Care Plan (RCP) dated 5/16/25 identified Resident #98 had altered respiratory status and difficulty breathing with hypoxemia (low levels of oxygen in the blood). Interventions included to position the resident with proper body alignment for optimal breathing and administer oxygen 2 liters per minute via nasal cannula. Observation on 9/8/25 at 12:41 PM and at 2:20 PM identified Resident #98 seated in wheelchair with oxygen at 2 liters via nasal cannula. The oxygen tubing was not dated when last changed. Observation on 9/9/25 at 11:30 AM identified Resident #98 seated up in bed with oxygen 2 L on via nasal cannula with no date label on oxygen tubing.Interview with LPN #1 on 9/9/25 at 11:46 AM identified Resident #98 is on oxygen, and the oxygen tubing should be changed and dated on Sundays. Further LPN #1 had not noticed that the oxygen tubing was not dated. Interview with Director of Nurses (DNS) on 9/9/25 at 2:18 PM identified oxygen tubing should be changed and dated weekly. Further if oxygen tubing is not dated, tubing should be changed, and a date label placed on by the nurse. Interview with LPN #1 on 9/10/25 at 10:02 AM identified Resident #98 did not have a physician's order for oxygen however, Resident #98 puts on the oxygen when he/she feels short of breath. Interview with Assistant Director of Nurses (ADNS) on 9/10/25 at 10:39 AM identified if Resident #98 placed oxygen on via nasal, there should be a physician's order. Review of the vitals summary on 9/10/25 at 12:30 PM identified Resident #98 received oxygen via nasal cannula on 7/10/25, 7/11/25, 7/12/25, 7/13/25, 7/14/25, 7/19/25, 8/5/25, 8/15/25, and 9/1/25.Subsequent to surveyor inquiry, a physician's order dated 9/10/25 directed to administer oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, and oxygen saturation below 90% on room air.A physician's order dated 9/12/25 directed to change oxygen tubing weekly every night shift on Sundays Review of the Oxygen Therapy policy directed physician's orders for oxygen should include the liter flow, type of oxygen, and delivery device and to change all disposable equipment weekly.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #4) reviewed for unnecessary medications, the facility failed to address pharmacy recommendations in a timely manner. The findings include: Resident #4 was admitted [DATE] with diagnoses included chronic respiratory failure with hypercapnia (too much carbon dioxide in blood), dependence on ventilator (a machine that helps person breathe), anxiety disorder, major depressive disorder, and gastrostomy (a small opening made in the stomach to put in a tube so person can get food and medicine). The RCP dated 4/28/24 identified Resident #4 had a nutrition diagnosis of swallowing difficulty. Interventions included to administer enteral nutrition (a method of providing nutritional support directly into the gastrointestinal tract through a tube) and flushes per Medical Doctor orders.A Pharmacy Consultant Drug Regimen Review dated 3/20/25 identified the resident with a as needed (prn) order for milk of magnesia to be administered by mouth. Noted to have most medications administered via feeding tube. Please consider updating route of administration, if appropriate. The form was not signed.Physician's order dated 5/14/25 directed to administer milk of magnesia suspension 400 milligrams (MG)/5 milliliters (ML), give 30 ML by mouth as needed for constipation daily. A physician's order dated 5/15/25 directed to administer protonix oral packet 40 MG, give 1 packet by mouth one time a day for gastroesophageal reflux and administer lorazepam tablet 0.5 MG, give 1 tablet by mouth every 8 hours as needed for anxiety.A Pharmacy Consultant Drug Regimen Review form dated 5/15/25 identified the recommendation; Resident with a standing order for pantoprazole and PRN orders for lorazepam and milk of magnesia to be administered by mouth. Noted to have most medications administered via G tube. Please consider updating route of administration, if appropriate. The form was dated 9/14/25.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was cognitively intact and required the assistance of 2 or more helpers with eating, oral hygiene, personal hygiene, dressing, and transfers. Further, Resident #4 had a feeding tube. The Resident Care Plan (RCP) dated 7/17/25 identified Resident #4 used psychotropic medications due to depression, and anxiety. Intervention included to administer psychotropic medications as ordered by physician and pharmacy review per protocol and as needed. A physician's order dated 8/18/25 directed to administer milk of magnesia suspension 400 MG/5 ML, give 30 ML via G-tube (feeding tube that goes directly into the stomach through the belly) as needed for constipation daily.Physician's order dated 9/10/25 directed to administer lorazepam tablet 0.5 MG, give 1 tablet via G tube every 8 hours as needed for anxiety for 14 days. Physician's order dated 9/14/25 directed to administer protonix oral packet 40 MG, give 1 packet via G-tube one time a day for GERD. Interview with the Director of Nurses (DNS) on 9/15/25 at 10:53 AM identified that pharmacy recommendations are emailed in a report to the DNS and Assistant Director of Nurses (ADNS) and the report is printed out and given to the unit managers. The unit managers then give it to the physician to review. Further, a pharmacy recommendation made in March 2025 should be addressed sooner than in August 2025, and a pharmacy recommendation made in May 2025 should be addressed sooner than in September 2025. Interview with the ADNS on 9/15/25 at 11:10 AM identified that pharmacy recommendations are emailed in a report to the ADNS and the DNS and they distribute that report to the unit managers to review with the Advanced Nurse Practitioner (APRN) to evaluate, sign and date the recommendation when reviewed. Further, the APRN would review the recommendations within a week of the report being received, and the previous DNS wanted to take responsibility for this process. Review of the Pharmacy Medication Review/Consultant Pharmacist Recommendations Policy revised 04/2023 directed findings and recommendations are communicated to those with responsibility to implement the recommendations, and to answer in a timely fashion.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1), reviewed for a change in condition, the facility failed to ensure the nursing assistant notified the nurse timely of a change in condition. The findings include: Resident #1 was admitted with diagnoses that included chronic kidney disease, heart failure and dementia. A resident care plan (RCP) dated 12/13/2024 had fluid deficit due to diuretic use and increased caloric demand. Interventions directed to monitor vital signs. A 5-day admission minimum data set (MDS) dated [DATE] identified Resident #1 had severe cognitive impairment (BIMS 3), and was dependent for ADLs. Record review identified the following blood pressures: 12/29/2024 at 2:59 PM was 158/67. 12/29/2024 at 5:50 PM was138/66. 12/30/2024 at 12:18 AM was 124/63. 12/30/2024 at 8:55 PM was 101/69. 12/31/2024 at 8:13 AM was 158/50. 12/31/2024 at 5:15 PM was 135/67. 1/1/2025 at 12:34 AM was 94/53. 1/1/205 at 9:46 AM was 76/33. Additional record review failed to identify the charge nurse was notified of the low blood pressure reading of 76/33 at 9:46 AM. Interview and record review with LPN #3 on 2/25/2025 at 2:10 PM identified she was assigned to Resident #1 on 1/1/2025 on the day shift (7 AM to 3 PM) and she was not aware of the 9:46 AM BP reading. She identified a NA had taken the vital signs and must not have told her of Resident #1's 9:46 AM BP of 76/33. If the NA had informed her then she would have notified the supervisor and documented an evaluation in Resident #1's medical record. LPN #3 stated she only checked the vital sign readings in the Electronic Medical Record (EMR) if there was a medication that directed specific vital signs parameters for administration, and Resident #1 did not have a scheduled medication that would have required her to check the recorded vital signs. Interview with RN #2 on 2/25/2025 at 2:04 PM identified she was the supervisor during 7 AM to 3 PM on 1/1/2025. RN #2 stated she was not notified of any change in condition for Resident #1 during her shift and she did not know why she was not notified of the low blood pressure of 76/33. She continued that she had made frequent rounds and if had she been told of Resident 1's BP reading, she would have rechecked it manually, completed an assessment then notified the on call APRN. She did not know why LPN #3 did not notify her. Interview with NA #1 was not obtained during the survey. Interview and record review with APRN #2 on 2/25/2025 at 1:08 PM identified on 1/1/2025 Resident #1's blood pressure (BP) was documented as 94/53 at 12:34 AM and 76/33 at 9:46 AM. APRN #2 stated the blood pressure of 94/53 could have been a one time reading, but when the next reading at 9:46 AM 76/33, she should have been notified. APRN #2 stated she would have expected to be notified, or the on-call provider be notified as the low blood pressures of 94/53 and 76/33 were a significant change in condition, and she would have requested additional information to determine any change to the treatment plan. Interview and record review with the DON on 2/25/2025 at 1:41 PM identified she would have expected LPN #3 (nurse on 1/1/2025 on the day shift) to notify the supervisor (RN #2) of Resident #1's recorded blood pressure at 9:46 AM of 76/33 as it was a significant change of condition. The DON stated an RN assessment should have been completed and the APRN should have been notified. The vital signs facility practice was for NAs to obtain vital signs, and to document them in the EMR, or give them to the nurse. The DON stated the nurse was responsible for reviewing the vital signs and determining any next steps needed. The DON stated she did not know why LPN #3 did not notify RN #2 of Resident #1's low BP of 76/33 or why an evaluation was not completed. The facility policy Change of Condition Notification, dated 10/17/2023, directed in part, staff should notify the licensed nurse of an identified change of condition and the licensed nurse will complete a physical and mental evaluation. documenting in the medical record.

Based on clinical record review, facility documentation, and staff interviews for one of three residents (Resident #3) reviewed for medication administration, the facility failed to ensure a physician order was transcribed accurately to ensure a medication was administered in accordance with physician orders. The findings include: Resident #3 had a diagnosis of non-displaced right femur fracture and urinary tract infection. The 5-day admission Minimum Data Set 2/15/23 identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition and received an antibiotic. The Resident Care Plan 2/24/2023 identified Resident #3 received Vancomycin (antibiotic) intravenous medication. Interventions directed to administer medication as ordered, and observe and report signs of infection at the intravenous site. Nursing note dated 3/3/23 at 4:27 PM identified per the infectious disease clinic Resident #3 should receive Vancomycin (antibiotic) every 24 hours until 3/13/2023. Infusion therapy order form dated 3/3/2023 directed to administer Vancomycin 1 gram (gm) every 24 hours until 3/13/2023. Physician order dated 3/3/2023 directed staff to administer Vancomycin 1000 milligrams (mg) intravenous solution every 24 hours until 3/13/2023. Nursing note dated 3/7/2023 at 11:45 AM identified Vancomycin was noted to be on hold. The note further indicated, per Infectious Disease on 3/3/2023, Vancomycin 1 gm was ordered to be administered daily. The physician was updated on the missed doses and an order was obtained to restart the Vancomycin. Facility incident report summary dated 3/21/2023 identified the unit manager working on 3/7/2023 identified the Vancomycin was inadvertently placed on hold on 3/4/2023. The APRN, power of attorney, and infectious disease clinic were notified, new orders were obtained, and no adverse effects resulted from the medication being placed on hold. Review of the medication administration record (MAR) identified Resident #3 did not receive Vancomycin as ordered on 3/3, 3/4, 3/5, and 3/6/2023. The MAR indicated Vancomycin was administered on 3/7/2023. Interview with RN #2 on 1/17/2025 at 2:52 PM identified she called infectious disease on 3/3/2023 and per infectious disease Resident #3 was supposed to receive Vancomycin every 24 hours until 3/13/2023. RN #2 stated the Vancomycin should have been started either on 3/3 or on 3/4/2023, depending on the time the medication was ordered to start. Interview identified when RN #2 entered the physician order, she entered a start date of 3/7/2023 in error, and she could not explain why the error occurred. Although attempted, and interview with the former DNS was not obtained during the survey. Review of facility Medication Pass Policy dated 9/23/24, directed in part, medications are administered safely and timely per the physician orders.

Based on record review and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the environment was free from hazards when the resident hit his/her leg on the side rail during a transfer resulting in a laceration that required 15 sutures. The findings include: Resident #1 had diagnoses that included difficulty in walking, muscle weakness, and unsteadiness on his/her feet. The admission [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and was dependent for transfers. The Resident Care Plan (RCP) dated 7/30/2024 identified Resident #1 had a deficit in self-care and mobility. Interventions directed to transfer with the assistance of 2 without an assistive device. Review of a physician's order dated 7/30/2024 directed pivot assist of two (2) staff for transfers without assistive device. Review of a facility incident report dated 7/31/2024 at 5:15 PM identified Resident #1 hit his/her leg against the side rail during a transfer and sustained a laceration on the left lower leg. The report indicated the side rail was padded after the incident. Review of the facility reportable event dated 7/31/2024 identified at 7 PM, Resident #1 required two (2) staff extensive assist for transfers, and during a transfer Resident #1 hit his/her leg against the side rail sustaining a laceration to the left lower extremity. Resident #1 was transferred to the hospital for evaluation. Record review identified Resident #1 returned from the hospital on 8/1/2024 and received 15 sutures to repair the laceration. The incident summary dated 8/5/2024 identified two (2) staff performed the transfer and during the transfer, Resident #1 extended his/her legs upwards hitting the siderail of the bed. Additional information dated 8/9/2024 identified Resident #1 sustained a 12-centimeter (cm) laceration and required sutures. Record review failed to identify that the resident was assessed for the use of the side rails, consent for the use of the side rails was obtained, and no physician's order that directed the use of the side rails for Resident #1. Review of the, Room of the Day Maintenance record, dated 6/24/2024 identified the bed was checked and was ok. Interview with NA #1 on 8/27/2024 at 11:09 AM identified she and NA #2 transferred Resident #1 back to bed on 7/31/2024 and during the transfer the resident hit his/her leg on the side rail. After Resident #1 was in bed, NA #1 and NA #2 noted Resident #1 had sustained a laceration to his/her left lower leg. Interview with NA #2 on 8/27/2024 at 12:30 PM identified after transferring Resident #1 into bed on 7/31/2024 they noted Resident #1 had a laceration on his/her leg. NA #2 stated there was no laceration prior to the transfer. Record review and interview with the DNS and Corporate Clinical Nurse on 8/27/2024 at 1:01 PM identified on 7/31/2024 Resident #1 sustained a laceration to his/her left lower leg by hitting the bedrail during the transfer from the wheelchair into bed. The DON stated upon investigation it was identified there was an edge on the bottom of the side rail, blood was noted on the bottom of the bedrail, and Maintenance padded the bedrail until rubber plugs could be ordered. Interview with the Director of Maintenance on 10/2/24 at 9:38 AM identified Resident #1's bed had a half side rail on both sides of the bed. The Director of Maintenance further stated that he had never been asked to remove or zip tie/secure Resident #1's side rails. Interview and record review with the DNS on 10/2/2024 at 11:39 AM identified Resident #1 did not have a physician order, an assessment or consent for use of the side rails. The DNS was unable to explain why the side rails were in use and that Maintenance could remove the rails if requested.

Based on record review, facility documentation, and staff interviews for three of three residents (Residents #1, #2, and #4) reviewed for side rail use, the facility failed to assess and obtain consent and a physician's order for the use of the side rails. In addition, 59 residents had no side rail orders and six (6) residents had no side rail assessments completed in accordance with facility policy. The findings include: 1. Resident #1 had diagnoses that included difficulty walking, muscle weakness, and unsteadiness on his/her feet. An admission [NAME] Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and was dependent for transfers. The Resident Care Plan (RCP) dated 7/30/2024 identified Resident #1 had a deficit in self-care and mobility. Interventions directed to transfer with the assistance of 2 without an assistive device. Review of the facility incident report dated 7/31/2024 at 5:15 PM identified at 7 PM Resident #1 required two (2) staff extensive assist for transfers, and during a transfer Resident #1 hit his/her leg against the siderail sustaining a laceration to the left lower extremity. The report indicated the side rail was padded after the incident. Resident #1 was transferred to the hospital for evaluation. The incident summary dated 8/5/2024 identified two (2) staff performed the transfer and during the transfer, Resident #1 extended his/her legs upwards hitting the siderail of the bed. Additional information dated 8/9/2024 identified Resident #1 sustained a 12-centimeter (cm) laceration and required sutures. The RCP was updated on 8/5/2024 to include use of half side rails for an enabler for bed mobility. Record review failed to identify that an assessment was conducted, consent was obtained, and a physician's order was obtained for the use of side rails for Resident #1. Record review and interview with the DNS on 10/2/2024 at 11:39 AM identified Resident #1 was using the side rails for support prior to completing an assessment, and that a physician's order and a consent for their use should be in place. 2. Resident #2 had diagnoses that included osteoporosis and muscle weakness. The admission MDS assessment dated [DATE] identified Resident #2 had moderate cognitive impairment and no restraints were used. The RCP dated 7/13/2024 identified a deficit in functional mobility. Interventions directed to assist as indicated. Observations during survey on 9/13/24 identified Resident #2 was in bed with both side rails up. Record review identified although a side rail assessment was completed on 6/20/24 and 9/13/2024, the record failed to identify a physician order for side rail use, no signed consent for use of side rails, and no care plan for side rail use. Record review and interview with the DNS on 10/2/2024 at 11:39 AM was unable to explain why a physician order and consent form were not obtained for use of the side rails. 3. Resident #4 had diagnoses that included muscle weakness and hemiplegia/hemiparesis (weakness of one side) after a cerebral infarction). The admission MDS assessment dated [DATE] identified Resident #4 had severe cognitive impairment and was dependent on staff for ADLs. The RCP dated 6/28/2024 identified a deficit in functional mobility. Interventions directed to use a mechanical lift for transfers. Observations during survey on 8/27/24 identified Resident #4 was in bed with both side rails up. Record review identified a side rail assessment was completed on 6/16/24. Subsequent to surveyor inquiry, a physician order was obtained on 8/27/2024 and a consent for use of side rails was obtained on 9/9/2024. Record review and interview with the DNS on 10/2/2024 at 11:39 AM, the DNS was unable to explain why the consent and physician orders were not obtained following the assesment for side rail use. 4. Observations during tour on 9/13/24 identified two half side rails were utilized on all beds observed. Interview with NA #3 on 10/2/2024 at 8:33 AM identified all the beds in the facility have side rails and residents use them for mobility. Interview with NA #4 on 10/2/2024 at 8:40 AM identified all the beds in the facility have side rails and residents use them for mobility. Interview with LPN #1 on 10/2/2024 at 8:35 AM identified all the beds in the facility have upper side rails (2 half rails) and when residents are admitted they are assessed and consent is given if the side rails are going to be utilized. LPN #1 stated the side rails are used for support and/or bed mobility and not every resident has a physician's order for the use of the side rails. Interview with the Director of Maintenance on 10/2/2024 at 9:38 AM identified he has worked at the facility over 30 years, and all the beds in the facility have half side rails. He stated if any resident did not need to use the side rails, nursing could request them to be removed from the bed or zip tied to the bed. The Director of Maintenance further indicated that nursing had never requested or notified him, or entered a request into the maintenance book to have side rails be removed or zip tied to prevent use for any resident. Interview and record review with the DNS on 10/2/2024 at 11:39 AM identified all beds in the facility have two (2) half side rails on each side and are used on all 136 (total census) residents for mobility. The DNS stated 59 residents had no side rail orders and six (6) residents had no side rail assessments completed. The DNS stated all residents should have evaluations/assessments completed on admission, readmission, significant change in condition, change in bed mobility, or as needed. Further, all residents should have physician orders, consents and care plans for use of the side rails and was unable to explain why they were not completed. Although the DNS stated if any resident did not require use of the side rails, nursing could request maintenance to remove the rails or zip tie the side rails to prevent use. The DNS was unable to provide documentation that maintenance was requested to disable side rails for any residents. Review of the, Side Rail Policy, revised 5/2023, identified upon admission, readmission, significant change, a change in bed mobility, and as needed, the resident will be evaluated for the need for side rails to assist with bed mobility. The resident/Significant Other/Responsible Party will be provided with education regarding the decision on the use of partial side rails to assit with bed mobility. Residents that require partial use of side rails will have an order from the healthcare provider indicating that partial side rails are in use to assist with bed mobility, and will be documented on the resident's plan of care.

Based on review of clinical records, facility documentation, and interviews, for one (1) of three (3) residents reviewed for incontinent care, (Resident #2), the facility failed to ensure incontinent care was provided timely after resident request. The findings included: Resident #2 had diagnoses of hemiplegia, and muscle weakness. Review of the Admission Minimum Data Set assessment dated [DATE] identified Resident #2 as cognitively intact, was occasionally incontinent of bladder and conitnent of bowel, and was dependent with toileting and personal hygiene. Review of the Resident Care Plan dated 4/26/24 identified a deficit in self-care, a deficit in functional mobility, and had functional bowel and bladder incontinence related to impaired mobility with interventions that directed assist of one with toilet use, and to check four times a shift and change as required for incontinence. Review of the facility reportable event Form dated 5/13/24 identified NA#1 had gone into Resident #2's room between 4:30 AM and 5:00 AM to check on Resident #2 and was informed he/she needed to be given incontinent care. NA#1 had indicated she would return to change the resident but needed to respond to other call bell lights and forgot to return to Resident #2 to provide incontinent care. Resident #2 had to wait until the first shift nurse's aide arrived before receiving incontinent care, two and a half (2.5) hours after requesting to be provided with incontinent care. Interview with Resident #2 on 5/30/24 at 2:10 PM identified he/she had requested incontinent care near the end of the 11:00 PM to 7:00 AM shift on 5/13/24 as h/her brief was soiled, and he/she did not receive the incontinent care he/she requested until the 7:00 AM to 3:30 PM shift NA came to his room. Interview with NA#1 on 5/30/24 at 1:38 PM identified he/she worked the passport unit on 5/13/24 on the 11:00 PM to 7:00 AM shift and had checked on Resident #2 several times during the early morning hours of 5/13/24 and during his/her last check, between 4:30 PM and 5:00 AM, Resident #2 had requested incontinent care. NA #1 had acknowledged Resident #2's request, however, informed Resident #2 that he/she needed to check on other residents and would return to provide his/her incontinent care. NA #1 further identified that he/she became busy responding to the call lights and providing care for other residents and had forgotten to return to Resident #2 to provide incontinent care, because she was the only NA assigned to the passport unit on the 11:00 PM to 7:00 AM shift. NA#1 further identified that NA#3 was supposed to come from another unit and assist with care, however, he/she never came to assist her on the Passport unit. Interview with LPN #1 on 5/30/24 at 4:30 PM identified he/she was unaware of NA#1 needing additional assistance during the 11:00 PM to 7:00 AM shift on 5/13/24, and had not been asked to assist NA#1 with Resident #2. LPN #1 further identified the passport unit to was short staffed from 11:00 AM to 7:00 PM as NA #1 was the only NA assigned to the floor on 5/13/24. Interview with NA#3 on 6/10/24 at 12:02 PM identified he/she was not asked to assist with care on the passport unit on 5/13/24 for the 11:00 PM to 7:00 AM shift, she remained on the 3 rd floor for her entire shift. Interview with NA#4 on 6/10/24 at 12:07 PM identified on 5/13/24, at the start of his/her shift around 7:30 AM, she entered Resident #2's room and Resident #2 requested incontinent care, and Resident #2 identified that h/she had requested incontinent care from the 11:00 PM to 7:00 AM NA, however, after the request the NA did not return to provide care. NA #4 further identified that she provided incontinent care to Resident #2 who was incontinent of loose stool. Attempts to reach the 11:00 PM to 7:00 AM on 5/13/24 were unsuccessful. Interview with the Assistant Director of Nursing Services (ADNS) on 5/30/24 at 4:40 PM identified it was facility practice to attend to the resident's needs promptly when informed incontinent care was needed. Review of the Certified Nurse's Aide Standard of Care Information Sheet directed to provide peri-care after each incontinent episode.

Based on review of clinical records and interviews for one (1) of three (3) residents reviewed for incontinent care (Resident #2), the facility failed to provide adequate staffing meet the needs of the residents. The findings included: Resident #2 had diagnoses of hemiplegia, muscle weakness. Review of the Admission Minimum Data Set assessment dated [DATE] identified Resident #2 as cognitively intact, was dependent with toileting, was occasionally incontinent of bladder and continent of bowel. Review of the Resident Care Plan dated 4/26/24 identified a deficit in self-care, a deficit in functional mobility, and has functional bowel and bladder incontinence related to impaired mobility with interventions that directed an assist of one with toilet use, and to check four times a shift and change as required for incontinence. Review of the Reportable Event Form dated 5/13/24 identified NA#1 had gone into Resident #2's room between 4:30 AM and 5:00 AM to check on Resident #2 and was informed he/she needed to be changed (given incontinent care). NA#1 had indicated she would return to change the resident but needed to respond to other call bell lights that had gone off and forgot to return to Resident #2 to provide incontinent care. Resident #2 had to wait until the first shift nurse's aide arrived before receiving incontinent care, two to two and a half hours after requesting to be changed. Interview with NA#1 on 5/30/24 at 1:38 PM identified he/she worked the passport unit on 5/13/24 on the 11:00 PM to 7:00 AM shift and had checked on Resident #2 several times during the early morning hours of 5/13/24 and during his/her last check, between 4:30 PM and 5:00 AM, Resident #2 had requested incontinent care. NA #1 had acknowledged Resident #2's request, however, informed Resident #2 that he/she needed to check on other residents and would return to provide his/her incontinent care. NA #1 further identified that he/she became busy responding to the call lights and providing care for other residents and had forgotten to return to Resident #2 to provide incontinent care, because she was the only NA assigned to the passport unit on the 11:00 PM to 7:00 AM shift. NA#1 further identified that NA#3 was supposed to come from another unit and assist with care, however, he/she never came to assist her on the Passport unit. Interview with LPN #1 on 5/30/24 at 4:30 PM identified he/she was the charge nurse on the passport unit on 5/13/24 for thee 11:00 PM to 7:00 AM shift. LPN #1 identified that she was unaware of NA#1 needing additional assistance on 5/13/24 and had not been asked to assist NA#1 with Resident #2. LPN #1 further identified that the unit was short staffed from 11:00 AM to 7:00 PM as NA #3, who was assigned to split her shift and work half of her shift on the third floor and the other half of the shift on the passport unit, had not come to the passport unit to assist NA #1. Interview with the Scheduler on 5/30/24 at 3:15 PM identified that the usual staffing pattern on the passport unit for the 11:00 PM to 7:00 AM shift is 2 NA's and one licensed nurse. On 5/12/24 into 5/13/24 LPN #1, NA #1, and NA #2 were scheduled to work the 11:00 PM to 7:00 AM shift on the Passport wing however, NA#2 had called out. The Scheduler had further indicated the census on the Passport wing on 5/12 into 5/13/24 was 25 and that he/she covered the call out by splitting NA #3's hours, NA#3 (who was originally scheduled to work 11:00 PM to 7:00 AM on the third floor on 5/12/24) would spend half of her shift on the third floor and the second half of her shift on the Passport unit. Interview with NA#3 on 6/10/24 at 12:02 PM identified he/she was not asked to split her 11:00 PM to 7:00 AM shift on 5/12/24 and only worked on the third floor that night. Interview with the Assistant Director of Nursing Services (ADNS) on 5/30/24 at 4:40 PM identified it was facility practice to attend to the resident's needs promptly when informed incontinent care was needed. Attempts to reach the 11:00 PM to 7:00 AM on 5/13/24 were unsuccessful. Review of the Certified Nurse's Aide Standard of Care Information Sheet directed to provide peri-care after each incontinent episode.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #45) reviewed for allegation of abuse, the facility failed to ensure the resident was free from sexual abuse. The findings include: a. Resident #45's diagnoses included encephalopathy (change in brain function), dementia, and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #45 was severely cognitively impaired, required extensive assistance of two staff members for bed mobility and transfers. A Resident Care Plan dated 1/8/23 identified Resident #45 was a victim of a sexual encounter as he/she was kissed by another resident. Interventions included encouraging family involvement, monitoring for changes in mood, behavior, offer in room activities and video chats, encourage resident attendance at activities, interactions with other residents and staff daily, allow for expression of feelings, identify potential stressors, provide emotional support as needed and behavior health intervention if needed. b. Resident #96's diagnoses included chronic obstructive pulmonary disease, ulcerative colitis, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #96, was moderately cognitively impaired, exhibited behavioral symptoms not directed at others and wandering behaviors. A Resident Care Plan (RCP) dated 12/19/22 identified to monitor resident's interaction with other residents. Interventions included educating resident on interacting appropriately with other residents, monitoring mood and behavior, provide behavioral health intervention, redirection and reassurance as needed, monitoring during activities and when interacting with female residents. RCP revised 1/9/23 identified resident had engaged in sexual activity with another resident, and had kissed another resident. Review of the Reportable Event Form dated 1/8/23 identified at 2:55 PM, identified NA #1 witnessed Resident #45 being kissed on the mouth by another resident.( Resident #96) this Resident #96 was redirected away to his/her room from Resident #45 and mouthcare was provided to Resident #45 following incident. A social worker's note dated 1/9/23 identified that nursing reported to social work that Resident #45 was kissed by another resident. Social work visited Resident #45 who was resting, got resident's attention by saying his/her name and noted that the resident was calm with no recollection of incident, no mood or behavior issues noted. A Psychiatric Progress note dated 1/13/23 identified Resident #45 as calm, no behavior issues, confusion that aggravates depression, and medication helps depression. However, the psychiatric noted failed to indicate evaluation of resident specifically related to the complaint of the 1/8/23 sexual encounter. A Psychiatric Progress noted dated 1/13/23 noted Resident #96 had a history of hypersexuality and dementia, that he/she had been sent to the emergency department for an exacerbation in hypersexual behavior, noted kissing another resident and was found to have urinary tract infection and AKI (acute kidney injury). Staff denies increased hypersexuality since return from hospital, and that confusion exacerbates hypersexuality. Resident moved to a different floor, away from other resident and a medication was discontinued as it may be causing increased sexual behaviors. Interview with NA #1 on 12/13/23 at 12:35 PM identified that on 1/8/23, she was coming down the hallway, returning from her break when she found Resident #96 standing up out of his/her wheelchair and bending over Resident #45's wheelchair and was kissing her/him in the lounge area near the nursing station. She was able to recall telling the nurse that she was going on her break, that her relief person was there to watch before she went on break but could not recall whose responsibility it was to watch the lounge area while she was on break. Interview with RN #1, Regional Nurse on 12/13/23 at 1:20 PM identified at the time of the altercation Resident #45 and Resident #96 resided on the locked dementia floor. Although, the residents were to be monitored for safety, RN #1 was unable to provide a policy or procedure regarding monitoring resident while in the shared community area. Interview with NA #2 on 12/13/23 at 1:33 PM identified when an aide is assigned to monitor the community recreation area and that her role was to make sure residents were safe, involved in activities, provide snacks, drinks, keep residents from falling, and to watch their interactions with each other. Interview and facility documentation titled CNA rotation for Dining room [ROOM NUMBER]-3 Shift (one for 4 and one for 5 Aides) and Recreation Room Schedule (one for 3 and one for 4 CNAs for 3:00 PM to 10:30 PM shift) reviewed with LPN #1 on 12/13/23 at 1:36 PM identified that aides know it is their turn to watch residents in the second-floor lounge because it is posted on the nurse's desk. She identified 4 documents taped to top of desk's elevated surface facing lounge/recreation room. She indicated the assignment of responsibility to monitor residents in the shared community area is based on the number of aides working that shift, she further indicated that a person from the recreation department is part of this watch and when recreation steps away, the nurse is informed, and the nurse is responsible to have an aide supervise the resident in the community area until recreation staff return. Interview with DNS on 12/18/23 at 12:15 PM indicated staff in the second-floor resident lounge area watch residents for safety concerns and any patient-to-patient interactions, that the charge nurse assigns the aides and keeps a schedule. Review of the facility's Residents' [NAME] of Rights Policy effective January 2023 indicates the facility to adhere, inform, and educate residents and staff of the Residents' [NAME] of Rights. Exercising rights indicates that the facility must protect and promote your rights and support, encourage, and assist you in exercising them, and residents have the right to be from verbal, sexual, physical, or mental abuse. Review of the facility's Abuse Policy & Procedure revised January 2023 identified that each resident has the right to be free from abuse, neglect or misappropriation of resident property and exploitation. It is the philosophy of all NHCA facilities to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Sexual abuse means non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Prevention 4. The facility will continue to provide individualized care plans that identify risk factors of residents as well as plans for protecting their rights. Procedure for Abuse Investigation Action: 1. Immediately protect Resident from alleged abuse. 2. Immediately notify your administrative staff or nursing supervisor on duty of abuse allegation. Reporting/Documentation Requirements: G. Care Plan Process - After the incident occurs the Interdisciplinary team will update the person centered-care plan with appropriate interventions.

Based on review of the clinical record and interviews for 2 (#39 and #68)of 4 residents reviewed for PASSR ,the facility failed to ensure PASSR 2 recommendations for a resident safety plan were incorporated into the plan of care and the facility failed to update a level of care with a new diagnosis. The findings include. 1. Resident #39's diagnosis included bipolar disorder, schizoaffective disorder, anxiety, hallucinations, and dementia. The Preadmission Screening and Resident Review (PASRR) Level 2 outcome dated 1/11/2022 indicated in part Resident #39 had a history of thoughts of self-injury and attempted to do so prior to the date of the evaluation and currently had passive thoughts of self-harm due to not wanting to be a burden to anyone. The following services and or support to be provided for Resident #39 while admitted to a Medicaid certified nursing facility included in part to provide the services of a crisis intervention and or a safety plan. The Quarterly Minim Data Set (MDS) assessment dated [DATE] indicated Resident #39 was cognitively intact and hallucinated (perceptual experiences in the absence of real external sensory stimuli) and had delusions (misconceptions or beliefs that are firmly held). The care plan dated 12/7/2023 indicated Resident #39 had a positive PASSR related to bipolar disorder with interventions to monitor for changes in mood and behavior, psych referral as needed and routine, engage and encourage attendance in activities and individual activities of interest and involve family in the care plan process and provide updates. Interview and record review on 12/13/2023 at 1:40 AM with Social Worker #1 indicated the PASSR level 2 outcome indicated Resident #39 had a history of self-harm and recommended while at the facility a crisis intervention plan or safety plan was to be put in place. Although SW#1 was not working at the facility at the time Resident #38 was admitted to the facility, indicated the social worker was responsible to update the care plan to include a safety plan. Subsequent to surveyor inquiry, Resident #39's care plan was updated on 12/13/2023 to indicate a focus of Crisis intervention with interventions to monitor for changes in mood and behavior, allow time to express feelings and thoughts, explore coping skills, reorient/redirect as needed, behavioral health intervention (LCSW and Psych APRN), validate feelings and provide with one-to-one visits for support as needed. The facility conducted staff development training on 12/13/2023 at 2:45 PM that included in part to check PASRR on admission for recommendations and develop a comprehensive care plan that included what interventions are to be attempted in the event a crisis occurs. Although a facility policy regarding PASSR was requested one was not provided. 2. Resident #68's diagnoses included psychotic disorder with delusions due to known physiological condition. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #68 as cognitively intact and required extensive assistance with transfers, dressing, toileting, and personal hygiene. The Resident Care Plan dated 1/7/22 identified potential for impaired cognitive function/dementia or impaired thought processes. Interventions directed to monitor/document/report as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The annual Minimum Data Set assessment dated [DATE] identified Resident #68 was moderately cognitively impaired and required substantial assistance with toileting, dressing, and mobility. The Resident Care Plan dated 4/1/23 identified potential for altered mood/behavior due to diagnosis of depressive episodes, generalized anxiety disorder, and psychotic disorder with delusions due to known physiological condition. Interventions directed to monitor for changes in mood and behavior and behavior health interventions, if needed. Review of facility documents and interview with SW #1 on 12/11/23 at 1:55 PM identified an updated level of care was not submitted Resident # 68 as the interdisciplinary team was not informed of his/her new diagnoses. SW #1 further indicated it was practice for the psychiatric advanced practical registered nurse to inform the interdisciplinary team of a new diagnosis so they could update the level of care. Interview with the Director of Nurses on 12/12/23 at 12:27 PM identified it was practice for the clinician adding the new diagnosis to the resident's profile to communicate the new diagnosis to the interdisciplinary team so an updated the level of care could be submitted. Furthermore, the DNS indicated the provider had added the diagnoses directly to the resident's profile on both occasions without notifying the interdisciplinary team of the new diagnoses. Although requested, the facility failed to provide a PASRR policy. _________________________________________________________________________________________________________________________________________

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1), reviewed for a change in condition, the facility failed to ensure the resident was served food consistency in accordance with physician orders when a resident on a ground dysphagia diet was served a peanut butter sandwich. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included a history of myocardial infarction, pulmonary embolism, end stage renal disease, and diabetes. The nursing admission assessment dated [DATE] identified Resident #1 was alert, oriented to person, place time and situation. A physician order dated 3/17/2022 directed to provide a renal diet Ground (Dysphagia level 2) texture, thin consistency diet. Speech evaluation dated 3/18/2022 identified that Resident #1 had impaired cognition and directed to remain on a ground dysphagia diet. The facility incident report dated 3/19/2022 at 8:15 P.M identified Resident #1 was given a peanut butter sandwich by RN #1. Statement from RN #1 indicated he had asked Resident #1 if he/she wanted a sandwich, Resident #1 said yes, and RN #1 provided the resident with a peanut butter sandwich from the evening snack tray at the nurse's station. Interview with RN #1 (shift supervisor) on 3/30/2022 at 2:21 PM identified that on 3/19/2022 he was walking by the resident's room when Resident #1 asked for something to eat. He stated that he offered a sandwich, and he did not check the resident record for any dietary restrictions or diet orders; he asked LPN #1/charge nurse if Resident #1 had any food restrictions. LPN #1 replied that Resident #1 had a fluid restriction and RN #1 indicated then gave Resident #1 a peanut butter sandwich. RN #1 further indicated he did not remember if there was any crust on the sandwich, and indicated that he should have checked Resident #1's diet orders himself before giving any food to Resident #1 to ensure the correct diet texture was followed. Interview with Cook Supervisor on 3/30/2022 at 2:41 PM identified that the kitchen sends a variety of snacks to the nursing units every evening for residents, and he was unable to identify if sandwiches are sent with or without any crust. He indicated that although the snacks are dated, they are not labeled to identify what the snack contains (specific food or diet type). Interview with Speech Therapist #1 (ST #1) on 3/31/2022 at 9:00 AM identified that she evaluated resident #1 on 3/18/2022 for a dysphagia evaluation to assess Resident #1's aspiration risk and safety for possible diet advancement. ST #1 indicated that the hospital record included a swallowing study dated 3/9/2022. The study indicated abnormal swallowing: mild to moderated oral dysphagia and mild pharyngeal dysphagia caused by laryngeal and pharyngeal edema more on the right then the left. It further identified a disorganized bolus extraction, delayed oral transit with advanced solids, and reduced airway protection and Resident #1 on a ground diet prior to admission to the facility. ST #1 identified that Resident #1 was on a ground dysphagia diet which would include a soft crustless sandwich, such as egg salad and tuna salad. ST #1 indicated that Resident #1 should not have received the peanut butter sandwich since peanut butter is not allowed on a ground diet. Interview with the Registered Dietician (RD) #1 on 3/31/2022 at 10:15 AM identified that a peanut butter sandwich was not allowed on a ground dysphagia 2 renal diet. She indicated that the dysphagia diet does include soft crustless sandwiches which would include tuna salad or egg salad. RD #1 further indicated that she did not know if sandwiches sent to the nursing unit were crustless, however indicated that peanut butter was not allowed on Resident #1's diet texture. Review of facility combination Therapeutic Diets Policy dated 8/2021 directed in part, dry tough or crusty bread will be avoided, and breads should be well moistened. Review of facility Dysphagia level 2 Diet Policy dated 8/2021directed in part, the consistency is a transition from puree to more solid textures and is appropriate for residents with mild to moderate dysphagia. Crustless bread is provided. The facility failed to ensure staff verified the resident's diet orders prior to serving food and failed to ensure food was provided in accordance with physician's diet texture order. Resident #1's diet order directed to provide a renal ground dysphagia diet, and peanut butter was not allowed on a ground dysphagia diet, which put Resident #1's health and safety at risk. A review of the facility's corrective action plan during an onsite visit on 3/31/2022 identified facility staff will be educated to ensure the correct diet including diet texture was provided to residents. Resident diets will be audited for accuracy of diets and textures. Audits will be conducted weekly for four weeks then monthly for three months.

Based on clinical record review, facility documentation review, and interviews for one of two residents (Resident #1), reviewed for allergies, the facility failed to ensure the resident was not served food that the resident was identified as allergic to. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included a history of myocardial infarction, pulmonary embolism, end stage renal disease, and diabetes. Review of hospital discharge summary dated 3/17/2022 identified Resident #1 was allergic to peanuts, all nuts and tree nuts. A physician's order dated 3/17/2022 directed that Resident #1 had an allergy to peanuts and tree nuts. The nursing admission assessment dated [DATE] identified Resident #1 was alert, oriented to person, place time and situation. The facility incident report dated 3/19/2022 at 8:15 PM identified Resident #1 was given a snack that contained peanuts. Resident #1 developed shortness of breath, tongue swelling, and vomited once. APRN #1 was notified, with new orders obtained to administer Benadryl (used to relieve symptoms of an allergy) 25 milligrams (mg) by mouth every six (6) hours as needed for reaction for three (3) days, and an EpiPen injection (epinephrine injection used for the emergency treatment of severe allergic reactions). Benadryl 25 mg was administered, and one EpiPen injection was administered for shortness of breath and low pulse ox (blood oxygen level) in the 80's (normal 90% and above). Oxygen at two (2) liters via nasal canula was applied, pulse ox improved to 94%, and Resident #1 was transferred to the hospital for evaluation. Review of Medication Administration for March 2022 identified Resident #1 received Benadryl 25 mg one capsule by mouth at 8:15 PM, and Epinephrine auto injector IM stat at 8:40 PM on 3/19/2022 for an allergic reaction. Nurses note dated 3/19/2022 at 9:41 PM identified Resident #1 had slurred speech, and his/her tongue appeared swollen. Benadryl and EpiPen injection were administered, and oxygen was applied. Resident #1's level of alertness improved with improved pulse ox of 94% on two liters oxygen by nasal cannula. Slurred speech persisted and Resident #1 was transferred to the hospital. Review of hospital record dated 3/19/2022 identified Resident #1 was diagnosed with angioedema and acute allergic reaction. Resident #1's hospital treatment included the administration of Zofran (used to prevent and treat nausea and vomiting) 4 mg intravenous (IV) at 10:29 PM, Decadron (used to relieve symptoms of an allergy) 10 mg IV at 10:30 PM, Benadryl 25 mg intravenous at 10:29 PM and 11:44 PM on 3/19/2022, and Albuterol (used to treat difficulty breathing) 2.5 mg/3 ml (milliliters) by nebulizer at 12:33 AM on 3/20/2022. Nurse's note dated 3/20/2022 at 7:05 AM identified Resident #1 was readmitted to the facility at 6:50 AM. Interview with RN #1 (shift supervisor) on 3/30/2022 at 2:21 PM identified that on 3/19/2022 he was walking by the resident's room when Resident #1 asked for something to eat. He stated that he offered Resident #1 a sandwich, and he did not check the resident record for any restrictions, diet orders or allergies; he asked LPN #1/charge nurse if Resident #1 had any food restrictions. LPN #1 replied that Resident #1 had a fluid restriction and RN #1 indicated he then gave resident #1 a peanut butter sandwich. RN #1 further indicated that he should have checked Resident #1's diet orders himself before giving any food to Resident #1 to ensure the diet was followed and to ensure allergies were identified prior to serving the sandwich. Interview and clinical record review with the DNS on 3/30/2021 at 3:20 PM identified that Resident #1's food allergies were clearly marked in the record. The DNS further indicated that RN #1 gave Resident #1 a peanut butter sandwich without checking the clinical record for any allergies. She indicated that all staff should check for any allergies before giving food to any resident, and RN #1 should have verified Resident #1's allergies before serving the peanut butter sandwich to Resident #1. Interview with LPN #1 on 4/1/2022 at 2:47 PM identified that she told RN #1 that Resident #1 had a fluid restriction and she would check for any food allergies. LPN #1 stated RN #1 walked away while she checked the record for any allergies, and she saw Resident #1 had a peanut allergy. LPN #1 indicated that she immediately went to Resident #1's room and arrived at the same time Resident #1 was ringing his/her call bell for assistance. When she entered the room, Resident #1 informed her that a staff member had given him/her a peanut butter sandwich and he/she was allergic to peanuts. LPN #1 identified that Resident #1 had eaten a few bites of the peanut butter sandwich, she removed the sandwich and threw it away, and she notified RN #1. A food allergy policy was not provided for surveyor review, however interview with the DNS indicated the expectation was that RN #1 should have checked the record for allergies before serving the peanut butter sandwich. A review of the facility's corrective action plan during an onsite visit on 3/31/2022 identified facility staff were educated to ensure that allergy alerts are reviewed prior to providing food to residents. Residents with food allergies will be identified by blue colored wrist bands, and the bracelets are checked every shift for placement. A list of residents with food allergies are posted on the nursing units, and the recreation department verifies the diet type and food allergies prior to all food related activities. An audit was completed to validate that all residents with food allergies were identified in the medical records and to ensure the allergy alert tab was visible to all care providers. Additional facility documentation review identified staff education was provided prior to survey, to include review of resident allergy alerts prior to providing food to residents. Residents with food allergies had blue-colored wrist bands applied to identify they had an allergy. Audits of all resident records were completed to identify resident allergies and ensure the clinical records had allergies clearly identified. Meal audits were conducted to ensure residents were not provided with food they were allergic to. Based on review, past non-compliance was identified for F806-J.

Based on clinical record review and staff interview for one of three residents in the survey sample reviewed for pressure ulcers (resident # 100), the facility failed to implement interventions to prevent a pressure ulcer. The finding include: Resident # 100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] indicated Resident # 100 had severe cognitive impairment (BIMs=5), required extensive assist of two persons for bed mobility, did not walk, and had no pressure ulcers. A Resident Care Plan dated (MONTH) (YEAR) (initiated on 1/19/18) identified a problem with potential for skin impairment related to immobility. Interventions included a preventative mattress and wheelchair cushion, daily and weekly skin checks, incontinent care, and turning and positioning every two hours. A Braden scale for predicting pressure sore risk dated 1/25/18 and 2/1/18, and 2/8/18 indicated the resident had a score of 15 (15-18=at risk). A weekly pressure ulcer flow sheet dated 2/11/18 indicated Resident # 100 acquired a 1.0 Centimeter (CM) x 0.5 CM un-stageable pressure ulcer on the outer aspect of the right ankle. The wound bed was moist with slough. A physician's orders [REDACTED]. On 2/15/18 the weekly pressure ulcer flow sheet indicated the area on the right ankle was a stage III pressure ulcer that measured 1.0 CM x 0.8 CM x 0.2 CM. The wound bed was 100% granulation. A wound care specialist note dated 2/15/18 indicated Resident # 100 had a stage III pressure wound of the right lateral heel. Recommendations included off-load wound, float heels in bed, and off-loading boots. The weekly pressure ulcer flow sheet dated 2/22/18, 3/1/18, and 3/8/18 indicated the area on the right ankle was a stage III 0.9 CM x 0.5 CM x 0.1 CM with 90% granulation and 10% slough in the wound bed. An observation on 3/9/18 at 11:51 A.M. with RN # 7 noted a small open area on the back of Resident # 100's right heel. The wound bed was noted to be white/gray in color. RN # 7 indicated based on his/her observations the pressure ulcer was healing. An interview on 3/9/18 at 2:45 P.M. with RN # 1 indicated although interventions were implemented to prevent skin breakdown, including turning and positioning every 2 hours, he/she was unable to provide documentation of interventions that were implemented to prevent skin breakdown on the resident's heels. He/she indicated heels are off-loaded preventatively if a resident is at risk. Although Resident # 100 was identified as at risk, his/her heels were not off-loaded until the pressure ulcer was identified on 2/11/18. Review of the facility Pressure Ulcer Preventative protocols indicated positioning devices to be used are pillows or foam to prevent direct contact between bony prominences (such as knees or ankles). If a pressure ulcer is on a heel, the ulcer should be off loaded.

Based on review of clinical records, review of facility documentation and interviews for one of three sampled residents (Resident #291) who had a decline in appetite and fluid intake and a weight loss, the facility failed to ensure appropriate care and services were implemented to ensure the resident's daily fluid intake meet the estimated fluid needs to prevent dehydration and/or for the only resident in the survey sample reviewed for hospitalization (Resident # 135), the facility failed to monitor and/or implement interventions to prevent dehydration. The findings include: 1.Resident #291's [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified Resident #291 rarely and/or never made daily decisions, required limited one (1) person assistance with eating, was frequently incontinent of urine and received antipsychotic and antidepressant medications. The Admission Nutritional Evaluation dated 11/2/17 identified the resident's weight was 184 pounds, the Body Mass Index (BMI) was 29.7 which indicated the resident was overweight, the resident's estimated fluid needs was 2520 cubic centimeters (cc) in a 24 hour period and the resident's food and fluid intake ranged from 50% to 75%. The Resident Care Plan dated 12/5/17 identified a self-care performance deficit and a potential for a nutritional problem. Interventions directed to monitor for signs and symptoms of inadequate hydration, to monitor weights, intake and labs as available, to provide supplements as ordered, dietitian consults to evaluate and make diet changes when necessary and to notify the physician of significant changes. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The nurse's note dated 1/9/18 identified Resident #291's appetite was poor, fluids were encouraged, and subsequent to notification the Advanced Practice Registered Nurse (APRN) ordered blood work. The laboratory report dated 1/9/18 identified the resident's Blood Urea Nitrogen (BUN) was 22 (normal range 10-24), the Creatinine was 1.0 (normal range 0.7-1.5) and the electrolytes all were within normal range. Review of the Nurse Aide flow record from 1/10/18 through 1/22/18 (twelve (12) days) identified the resident refused food intake at meal time fifteen (15) out of thirty-six (36) occasions and only ate 0 to 25% the remainder of the twenty-one (21) meals. Review of the fluid intake identified the resident consumed 600cc or less in a twenty-four (24) hour period and the urine output was not documented. Review of the nurse's notes from 1/10/18 through 1/22/18 failed to reflect documentation that complete assessments for dehydration were conducted and/or the APRN and dietitian were notified of the resident's continued poor intake until 1/22/18, twelve (12) after the first update on 1/9/18. The APRN's progress note dated 1/22/18 identified the resident was seen for poor oral intake and weight loss and directed a dietary consult and blood work. The laboratory report dated 1/23/18 identified the resident's BUN was now 112 (normal range 10-24), the Creatinine was 2.9 (normal range 0.7-1.5), the Sodium level was 165 (normal range 133-145), and the white blood count was 38.4 (normal range 4.8-10.8). The significant change Minimum Data Set assessment dated [DATE] identified Resident #291 had a weight loss of 5% or more in the last month and/or 10% in the last six months. Interview and review of the clinical record with the Advanced Practice Registered Nurse (APRN) #1 on 3/6/18 at 2:15 PM identified the bloodwork results dated 1/23/18 suggested an infection,[MEDICAL CONDITION], and fluid volume depletion. APRN #1 identified that subsequent to family notification, Resident #291 was transferred to the Emergency Department for an evaluation. APRN #1 stated although was aware of the resident's poor intake prior to 1/9/18, she was not notified of the resident's continued poor intake until 1/22/18. APRN #1 identified that intravenous fluid hydration might have been an option if notified sooner. Interview and review of the clinical record with the Dietitian on 3/6/18 at 2:30 PM identified she was aware that the resident was losing weight but failed to address hydration needs until 1/23/18. The Nutritional Evaluation dated 1/23/18 identified that due to the resident's weight loss the estimated fluid needs were now 1920cc and complete monitoring of the resident's Intake and Output should be implemented to ensure fluid goals were met. Interview and review of the clinical record and facility policy with the Director of Nursing (DON) on 3/6/18 at 1:30 PM identified the clinical record failed to reflect documentation the resident's Intake and Output was monitored, ongoing assessments for signs and symptoms of dehydration were conducted and/or timely notification of the physician, APRN, and/or Dietician when the resident had a decline in oral intake and the fluid needs were not met. The Facility Hydration Policy directed the licensed nurse will perform on going hydration assessments when there is a change in the resident's condition and will updated the care plan to include preventative measures and the physician, APRN, and Dietitian will be notified if the resident's average fluid intake is below the fluid requirements for seventy-two (72) hours. 2. Resident # 135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An initial nursing assessment dated [DATE] indicated Resident # 135 was alert and disoriented with incoherent speech. The resident was dependent on staff for feeding, noted coughing or choking during meals or when swallowing medications, had shortness of breath or trouble breathing while lying flat and indicated the resident's right and left breath sounds was noted with wheezing. A RCP dated 1/7/18 identified a problem with potential for nutritional problems related to a poor oral by mouth intake and a mechanical therapeutic diet. Interventions included monitor/record/report to the physician as needed signs and symptoms of malnutrition, to monitor/report as needed signs and symptoms of difficulty swallowing, obtain and monitor laboratory/diagnostic work as ordered, weigh per physician's orders [REDACTED]. An APRN note dated 1/8/18 indicated Resident # 135 was seen for [MEDICAL CONDITION] with oxygen saturation of 86%. On oxygen the resident's saturation increased to 96%. The APRN directed a chest x-ray to be done and to monitor the residents Intake and Output (I & 0). Review of a neurology consultation dated 1/8/18 indicated to monitor Intake and Output and to supplement with fluids and/or Ensure as needed. Review of Resident # 135's intake records dated 1/8/18 noted the resident's total daily intake was 240 cc and on 1/9/18 the total daily intake was 1220 cc. Review of a laboratory record dated 1/9/18 indicated the resident's BUN was 11 (10-24 Normal Range) and the creatinine was 1.1 (0.7-1.5 Normal Range). A chest x-ray report dated 1/9/18 indicated there was no significant abnormality. A physician's orders [REDACTED]. A nurse's note dated 1/9/18 indicated fluids were encouraged. A laboratory report dated 1/10/18 indicated the resident' BUN was 13 (10-24 ) and the creatinine was 1.2 (0.7-1.5) An intake record dated 1/10/18 indicated the resident's total daily intake was 1440 cc, A nurse's note dated 1/10/18 indicated fluids were encouraged and there were no signs or symptoms of dehydration. An intake record dated 1/11/18 indicated the resident's total daily intake was 1320 cc. A laboratory report dated 1/11/18 indicated the ammonia level was 33 (16-53 Normal Range). A nurse's note dated 1/12/18 indicated the resident had a low intake. An intake record dated 1/12/18 indicated the resident's total daily intake was 720 cc. A urine culture laboratory report dated 1/12/18 indicated <10,000 multiple gram positive organisms. A nurse's note dated 1/12/18 indicted the resident had a low by mouth intake. An intake record dated 1/13/18 indicated the resident's total daily intake was 1540 cc. A dietician assessment dated [DATE] indicated Resident # 135's food and fluid intake was less than 50%. The dietician made no recommendations, but indicated the resident may need a supplement if by mouth intake does not pick-up. The assessment indicated the resident's fluid requirement was 2430 cc/day. A nurse's note dated 1/13/18 indicated the resident's fluid goal was not met. A review of intake records noted the following total daily intakes: 1/14/18=1320 cc, 1/15/18=840 cc, 1/16/18= 900 cc. A nurse's note dated 1/16/17 indicated the resident's fluid goal was not met. An APRN note dated 1/17/18 indicated the resident had a poor oral by mouth intake, noted will check laboratory blood work, order a dietician consultation, and order supplements. Review of the intake record indicated the total daily intake was 1580 cc A dietary note dated 1/17/18 indicated he/she was alerted that Resident # 135's by mouth intake was very poor. The resident was coughing with po intake at that time. The note further indicated he/she would obtain a weight, would ask speech therapy to evaluate diet tolerance, and would add 120 cc of house supplement three times a day. A review of intake record dated 1/18/18 indicated the resident's total daily intake was 1320 cc. A laboratory test dated 1/18/18 indicated the BUN was 48 (10-24) and the creatinine was 4.5 (0.7-1.5). An APRN note dated 1/18/18 indicated the resident had acute [MEDICAL CONDITION], liver failure, and poor intake with weight gain. The resident was sent to the emergency room for evaluation. An interview on 3/12/18 at 10:20 AM with the dietician indicated although, he/she was aware the resident's intake was poor, he/she was not aware the resident was not meeting his/her fluid goal. He/she was not aware of how to access the resident's total daily fluid intake which was recorded in the computer. He/she expected the nursing department to notify him/her if the resident did not meet his/her fluid goals. On 1/17/18 he/she was notified that the resident was not eating well. At that time he/she indicated the resident appeared dry to him/her. He/she recommended a supplement and laboratory blood work be drawn. The dietician indicated he/she was not aware the resident was not meeting his/her fluid goal of 2430 cc that he/she had calculated on 1/13/18. The dietician indicated the nursing staff should attempt a goal of at least 1500 cc/ day of fluid a day before he/she is able to calculate individual fluid goals. He/she was also not aware Resident # 135 was not consuming at least 1500 cc of fluid a day prior to her assessment on 1/13/18. An interview on 3/12/18 at 10:45 A.M. with RN # 4 indicated monitoring fluid intake to ensure residents maintain their fluid goal had been an issue with the recent computer documentation. There had been recent discussion on hydration issues related to documenting and monitoring the total daily fluid intake on the computer. RN # 4 was unable to provide documentation that the documented daily fluid intake for Resident # 135 was monitored and/or interventions implemented when the resident did not reach established fluid goals. Review of a facility policy on hydration indicated the licensed nurse will notify the physician, dietician, and family if average fluid intake is below fluid requirement for 72 hours. The dietician will evaluate the resident and make recommendations as necessary. The care plan will be revised as necessary with appropriate communication to nursing staff. The license staff will document in the nurse's note the implementation and outcome of all interventions. The Interdisciplinary team will establish a plan of care based on clinical conditions, risk factors identified and the resident's fluid requirements. The care plan will be evaluated and revised as indicated.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #3) who was at risk for falls, the facility failed to provide the appropriate number of staff to assist during a transfer to prevent an accident that resulted with an injury. The findings include: Resident #3's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had no cognitive or memory deficits, no behavioral symptoms, required extensive two person assistance with transfers, was non-ambulatory, the functional limitation in range of motion was impaired on both sides of the lower extremities, left hand and elbow contractures, had a height of 5'1, weight of 162 pounds, and had utilized a walker and/or wheelchair for mobility. The Resident Care Plan dated 4/12/17 identified a history of falls and an unsteady gait. Interventions directed to transfer from in and/or out of the bed and chair stand lift assist of two (2) and to ambulate with physical therapy only. A physician's monthly orders dated 5/4/17 directed to transfer stand pivot with assist of two (2), ambulate with rehab only until specified, to apply the left ankle foot orthosis (AFO) boot on at 6:00 PM and off at 12:00 PM daily to prevent contractures and the resident was able to walk with the boot. The Reportable Event Form dated 5/4/17 at 12:45 PM identified Resident #3 became weak during a transfer following bathing activity in the shower room, and the resident was lowered to the floor with an assist of one. The assessment dated [DATE] at 2:00 PM identified Resident #3 was assessed post fall with full range of motion (ROM) of all extremities, the Advanced Practice Registered Nurse (APRN) was notified and x-rays of the left lower leg were ordered. The x-ray report dated 5/4/17 at 7:15 PM identified a definite oblique fracture through the left proximal fibula with minimal displacement and a questionable tibial metaphyseal fracture. A physician's orders [REDACTED]. The nurse's note dated 5/10/17 identified Resident #3 was readmitted to the facility after a five (5) day hospital stay. Interview with Resident #3 on 10/2/17 at 9:40 AM identified that on 5/4/17 after the shower was finished and he/she was waiting for assistance with transferring from the shower chair to the wheel chair when he/she experienced pain sitting in the shower chair. Resident #3 indicated that two staff were required to assist with transferring him/her and although the nurse aide had put the emergency bell on, nobody came to help and the nurse aide transferred him/her without assistance of another nurse aide. Interview with a 7-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 10/2/17 at 10:55 AM identified on 5/4/17 she was aware Resident #3 was in the shower room as the lunch meal started. LPN #1 stated she was returning to the unit with some meal trays when NA #1 was heard calling out from the shower room that help was needed. LPN #1 identified that the emergency call light was activated. Interview with the 7-3PM nurse aide, Nurse Aide (NA) #1, on 10/3/17 at 10:27 AM identified she assisted Resident #3 with the shower on 5/4/17. NA #1 stated when Resident #3 complained of leg pain and attempted to get up, she put the call light on, no one came to assist with the transfer and she lowered the resident to the floor. Interview with LPN #2 on 10/3/17 at 11:10 AM identified she could not recall if the emergency call system was activated and was in the hallway completing the medication pass when she heard NA #1 calling out from the shower room. LPN #2 stated she observed LPN #1 running out of the dining room to respond to the shower room. Interview, clinical record review and review of the facility Transfer Technique Policy with the Assistant Director of Nursing Services (ADNS) on 10/3/17 at 11:47 AM identified the transfer was not completed in accordance with the care plan.

Based on clinical record reviews, review of facility and law enforcement documentation, review of facility policies and interviews for 1 of 3 residents who exhibited combative behavior (Resident #1), the facility failed to ensure that the resident was free from physical abuse. The finding includes: Resident #1 had [DIAGNOSES REDACTED]. The Minimum data set (MDS) assessment dated [DATE] identified that the resident was cognitively impaired, exhibited physical behavioral symptoms directed at others and rejected care. The assessment also indicated that the resident was incontinent of bowel and bladder, required staff assistance for hygiene, and had impaired range of motion to the left upper extremity. The plan of care dated 2/13/12 identified that the resident was combative and incontinent, and directed the assistance of one staff member for turning in bed, incontinent care and to reapproach the resident when the resident was calm. Nursing narratives and the facility investigation dated 4/14/12 (evening shift) indicated that NA #1 reported to RN #1 that the resident was incontinent of stool, combative with care, pulled away from NA #1 and hit his/her right side of the face on the side rail. Nursing narratives dated 4/14/12 further noted that the resident had redness and swelling under the right eye and pointed to the side rail when asked what had happened. Nursing narratives and the facility investigation dated 4/15/12 (day shift) indicated that without a subsequent incident, the resident's left hand/ring finger was noted bruised and swollen and the x-ray of the left hand dated 4/15/12 was negative for fracture. The resident was sent to the ER following physician assessment on 4/17/12 and was diagnosed with [REDACTED]. Interview with NA #1 on 10/18/12 at 2:00 PM noted that the resident almost fell off of the bed and when s/he pulled the resident back, the right side of the resident's face hit the side rail. S/he further indicated that the resident had stool on the left hand, resisted when s/he tried to clean the hand, and that this was the most likely cause of the resident's left finger injury. The facility abuse policy identified that physical abuse was the willful infliction of injury and included controlling behavior through corporal punishment. The nurse aide job description indicated that the nurse aide perform duties as instructed by written assignment to include resident care.

Based on staff interviews, clinical record reviews and review of facility investigations for six of six residents sampled residents who were dependent on staff for transfers and mobility and reviewed for injuries of unknown origin (R #108, 33, 93, 64, 12, 6), the facility failed to ensure proper handling during care and transfers to prevent injuries and/or failed to store oxygen appropriately. The findings include: 1. Resident #108's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified the resident was moderately cognitively impaired, unable to ambulate, totally dependent on staff for transfers and personal care needs, and had no history of falls. The care plan 8/20/10 identified the resident was dependent on staff for transfers. Interventions included utilizing a mechanical lift with two staff for transfers. The care plan also identified that the resident was at risk for skin breakdown due to skin fragility, and impaired mobility. Interventions failed to reflect protective actions to be taken during transfers or with limbs. Nurse's notes dated 10/29/10 at 12 noon noted that the resident sustained [REDACTED]. One tear was 2 cm semicircular and the other 5 by 2 cm. The areas were noted as healed on 12/1/10. Review of the care plan after the injury noted that the care plan failed to reflect interventions to prevent further injuries to the lower extremities other than to pad the Hoyer bar. Observations on 2/4/11 at 11:30 AM noted that although most of the Hoyer's were padded, not all the bars were padded. Review of the clinical record, care plan, and investigation with the ADNS on 2/4/11 at 12:15 PM failed to provide documentation that a thorough investigation had been completed after the resident's injury, or that the staff had transferred the resident safely to prevent injuries. 2. Resident #6's [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified that the resident was moderately cognitively impaired, unable to ambulate, totally dependent on staff for transfers and had no history of falls. The care plan dated 7/17/10 noted the need for assistance with ADL's. Interventions included to transfer with a mechanical lift and the assistance of two staff. Nursing notes dated 8/19/10 at 4:20 PM indicated that the resident claimed his/her head was struck by the Hoyer bar prior to transfer into bed. The resident complained of left parietal lobe pain. Resident later complained of a headache and Tylenol was administered with effect. Review of the facility investigation dated 8/19/10 noted that the nurse aide hit the resident in the head with the Hoyer bar. The statement from the nurse aides indicated that the resident was sitting in the chair waiting to be hooked up to the mechanical/Hoyer lift when the resident screamed when being struck by the mechanical lift bar. The nurse aides involved were provided education and competencies were performed. 3. Resident #12's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident with short and long-term memory problems, non-ambulatory and total care with transfers. The resident care plan dated 11/30/10 identified that the resident received anticoagulant therapy. Interventions included medications as ordered, monitor labs, gentle handling with care, and monitor for side effects of anticoagulant therapy, including bruising and bleeding. Nurse's notes dated 12/1/10 at 1:30 PM identified a bruise was noted to the inner aspect of the upper right arm. Additionally, the note identified that an inservice was conducted on gentle handling of the resident. No further assessment of the bruise was noted until 12/4/10 at 10:00 AM when a right upper arm discoloration was noted with the area spreading. Dark purple discoloration was noted to the entire anterior aspect of the right upper arm, extending to the right shoulder, chest and right breast. The arm, chest, breast and shoulder were noted to be swollen and warm to the touch. Upon light palpation to the area the resident complained of pain and stated "ouch". The physician was notified and the resident was sent to the hospital and admitted with a [DIAGNOSES REDACTED]. The hospital discharge summary noted that x-rays revealed that a right 2nd rib acute fracture could not be ruled out. Review of the facility investigation dated 12/1/10 at 8:00 AM identified a bruise was noted to the right upper arm, the cause unknown. Additionally, an inservice on gentle handling was provided to the staff. Interview and review of R#12's clinical record, 24 hour report sheets and treatment kardex's with RN # 4 on 2/3/11 at 11:45 AM identified that on 12/1/10 when R#12's right upper arm bruise was identified it was the size of a dime and looked like a "fingernail imprint". RN# 4 further stated that is why an inservice was done on gentle handling, for staff not to use their hands because many of them have long fingernails, but to move the residents with the palms of there hands. 4. Resident #33's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified that the resident had no memory problems and was totally dependent on staff for transfers. The resident care plan (RCP) dated 2/8/10 identified a problem with activities of daily living (ADL) function. Interventions included to transfer R#33 via a Hoyer lift with the assistance of two staff. The care plan also identified diabetes as a problem with interventions that included diabetic foot checks as ordered. During an interview with R#33 on 2/01/11 at 7:54 AM, the resident indicated that the staff had banged his/her lower extremity with the Hoyer lift during a transfer. He/she indicated that it occurred late in the morning around 11:00 AM and that the staff was rushing because they would be late for lunch. R #33 further indicated that the staff tell him/her they have too many people to care for. A nurse's note dated 04/20/10 at 8:30 PM identified that during evening care, a nurse aide (NA) caring for R#33, reported seeing something on the resident's big toe. The note further identified that a skin tear measuring 1.0 CM x 0.5 CM was observed on the dorsal aspect (top) of the resident's large toe. the note further indicated the resident stated the Hoyer hit my big toe this morning. Review of a facility investigation dated 4/20/10 identified that R#33 sustained a skin tear to his/her right toe during a Hoyer transfer. The investigation identified that NA#2 and NA#3 had provided care and/or Hoyer transfers the morning of 4/20/10. The investigation included a statement from NA #3 who indicated she didn't bump or note a skin tear on transfer. A transfer competency dated 4/22/10 was completed with NA #3. The investigation did not include an interview/statement and/or transfer competency with NA # 2. 5. Resident #64's [DIAGNOSES REDACTED]. A minimum data assessment dated [DATE] identified the resident with short-term memory problems and requiring extensive assistance with transfers. A care plan dated 9/23/10 identified a problem with ADL's. Interventions included transfer with mechanical lift and assist of 2 staff. A nurse's note dated 10/13/10 at 12:00 PM noted the nurse aide observed a skin tear on the resident's right hand as a result of improper hand placement (during the mechanical lift transfer). The note further indicated the nurse aide was educated about safety precautions while transferring. A reportable event dated 10/13/10 noted R#64 sustained a skin tear during a transfer with a Hoyer lift . Review of an investigation indicated the resident had his/her hand on the chair when the lift went down on his/her hand. An interview on 2/7/11 at 11:15 AM with Nurse Aide # 6 indicated she had the resident's arm on the shower chair arm rest and the Hoyer lift hit his/her arm when she lowered the lift. She further indicated the resident's arms should be on his/her lap when transferring with a Hoyer lift. 6. Resident # 93's [DIAGNOSES REDACTED]. A minimum data assessment dated [DATE] identified the resident with memory problems, unable to ambulate, and totally dependent on staff for transfers and personal care needs, and had no history of falls. The care plan dated 9/18/10 identified the resident was dependent on staff for transfers. Interventions included utilizing a mechanical lift with two staff for transfers. A review of R #33's nurses' notes noted the following: on 8/2/10 at 11:30 AM a 7cm x 3cm ecchymotic area on the left jaw; on 9/20/10 at 10:45 AM a 9cm x 8cm ecchymotic area on the left upper arm and a 6cm x 2cm ecchymotic area on the left breast; on 10/31/10 at 12:30 AM a 10cm x 3cm scattered ecchymosis on the left inner thigh; on 11/18/10 at 3:00 PM a 2cm x 1cm abraised area on the lower lip; on 12/21/10 a bruise on the right thumb. Review of facility reportable events and investigations noted the following: The 8/2/10 investigation obtained statements from NA #8 who discovered the bruise on the resident's jaw and NA #9 assigned to the resident on 8/1/10 on the 3-11:30 PM shift. Competencies were completed with NA #9 and NA #10 on gentle handling. Statements were not obtained from the 11P- 7A shift. The 9/20/10 investigation noted a nurse aide actually identified the bruise to the left arm and breast on 9/19/10 on the 3P-11P shift and notified the nurse. The 10/31/10 investigation lacked a cause of incident. Although statements were received from 3 NAs, transfer and gentle care competencies were completed only with NA # 11. An interview and review of facility reportable event investigations on 1/3/11 at 2:00 PM with the ADON failed to explain why statements were not completed on all 3 shifts prior to discovering an injury of unknown origin, why nurse aide statements were not reviewed with the nurse aides, how it was determined what NAs would have competencies completed, and why reportable events and investigations were not completed for the 11/18/10 and 12/21/10 injuries. An interview on 1/7/11 at 11:00 AM with the Staff Development Director indicated that although Hoyer transfer competencies were completed annually, she was not involved in what competencies and/or with who competencies would be completed with after a resident injury. She indicated those competencies were completed by the nurse on the unit. She was unable to provide any documentation that inservices were held on handling dependent residents appropriately to prevent injuries during care. An interview and review of facility reportable event investigations on 1/3/11 at 2:00 PM with the ADON indicated the resident received Plavix and aspirin and bruised easily. She indicated she could not identify the exact cause of the bruises, but thought maybe it was from the Hoyer lift transfers.

Based on clinical record review and staff interview for one of six residents reviewed with injuries (R # 12), the facility failed to provide ongoing assessments of a bruise and/or pain. The findings include: Resident #12's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident had short and long-term memory problems, was non-ambulatory and required total care with transfers. The resident care plan dated 11/30/10 identified alteration in comfort due to pain as evidenced by facial expressions. Interventions included pain assessment every shift and PRN, monitor for subjective/objective symptoms of discomfort, medicate as ordered, and monitor effectiveness. Nurse's notes dated 12/1/10 at 1:30 PM identified a bruise was noted to the inner aspect of the upper right arm. Additionally, the note identified that an inservice was conducted on gentle handling. Nurse's notes dated 12/2/10 at 10:30 PM identified R#12 was medicated for pain/discomfort. The resident was observed crying and yelling out. The nurse's note failed to identify the location of the pain. Nurse's notes dated 12/3/10 at 10:50 PM identified R#12 was crying out in pain and stated "ouch". The resident was again medicated for pain, but the clinical record failed to identify the location of the pain. Nurse's notes dated 12/4/10 at 10:00 AM identified the right upper arm discoloration continued, now with the area spreading. Dark purple discoloration was noted to the entire anterior aspect of the right upper arm, extending to the right shoulder, chest and right breast. The arm, chest, breast and shoulder were noted swollen and warm to touch. Upon light palpation to the area the resident complained of pain and stated "ouch". The physician was notified and the resident was sent to the hospital and admitted with a [DIAGNOSES REDACTED]. Review of the medication kardex's for December 2010 identified R# 12 received [MEDICATION NAME] 5-500mg on 12/2/10 and 12/3/10 for severe pain. The medication kardex failed to identify the location of the pain. Interview and review of R#12's clinical record with RN #2 on 2/3/11 at 11:45 AM failed to provide documentation that a complete assessment of pain, including location and assessment of area had been conducted and/or that the bruise noted on 12/1/10 had been monitored and assessed. Additionally, RN# 4 stated when a resident complains of pain, the location is to be assessed, medicate the resident and assess for effectiveness of the medication. Additionally, RN # 4 stated if the pain continues or worsens it is then reported to the physician. Review of the Pain Management policy identified to monitor residents for symptoms of pain and provide a detailed pain assessment and develop a care plan to provide treatment and services to alleviate pain. Additionally, the pain management policy identified, assess the resident for physical changes or manifestations, including examination of pain site. b. Review of R#12's hospital discharge summary dated 12/7/10 identified R #12 was found to have a mild deformity in the anterior right rib, second rib and "cannot exclude an acute non-displaced rib fracture". The [MEDICATION NAME] will be held pending re-evaluation by the primary physician and orthopedic. Review of physician progress notes [REDACTED]. Review of physician order [REDACTED]. Interview and review of R #12's clinical record on 2/3/11 at 12:10 PM with the ADNS failed to identify that the physician order [REDACTED].