Every finding on record at Lutheran Home Of Southbury Inc

. Based on observations, review of the clinical record, facility documentation and facility policy, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure staff responded appropriately to wander guard alarms and failed to ensure staff visually verified residents before re-setting alarms, resulting in the resident leaving the nursing unit without staff knowledge. Further, the facility failed to maintain a secured exit door in proper working order and failed to ensure staff searched for a resident timely when an exit door alarm sounded, resulting in Resident #1 exiting the facility without staff knowledge or supervision. The failures resulted in the finding of Immediate Jeopardy. The findings include: Resident #1 was admitted 4/2026 with diagnoses that included dementia, major depressive disorder, and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of four out of fifteen (4/15), indicating severe cognitive impairment, had no wandering behaviors and ambulated with supervision. Elopement Risk assessment dated [DATE] identified a new assessment was completed due to new exit-seeking behaviors, and the score identified Resident #1 was high risk for elopement (score 22). The facility determined Resident #1 required enhanced elopement prevention interventions, including the application of a wander guard bracelet to the left ankle. The Resident Care Plan dated 4/24/26 identified a risk for elopement/wandering as evidence by disoriented to place, history of attempts to leave the facility unattended, and wandering aimlessly. Interventions directed to assess for elopement risk, identify wander patterns, distract and redirect as needed, wander guard device to left ankle, and monitor for placement and function of the wander guard. Facility reportable event (RE) dated 6/20/26 at 1:30 PM identified Resident #1 eloped from the facility, was returned to the building with no injuries identified and was placed on one-to-one (1:1) observation. The facility RE summary dated 6/25/26 identified Door #7 was equipped with a wander guard alarm, however the electronic magnet was malfunctioning, and only intermittently engaged when the door was tested. Resident #1 exited the unit at 1:35 PM, exited through Door #7 at 1:38 PM, NA #2 silenced Door #7 alarm at 1:42 PM and Resident #1 was observed outside at 2 PM (25 minutes after he/she exited the unit). Review of the facility video surveillance with the Administrator and Director of Nursing (DON) on 7/15/2026 at 2:15 PM identified Resident #1 followed behind a visitor and another resident when they exited the unit. Dietary Aide (DA) #1 was observed speaking with NA #1 immediately after Resident #1 exited the unit, and NA #1 then proceeded through the alarmed unit exit door, briefly looked into the immediate area outside the unit, and returned to the nursing unit without identifying Resident #1 had exited the secured area. Continued review identified Resident #1 exited the facility through a secured exterior door (Door #7) at approximately 12:30 PM and at approximately 12:35 PM, NA #2 was observed silencing Door #7's wander guard alarm, without visually assessing the exterior of the facility or looking through the door windows to determine the source of the alarm. Video surveillance further identified NA #2 entered the adjacent nursing unit and communicated with LPN #1 at approximately 12:38 PM. Neither staff member was observed responding to the activated wander guard alarm, initiating a search for Resident #1, or implementing the facility's elopement response procedures before resuming their assigned duties. Interview with DA #1 on 7/15/2026 at 11:40 AM identified that on 6/20/2026, DA #1 and DA #2 were on Resident #1's unit when a visitor and another resident were exiting the unit. DA #1 observed Resident #1 following immediately behind the couple through the secured doorway. The wander guard alarm activated and DA #1 asked NA #1 Is he/she allowed out of the unit? NA #1 responded yeah, that's his/her spouse and DA #1 then silenced the alarm and allowed the people to exit the unit. About five (5) minutes later DA #1 observed Resident #1 alone in the common area adjacent to the kitchen, and she did not intervene because she continued to believe Resident #1 had been authorized to leave the secured unit. Interview with NA #1 on 07/16/2026 at 10:15 AM identified on 6/20/2026 a visitor and resident were leaving the unit and the alarm sounded. The dietary staff asked her if they were allowed to leave, and she proceeded through the doorway to verify who exited the unit and she did not see Resident #1 had left the unit. NA #1 indicated she did not verify the identity of the resident who activated the wander guard alarm or determine whether another resident had exited the secured unit before staff silenced the alarm. Interview with NA #2 on 7/15/2026 at 1:25 PM identified that on 6/20/2026, she heard the wander guard alarm at secured exterior (Door #7) sound and she silenced the alarm. NA #2 stated looked through the door windows, however, she confirmed she did not open the door, exit the building, or conduct a search of the exterior to determine the source of the alarm or verify whether a resident had exited the facility, and she notified LPN #1 that the exterior door alarm had sounded. Interview with LPN #1 on 7/15/2026 at 2:35 PM identified she did not recall NA #2 notifying her that the exterior Door #7 wander guard alarm had sounded on 6/20/2026, and she was later informed that Resident #1 had eloped from the facility. LPN #1 confirmed she did not respond to the activation of the wander guard alarm, assess the secured exit, or participate in locating Resident #1 at the time of the event because she was unaware the resident had exited the facility. Review of the Elopement of a Resident Policy dated 3/1/2022 identified in part, staff will be trained on the Center's door security system and were required to response to a sounding alarm; if alarm sounds and no resident is at or outside of the door, an accounting of all residents will be conducted immediately. Staff witnessing a confused resident or an identified elopement risk resident attempting to leave the Center will intervene as appropriate to redirect the resident to a safe area and prevent elopement. Review of facility documentation identified staff education was initiated on 6/22/26 and included staff response to wander guard alarms, and notification of doors identified to not function properly. Audits were initiated on 6/21/26, with results reviewed by QAPI. Based on review of facility documentation, past non-compliance was identified.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident with dementia who was known to require assistance with transfers and only able to ambulate with therapy, was transferred without injury. The findings include: Resident #1 had a diagnosis of altered mental status and dementia. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 10 indicating moderately impaired cognition, had no behaviors and required partial assistance with transfers. The Resident Care Plan (RCP) dated 4/7/26 identified a risk for falls and self-care deficit. Interventions directed to ensure call light was within reach and provide assistance of two (2) with transfers with rolling walker and to ambulate only with rehab. Physician order review failed to identify an order directed transfer status. Facility Reportable Event (RE) dated 5/4/26 at 10:29 AM identified Resident #1 required assist of one (1) for transfers and had a witnessed fall on 5/2/2026 at 12:30 PM as a Nurse's Aide (NA) transferred Resident #1 into a wheelchair and his/her foot became caught in the wheelchair. Resident #1 lost balance and fell to the floor. And RN assessment identified a laceration above the right eyebrow and abrasions to the right knee and right thumb, and complained of a headache. The physician/APRN was notified, and Resident #1 was transferred to the hospital. Resident #1 returned to the facility with six (6) stitches to the right eyebrow laceration. Nursing note dated 5/2/26 at 12:57 PM identified Resident #1 was transferred to the hospital at approximately 12:58 PM. Physician order dated 5/3/2026 (the day after the fall) directed two (2) assist for transfers. The facility RE summary dated 5/9/2026 identified was wearing non-skid socks at the time of the fall, and when the NA assisted with the transfer, Resident #1 stood up and quickly turned to the left catching his/her right foot on the front of the wheelchair causing him/her to pitch forward, pushing into the NA and landing on the floor. Despite the NA having a hold on him/her, she wasn't able to maintain the grasp as his/her weight pushed past her. The RCP was revised to encourage Resident #1 to sit on the edge of the bed for one (1) minute to allow blood pressure to accommodate the change in position and then to stand and slowly pivot with assist. The summary indicated the fall was caused by an abrupt quick turn while being transferred into the wheelchair to be toileted, causing the NA to lose her balance and not being able to prevent or intercede in the fall. The summary further indicated a recent UTI caused haste to get to the toilet and poor balance. Interview with NA #1 on 5/27/26 at 11:35 AM identified although the RCP directed two (2) staff for transfers, NA #1 stated Resident #1 required assist of one (1) staff for transfers. On 5/2/2026 she attempted to transfer Resident #1 from the bed into the wheelchair (without a second staff member) and Resident #1 stood up faster than usual. As Resident #1 stood up, he/she began to pivot before fully standing up and Resident #1 tripped over his/her foot, causing him/her to lose balance and fall. NA #1 stated she did not use a gait belt when transferring Resident #1 because it was not in the plan of care and she did not think she should have used a gait belt. Interview with the Director of Rehabilitation (DOR) on 5/27/26 at 12 PM identified Resident #1 required an assist of one (1) to stand and pivot and she did not know why the care plan directed two (2) staff assist. The DOR stated if a gait belt had been used for the transfer it could have prevented the fall. Interview and record review with the Director of Nursing (DNS) on 5/27/26 at 1:15 PM identified the RCP directed two (2) staff for transfers. The DNS stated a gait belt was not required to be used for the transfer, however Resident #1 had no contraindications for use of a gait belt. Interview failed to identify why Resident #1 was not transferred in accordance with the current plan of care, why a gait belt was not used for a resident with dementia that required assistance with transfers and who had a recent UTI that may cause haste to get to the toilet and poor balance, as described in the RE summary. Review of facility Gait Belt (Transfer Belt) Policy dated 3/10/22 directed in part, gait belts may be used for all transfers of residents who require the assistance of 1 or 2 persons, and the purpose was to enhance safety and protection of the resident during transfers. Gait belts are not mandatory or appropriate for all circumstances and individual plans of care will address specific resident needs; the following residents may be exceptions to the use of gait belts: colostomy, ileostomy, rib fractures, severe degenerative disease, history of pathological fractures, recent surgery in the area of the belt, gastrostomy tube and other conditions identified by the interdisciplinary care team.

Based on record review, facility documentation review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to act timely when therapy recommended to change the resident transfer status. The findings include: Resident #1 had a diagnosis of altered mental status and dementia. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 10 indicating moderately impaired cognition, had no behaviors and required partial assistance with transfers. The Resident Care Plan (RCP) dated 4/7/26 identified a risk for falls and self-care deficit. Interventions directed to ensure call light was within reach and provide assistance of two (2) with transfers with a rolling walker and ambulate with rehab only Physician order review failed to identify an order that directed transfer status. Facility Reportable Event (RE) dated 5/4/26 at 10:29 AM identified Resident #1 required assist of one (1) for transfers and had a witnessed fall on 5/2/2026 at 12:30 PM as a Nurse's Aide (NA) transferred Resident #1 into a wheelchair and his/her foot became caught in the wheelchair. Resident #1 lost balance and fell to the floor. And RN assessment identified a laceration above the right eyebrow and abrasions to the right knee and right thumb, and complained of a headache. The physician/APRN was notified, and Resident #1 was transferred to the hospital. Resident #1 returned to the facility with six (6) stitches to the right eyebrow laceration. Physician order dated 5/3/2026 (the day after the fall) directed two (2) assist for transfers. The facility RE summary dated 5/9/2026 identified was wearing non-skid socks at the time of the fall, and when the NA assisted with the transfer, Resident #1 stood up and quickly turned to the left catching his/her right foot on the front of the wheelchair causing him/her to pitch forward, pushing into the NA and landing on the floor. Despite the NA having a hold on him/her, she wasn't able to maintain the grasp as his/her weight pushed past her. The RCP was revised to encourage Resident #1 to sit on the edge of the bed for one (1) minute to allow blood pressure to accommodate the change in position and then to stand and slowly pivot with assist. The summary indicated the fall was caused by an abrupt quick turn while being transferred into the wheelchair to be toileted, causing the NA to lose her balance and not being able to prevent or intercede in the fall. The summary further indicated a recent UTI caused haste to get to the toilet and poor balance. Interview with NA #1 on 5/27/26 at 11:35 AM identified although the RCP directed two (2) staff for transfers, NA #1 stated Resident #1 required assist of one (1) staff for transfers. Interview failed to identify where NA #1 obtained information that directed one (1) staff to transfers. Interview with the Director of Rehabilitation (DOR) on 5/27/26 at 12 PM identified Resident #1 required an assist of one (1) to stand and pivot. The DOR stated she did not know why the care plan directed two (2) staff to assist. Further, rehab note dated 5/1/2026 indicated rehab changed Resident #1's transfer status to one (1) assist for transfers. Therapy's process to change resident orders was to enter the order into the electronic medical record (EMR) queue for nursing to obtain new orders. The DOR stated she thought rehab entered the change in status into the queue for nursing to obtain orders, however she was unable to identify the request was in the queue. The DOR stated that nursing may have deleted the request from the queue, and therapy's recommendation was never processed (acted upon). The DOR stated therapy should have entered the request into the queue for nursing to obtain updated physician orders, and the request should have been acted upon by nursing. Interview and record review with the Director of Nursing (DNS) on 5/27/26 at 1:15 PM identified although the RCP directed two (2) assist for transfers, the DNS stated Resident #1 required an assist of one (1) assist for transfers. The DNS stated therapy staff usually communicate changes in residents' status in morning report, and it was the responsibility of the unit manager to obtain the physician orders and update the care plan. Although both the DNS and NA #1 stated Resident #1 required one (1) staff for transfers, interview failed to identify how she and NA #1 were notified of the change to one (1) assist for transfers, and if the therapy recommendation from 5/1/2026 for transfer status was entered into the EMR queue for nursing to obtain new orders. A policy for acting upon therapy recommendations was not provided during survey.

Based on clinical record reviews, facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for an allegation of misappropriation of resident property, the facility failed to safeguard a resident's personal valuables when Resident #1's cash money was removed from the facility's safe. The findings include:Resident #1's diagnoses included dementia, depression, and anxiety disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had poor decision-making skills regarding tasks of daily living and required assistance from staff with activities of daily living. The nursing progress note dated 9/4/25 at 7:35 PM identified a nurse aide brought Resident #1 to the shower room to give Resident #1 his/her weekly shower and the nurse aide found $20.00 dollars in cash in Resident #1's brief, and later in Resident #1's room the nurse aide found $340.00 dollars cash hidden in Resident #1's soiled bedding, along with three (3) checkbooks. The note indicated all necessary parties were notified, Resident #1 was allowed to keep the $20.00 dollars on his/her person, and the $340.00 dollars and checkbooks were locked in the nursing narcotic box safe on the unit until the business office opened on 9/5/25. The social service progress note dated 9/5/25 at 3:09 PM indicated nursing informed social services that Resident #1 had $340.00 dollars in cash and three (3) checkbooks on his/her person, which were taken by the nurse and locked in the facility's safe. The Facility Reported Incident report dated 9/10/25 identified Resident #1's cash, which was stored in the facility safe, was noted to be missing from the facility safe on 9/10/25 at 4:00 PM. The investigation identified Resident #1 had $340.00 in cash and three (3) checkbooks found on 9/4/25 on Resident #1's person, which were placed in a biohazard bag by nursing and placed the bag in the nursing unit narcotic box. On 9/5/25 the money and checkbooks were then placed into the facility's locked safe by the [NAME] Assistant with the Administrator present for the facility to safeguard Resident #1's personnel belongings while at the facility. On 9/10/25, the money was identified as missing from the facility safe when the safe was opened by the Business Office Manager with the [NAME] Assistant present. The investigation determined that on 9/10/25 the Business Office Manager and [NAME] Assistant both left the office to attend a meeting earlier that day and the only person in the office alone was a Customer Service Liaison. Interview with the Business Office Manager on 9/25/25 at 11:10 AM identified the facility was asked on 9/5/25 to keep Resident #1's cash and three (3) checkbooks in the facility safe while Resident #1 resided at the facility, and the money was first identified as missing on 9/10/25 at 4:00 PM by herself and the Assistant Biller. The Business Office Manager indicated she and the Assistant Biller typically kept the key to the safe hidden in a pen holder on a desk in the office and the door to the office was locked when neither she nor the Assistant Biller was in the office. The Business Office Manager identified on 9/10/25 a Customer Service Liaison was assigned to work from the office so the door to the office was left open while she and the Assistant Biller went to a meeting because the Liaison did not have a key to the office. The Business Office Manager explained although she, the Assistant Biller, and the Administrator were the only ones to have access to the key to the facility safe, the key was left unsecured in a pen holder on a desk in the office when she and the Assistant Biller left for the meeting on 9/10/25. Interview with the Assistant Biller on 9/25/25 at 11:20 AM identified she had last seen the money in the facility safe, which she had placed into the safe with the Administrator present in early September. The Assistant Biller identified the money was first noticed as missing on 9/10/25 after she and the Business Office Manager saw the clear biohazard bag had been opened. Interview and review of the facility incident report with the Administrator on 9/25/25 at 12:05 PM identified at the beginning of September, she witnessed the Assistant Biller place Resident #1's cash money and three (3) checkbooks into the facility safe after nursing found the money and checkbooks on Resident #1. The Administrator indicated Resident #1's money and checkbooks were inside a biohazard bag, which was then placed into the facility's safe and on 9/10/25 at 4:30 PM, she was informed by the Business Office Manager that the money from the biohazard bag was missing. The Administrator explained she was unable to determine who was responsible for removing Resident #1's money from the safe, Resident #1 was reimbursed and the Customer Service Liaison resigned. Interview with Customer Service Liaison on 9/25/25 at 1:15 PM via phone indicated he/she was not sure what happened to Resident #1's money. Review of the facility Abuse Prevention Program Policy dated 5/25/25 defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent and directed that residents had the right to be free from misappropriation of resident property.

Based on review of the clinical record, facility documentation, policies, and interviews, for one (1) of three (3) residents (Resident #4) reviewed for discharge, the facility failed to ensure the receiving provider's acceptance prior to transfer and failed to provide the receiving health care facility with the resident's discharge summary before the resident's arrival.Resident #4 had diagnoses that included anoxic brain damage, dementia with behavioral disturbance, fracture of the upper end of the left humerus, atrial fibrillation, malignant neoplasm of the prostate, and dysphagia.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8), was frequently incontinent of bowel, occasionally incontinent of bladder, and required moderate assistance with personal hygiene, bed mobility, ambulation, and transfers. The MDS further identified Resident #4's goal for discharge was to be discharged to the community.The care plan dated 9/10/2025 identified Resident #4 wished to return to the community where he/she resided with his/her spouse. Interventions directed to establish a pre-discharge plan, evaluate progress, revise the plan as needed, make arrangements with required community resources to support independence post-discharge, prepare and give resident/family member/caregivers contact numbers for all community referrals.The nurse's note dated 9/10/2025 at 11:26 A.M. by Registered Nurse (RN) #3 (MDS coordinator), identified Resident #4's spouse was contacted to inform him/her that Resident #4 received a Notice of Medicare Non-Coverage (NOMNC) with the last covered day as 9/12/2025. RN #3 identified Resident #4's spouse requested to file an appeal. RN #3 indicated she provided Resident #4's spouse with the contact number and information needed to request an appeal.The nurse's note dated 9/11/2025 at 12:50 P.M. by RN #3 identified Resident #4 lost the appeal. RN #3 identified Resident #4's spouse offered to privately pay to keep Resident #4 at the facility but stated he/she could not afford it. RN #3 identified Resident #4's spouse stated he/she filed a second-level appeal and would pick Resident #4 up on 9/13/2025. RN #3 indicated social services would set up home care services.The nurse's note dated 9/12/2025 at 2:16 P.M. by Licensed Practical Nurse (LPN) #2 (MDS coordinator) identified she and Social Worker (SW) #2 spoke with Person #2 who had concerns about Resident #4 returning to prior living arrangements with his/her spouse secondary to Resident #4 being recently hospitalized , and the spouse unable to provide Resident #4 with the care he/she needed. LPN #2 indicated Person #2 arranged transportation, for Resident #4, to a short-term hospital. LPN #2 indicated that on 9/13/2025, the nursing staff would call Resident #4's spouse to call transportation.APRN #1's note dated 9/12/2025 at 10:31 A.M. identified Resident #4's insurance was requesting a discharge home. APRN #1 identified Resident #4 resided in a hotel with his/her spouse due to homelessness. APRN #1 identified Resident #4 needed to be discharged with 24-hour care because he/she could not care for himself/herself, was at high risk for falls, and was at high risk for rehospitalization.APRN #1's note dated 9/12/2025 at 2:13 P.M. identified Resident #4 was being transferred to the hospital.The nurse's note dated 9/13/2025 at 3:34 P.M. by LPN #3 identified Resident #4 was transferred to the hospital.Interview with SW #1 on 9/30/2025 at 9:45 A.M. identified that initially, Resident #4's discharge plan was to be discharged back to the community where Resident #4 lived with his/her spouse. SW #1 identified she was not involved when Resident #4's discharge plans changed on 9/12/2025 to Resident #4 being discharged to another healthcare institution. Interview with SW #2 on 9/30/2025 at 10:05 A.M. identified she was contacted by Person #2 on 9/12/2025 because Resident #4's spouse contacted him/her regarding Resident #4's discharge home on 9/13/2025. SW #2 indicated Person #2 stated Resident #4's spouse was recently hospitalized and could not take care of Resident #4. SW #2 indicated Person #2 reported he/she arranged transportation on 9/13/2025 to another health care institution. SW #2 identified that on 9/12/2025, she did not contact the receiving health care institution to confirm Resident #4's admission on [DATE]. SW #2 identified on 9/12/2025 and 9/13/2025, she did not contact, convey, or electronically transmit Resident #4's discharge summary to the receiving health care institution or health care provider.Interview with Person #2 on 9/30/2025 at 10:27 A.M. identified on 9/12/2025 he/she received a call from Resident #4's spouse, who reported Resident #4 was scheduled to be discharged on 9/13/2025 from the facility back to the hotel. Person #2 indicated Resident #4's spouse had been recently hospitalized and stated he/she was unable to care for Resident #4. Person #2 indicated Resident #4's spouse asked if he/she could help coordinate transportation to a short-term care hospital on 9/13/2025. Person #2 identified he/she spoke to SW #2 on 9/12/2025 to notify him/her of the arranged transportation on 9/13/2025 to the short-term care hospital.Interview with the Administrator on 9/30/2025 at 11:41 AM identified that on 9/13/2025, when Resident #4 left the facility, he/she had a copy of his/her discharge summary. The Administrator was unable to provide documentation to reflect the facility confirmed Resident #4's discharge destination or that a discharge summary was provided to the receiving health care institution on 9/13/2025. Interview with RN #1 (supervisor) on 9/30/2025 at 1:11 P.M. identified on 9/13/2025 at 4:30 P.M., RN #2 reported Resident #4 was discharged between 12:00 P.M. and 1:00 P.M., with his/her discharge paperwork. RN #1 identified that on 9/13/2025 at approximately 4:30 P.M., she received a call from a nurse at the health care institution asking why Resident #4 was sent there and requested that she send over a copy of Resident #4's discharge summary.Interview with the DNS on 9/30/2025 at 2:10 P.M. identified on 9/12/2025 SW #2 should have contacted the receiving health care institution to confirm Resident #4's admission on [DATE] and then sent over Resident #4's discharge summary. The DNS was unable to explain why there was no communication with the receiving health care institution or why the discharge summary was not sent before Resident #4 left the facility.Although attempted, an interview with RN #2 was not obtained.Review of the facility's Transfer or Discharge Emergency Policy dated 12/2021, directed in part, should it become necessary to transfer or discharge to a hospital or other related institution our facility will implement the following procedure: notify the receiving facility that the transfer is being made.Review of the facility's Transfer or Discharge Policy dated 12/2016, directed in part, nursing services is responsible for preparing the discharge summary and post-discharge plan.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #4) reviewed for discharge, the facility failed to obtain a physician's order for discharge. The findings include:Resident #4 had diagnoses that included anoxic brain damage, dementia with behavioral disturbance, fracture of the upper end of the left humerus, atrial fibrillation, malignant neoplasm of the prostate, and dysphagia.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8), was frequently incontinent of bowel, occasionally incontinent of bladder, and required moderate assistance with personal hygiene, bed mobility, ambulation, and transfers. The MDS further identified Resident #4's goal for discharge was to be discharged to the community.The care plan dated 9/10/2025 identified Resident #4 wished to return to the community where he/she resided with his/her spouse. Interventions directed to establish a pre-discharge plan, evaluate progress, revise the plan as needed, make arrangements with required community resources to support independence post-discharge, prepare and give resident/family member/caregivers contact numbers for all community referrals.The nurse's note dated 9/12/2025 at 2:16 P.M. by Licensed Practical Nurse (LPN) #2 (MDS coordinator) identified she and Social Worker (SW) #2 spoke with Person #2 who had concerns about Resident #4 returning to prior living arrangements with his/her spouse secondary to Resident #4 being recently hospitalized , and the spouse unable to provide Resident #4 with the care he/she needed. LPN #2 indicated Person #2 arranged transportation, for Resident #4, to a short-term hospital. LPN #2 indicated that on 9/13/2025, the nursing staff would call Resident #4's spouse to call transportation.APRN #1's note dated 9/12/2025 at 10:31 A.M. identified Resident #4's insurance was requesting a discharge home. APRN #1 identified Resident #4 resided in a hotel with his/her spouse due to homelessness. APRN #1 identified Resident #4 needed to be discharged with 24-hour care because he/she could not care for himself/herself, was at high risk for falls, and was at high risk for rehospitalization.APRN #1's note dated 9/12/2025 at 2:13 P.M. identified that Resident #4 was transferred to the hospital.The nurse's note dated 9/13/2025 at 3:34 P.M. by LPN #3 identified Resident #4 was transferred to the hospital.Interview and clinical record review with the DNS on 9/30/2025 at 2:10 P.M. failed to Identify documentation to reflect a physician's order was obtained when Resident #4 was discharged on 9/13/2025. The DNS identified that when a resident is being discharged , the charge nurse should ensure a physician's order is obtained for discharge. The DNS was unable to explain why a physician's order was not obtained to discharge Resident #4. Review of the facility's Transfer or Discharge Policy dated 12/2016, directed in part, that nursing services is responsible for obtaining orders for discharge.

Based on observations, interviews, record and policy review, the facility failed to post and provide information or means to file a grievance and follow up on grievances. The findings included: 1. Resident #31's diagnoses included diabetes, chronic obstructive pulmonary disease, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 was mildly cognitively impaired, required set up for eating and oral hygiene and substantial/maximal assistance for dressing and transfers. 2. Resident #57's diagnoses included emphysema, a pressure ulcer to the sacral area and irritable bowel syndrome. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 was cognitively intact, independent for eating and required partial/moderate assistance for dressing and transfers. 3. Resident #61's diagnoses included chronic obstructive pulmonary disease, depression and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #61 was cognitively intact, was independent for transfers and required partial/moderate assistance with toileting and dressing. 4. Resident #81's diagnoses included epilepsy, asthma, and insomnia. The quarterly MDS assessment dated [DATE] identified Resident #81 was moderately cognitively impaired, required set up for dressing, toileting and partial/moderate assistance for transfers. Interview with Resident #57 on 6/9/25 at 11:03 AM identified he/she heard staff speaking inappropriately in the hallway to each other, such as using swear words in their conversations, which was unpleasant to hear. However, Resident #57 did not report it to anyone, because he/she was not aware of who to report it to or where to go with complaints. Interview with Resident #31 on 6/11/25 at 10:03 AM identified he/she was not aware of who the grievance officer was or how to file a grievance, but that he/she had a missing sweater and sneakers in the past, and although the sweater was found the sneakers were not. (Review of the grievance book failed to identify grievances/ missing items forms were completed for Resident #31). Interview with Resident #61 on 6/11/25 at 10:05 AM identified she was not aware of who to speak to at the facility if he/she had issues and it did not seem like issues in the facility were addressed. There were multiple concerns brought up regarding Nurse Aides not introducing themselves and it was still ongoing. (Resident council minutes from 2/24/25 and 4/28/25 identified there were concerns with staff not introducing themselves. Interview with Resident #81 on 6/11/25 at 10:06 AM identified he/she was not aware of who the grievance officer was or how to file a grievance. Interview with Person #1 on 6/11/25 at 10:39 identified he/she was not aware of how to file formal grievance with the facility, nor did anyone provide information on how to do so. He/she identified having multiple meetings with the facility management staff (unit manager and the Administrator) to bring up concerns, and stated that although they wrote things down, the complaints have not been rectified, nor has he/she received follow up. (Review of the facility Grievance book identified there were no grievances filed or recorded from Person #1). Tour of the facility on 6/11/25 at 10:45 AM failed to identify signage regarding how to file a grievance, the grievance process in the facility or forms available in a conspicuous area. Interview with Registered Nurse (RN) #1 on 6/11/25 at 11:02 AM identified it was facility policy that any staff member could initiate a grievance when one was brought forth, then depending on the severity of the concern, report it to the Director of Nurses or Social Services. Additionally, RN #1 identified that individuals would know how to file a grievance because it was common knowledge that it was their right to contact the state and the ombudsman if they wanted to file a grievance. RN #1 further identified forms were available in a folder at the nurse's station for anyone wishing to file a grievance but could not locate the folder upon surveyor request. (Subsequent to surveyor inquiry RN #1 identified the folder was in a back office and located it at the nurses' station). Interview and education review with the Director of Social Services (SW) #1 on 6/11/25 at 11: 11 AM identified it was facility policy that anyone could initiate a grievance by utilizing grievance forms located at the nurse's stations, in the lobby and that information on filing grievances was posted and part of the resident rights packet. Additionally, she identified that new forms were introduced from the corporate office and staff was in-serviced on Friday 6/6/25. A review of the in-service sign in sheet with SW#1 identified only 15 staff member signatures, which she confirmed was the only education on the updated grievance policy so far. Interview and observation with SW #1 on 6/11/25 at 11:20 AM failed to identify the grievance policy/procedure was posted or that there were forms available in the lobby. Subsequent to surveyor inquiry, SW #1 posted the grievance policy in the lobby including the process with forms available in the front lobby. Interview with the Administrator on 6/11/25 at 11:24 AM identified the grievance process could be initiated by anyone by utilizing the forms that were available, but the goal was to rectify concerns on the spot. Additionally, the Administrator identified that since she had been with the facility (around 2 weeks), she had spoken to family members, but there were no current concerns, but rather a recap of past issues so she did not initiate any grievances in writing. Interview and Resident Council Minutes review with the Director of Recreation on 6/17/25 at 11:02 AM identified that she only invites guest speakers to Resident Council if there was a request by the residents, and that in the last 6 months no one had reviewed the grievance procedure with the residents. Additionally, the Director of Recreation identified that if there was a concern brought up, the department with the identified concern was immediately notified, but nothing was put in writing. A review of the Resident Council minutes from 2/24/25 and 4/28/25 identified the concerns about NA's not introducing themselves was verbally passed on to the DNS and Administrator. Interview with the Director of Nurses (DNS) on 6/17/25 at 11:22 AM identified it was facility policy to take all grievance seriously and involve social services and the administrator to implement an appropriate resolution. The DNS identified that she was aware of the concerns brought up in Resident Council in February 2025 and April 2025 regarding NAs not introducing themselves to residents and held staff meetings to reeducate the NA's on introducing themselves prior to providing care. Re-interview and staff meeting minutes review with the DNS on 6/17/25 at 11:43 AM identified there was a Staff Meeting on 4/24/25 that in part reviewed staff identification to residents consisted of 24 nursing department employees. The DNS failed to identify any other meetings or education provided to staff in response to Resident Council concerns brought up on 2/24/25 and 4/28/25. Review of The Grievance/Concern Procedure directed in part that concern forms can be initiated by anyone and are located at all the nurses' stations. When a concern is verbally reported to the Administrator or Social Services the form will be initiated. Review of The Grievance/Concern Program directed in part that grievances will be documented and responded to in an orderly time and manner. When a resident, visitor or employee has a concern they may fill out a complaint/grievance form, located by the entryways or lobbies and on the nursing units. The grievance officer or Administrator receiving the verbal complaint will complete the top portion of the Record of Resident and Family Concerns and provide it to the appropriate Department Head or follow up.

Based on observations and staff interviews for 30 residents reviewed for placement on a secured unit, the facility failed to identify required clinical criteria for placement on the unit, failed to develop a policy for the secured unit, and failed to document that information for independent egress had been provided to appropriate residents. The findings include: Observations on 6/9/25, 6/10/25, 6/11/25, 6/16/25, and 6/17/25 identified 30 residents resided on the lower level secured unit. Although entrance onto the unit did not require a code to enter, exit from any of the doors (including the door used to enter that unit) on the unit required input of a number code into a keypad adjacent to the door. Additionally, it was noted that if a number code was not entered, the handle to the door needed to be engaged (held down) for 15 seconds for the door to open, and if the handle was not held down for 15 seconds, an alarm would sound. Intermittent observations on all days of the survey identified staff entering the number code into the keypad for residents to exit the unit. Interview with the Administrator on 6/17/25 at 11:20 AM identified the unit on the lower level was not considered a secured unit because if the resident held down the door handle for 15 seconds, the door would open. The Administrator further noted that she was not sure if those residents who were alert and oriented were aware that if they held the door until it released they could exit. Interview with RN #6 on 6/17/25 at 11:28 AM identified that while the lower level unit doors were secured requiring a code to exit, it was not considered by the facility to be a locked/secured unit, and there was no policy for that unit. RN #6 was not aware that a unit which required input of a code to exit the unit was considered a secured unit. RN #6 identified the main clinical criteria for putting a resident on the lower level unit was aggressively exit seeking and/or exhibited consistent wandering. RN #6 identified that the unit was an alarmed (requiring the person exiting to hold down the door handle for 15 seconds to disengage the locking component or an alarm would sound but would not unlock the door) unit but that it was not dedicated to those residents that required that. RN #6 identified elopement assessments along with a lot of team discussion and collaboration with daily discussions would be used to determine if a resident would benefit from placement on the lower level unit. RN #6 identified that those residents who didn't require placement on an alarmed unit would be provided with the code for the door and that there was not an assessment process to get a code. Interview with RN #2 on 6/17/25 at 12:00 PM identified he was the unit manager for the lower level alarmed unit, and 9 out of 30 of the residents on his unit had wanderguards. RN #2 identified that residents without wanderguards were permitted to leave the unit and come to the adjacent unit where the dining room was. RN #2 identified any resident that required exiting through the alarmed door would need to be assisted off the unit and accompanied by a staff member. RN #2 identified that residents were not provided the code to independently leave the unit, that the unit was considered a secure unit, but not like a memory care unit because there was no special criteria to reside there. RN #2 further identified that the unit was for long term care, but that he often got overflow from the rehabilitation unit. Observation with the Director of Maintenance on 6/17/25 at 12:15 PM identified the doors to exit the lower level secured unit would open without a code if the door bar was pressed continuously for 15 seconds, however the door would begin to alarm as soon as exit was attempted without input of a code, but would not open unless the door bar was pressed down for 15 seconds. Interview with Resident #23 (a 5-day Minimum Data Set assessment indicated Resident #23 had intact cognition) on 6/17/25 at 1:10 PM identified he/she did not have the code to independently leave the unit, that it was never provide to him/her, but that his/her family member had the code to independently leave the unit. Resident #23 further identified that he/she required assistance to leave the unit because he/she was in a wheelchair and required someone to put the code in. Interview with Resident #31 (a quarterly Minimum Data Set assessment indicated Resident #31 was moderately cognitively impaired) on 6/17/25 at 1:15 PM identified that he/she did not have the code to independently leave the unit and that if Resident #31 or his/her visitors want to leave the unit, they must ask a staff member to assist them. Although requested, a facility policy for the secured unit was not provided.

Based on observation, review of the clinical record, facility policy and interviews for 4 of 4 residents (Resident #24, Resident #54, Resident #63, Resident #76) observed to be eating their meals in the hallway, the facility failed to provide a dignified dining experience. The findings include: 1. Resident #24's diagnoses included adjustment disorder, anxiety, and right sided weakness related to a cerebral vascular accident. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 was severely cognitively impaired, required maximal assistance for toileting, and bathing. Also identified Resident #24 required moderate assistance with eating, transfers and personal hygiene. The Resident Care Plan (RCP) dated 4/25/25 identified Resident #24 was at risk for nutritional problems with interventions that included to monitor intake and record every meal, and to provide and serve meals as ordered. Further identifying Resident #24 had a self-care deficit with interventions that included assistance of 1 for meals and transfers. 2. Resident #53's diagnoses included dementia, anxiety, and heart disease. The admission MDS assessment dated [DATE] identified Resident #53 was severely cognitively impaired, and was dependent on staff for toileting, and bathing. Also identifying Resident #53 required supervision of touch assistance with transfers, and oral hygiene. Further identifying Resident #53 required setting up assistance for eating. The RCP dated 6/16/25 identified Resident #53 had a problem with impaired cognitive and thought process with interventions that included to provide the resident with a homelike environment, consistent care routines, and familiar objects. Also identifying nutritional problems with interventions that included to invite Resident #53 to activities that promote additional intake, assisting Resident #53 with developing a support system to aid in increasing meal intake efforts, including friends, and other residents. 3. Resident #63's diagnoses included dementia, dysphagia, and myocardial infarction. The quarterly MDS assessment dated [DATE] identified Resident #63 was severely cognitively impaired, dependent on oral hygiene, and toileting. Also identifying Resident #63 required maximal assistance for transfers, bathing and dressing and set up assist for eating. The RCP dated 4/24/25 identified Resident #63 was at risk for alteration in nutrition with interventions that included to attempt to have meals in the dining room and assist him/her to finish meals. Further identifying Resident #63 was a risk for falls related to deconditioning, and confusion with interventions that included encouraging the resident to eat breakfast in the dining room and educate family to staff when they are leaving. 4. Resident #76's diagnoses included dementia, dysphagia, and peripheral vascular disease. The quarterly MDS assessment dated [DATE] identified Resident #76 was severely cognitively impaired, dependent on transferring, dressing, and personal hygiene. Also identifying Resident #76 required maximal assistance for bathing, eating and oral hygiene. The RCP dated 5/6/25 identified Resident #76 was at risk for weight loss with interventions that included to provide assistance of 1 with meals, encourage activities that promote additional intake, and aspiration precautions be maintained. Observation on 6/9/25 at 12:31 PM noted Residents #24, #63 and #76 were in the C1 South hallway having lunch, all were sitting in wheelchairs with their backs against the wall and their tray tables in front of them. The 3 residents were feeding themselves. An observation made on 6/9/25 at 12:40 PM of the resident dining room for the C1 South unit was well lit, with windows on both sides looking out on flower beds with numerous open sits and tables available for more residents to sit at. Numerous residents observed sitting at the tables having lunch. A second observation made on 6/11/25 at 12:42 PM identified Resident #24, #54, #63, and #76 in the hallway on C1 South. Resident #54 was sitting in a chair with his/her tray table in front of him/her while Residents #24, #63 and #76 were sitting in their wheelchairs, backs against the wall with their tray tables in front of them. The residents were all feeding themselves lunch. A third observation made on 6/17/25 at lunch time noted Residents #24, #54, #63, and #76 were set up for dining in the hallway on the C1 South unit. An interview with Nurse Aid (NA) #6 on 6/11/25 at 12:46 PM identified that the residents eat in the hallway because they were a choking hazard and they were placed in the hallway to monitor how much they were eating. Also identifying that she was unsure of the reason the residents did not eat in the dining room. An interview with Registered Nurse (RN) #2 on 6/11/25 at 12:49 PM identified that residents eat in the hallway because of personal preference, to offer different options, aspiration precautions per speech therapy or high-risk resident to keep eye on them and assist with feeding. An interview with RN #6 and the Director of Nursing (DNS) at 6/17/25 at 10:30 AM identified that eating in the hallway was not a homelike environment. Although requested, a policy on facility dining was not provided.

Based on review of the clinical record, facility policy and interviews for 1 of 5 residents (Resident #64) reviewed for unnecessary medications, the facility failed to notify the provider of a positive orthostatic blood pressure for a resident on a new antipsychotic medication. The findings include: Resident #64's diagnoses included dementia with agitation, anxiety, and hypertension. A significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 was severely cognitively impaired, was receiving an antipsychotic medication, required setup or clean-up assistance with eating, was independent with bed mobility, and required supervision or touching assistance with chair/bed transfers. The Resident Care Plan (RCP) dated 4/24/25 identified Resident #64 used psychotropic medications related to behavior management, received antipsychotic medication and had a history of delusions. Interventions included administering anti-psychotic medications as ordered, monitor/document the side effects and effectiveness, and obtain orthostatic blood pressure's per facility protocol. A physician order dated 6/5/25 directed to administer Olanzapine (an antipsychotic medication) 2.5 milligrams (mg) by mouth at bedtime for dementia with agitation. A physician order dated 6/10/25 directed to obtain an orthostatic blood pressure lying, sitting, and standing every Friday during the 7:00 AM to 3:00 PM shift for 4 weeks every month. Review of the orthostatic blood pressures obtained by Licensed Practical Nurse (LPN) #1 on 6/13/25 on the 7:00 AM to 3:00 PM shift identified: the blood pressure when lying was 164/86 millimeters of Mercury (mmHg), the blood pressure when sitting was 144/88 mmHg, and the blood pressure when standing was 137/80 mmHg. Comparison of the lying value (164/86 mmHg) to the sitting value (144/88 mmHg) identified a drop of 20 mmHg in the systolic blood pressure with the position change. Comparison of the sitting value (144/88 mmHg) to the standing value (137/80 mmHg) identified a drop of 7 mmHg in the systolic blood pressure and a drop of 8 mmHg in the diastolic blood pressure with the position change. Comparison of the lying value (164/86 mmHg) to the standing value (137/70 mmHg) identified a drop of 27 mmHg in the systolic blood pressure and a drop of 16 mmHg in the diastolic blood pressure. Nursing progress notes from 6/13/25 through 6/17/2025 failed to identify documentation that Resident #64 had a positive orthostatic blood pressure on 6/13/2025, and failed to identify that Resident #64 had abnormal orthostatic blood pressure readings and that the Advanced Practice Nurse (APRN)/Medical Doctor (MD) had been notified of the abnormal orthostatic blood pressure readings on 6/13/25. Review of the clinical record failed to identify Resident #64 had abnormal orthostatic blood pressures prior to 6/13/25. Interview with LPN #1 on 6/17/25 at 12:30 PM identified she had obtained the orthostatic blood pressures for Resident #64 on 6/13/2025 and when entering the orthostatic blood pressure values she would look to see if there was a big drop in the systolic blood pressure. LPN #1 indicated that a big drop would be for example if the systolic blood pressure went from 140 mmHg to 90 mmHg. LPN #1 identified that if there had been a big drop in Resident #64's orthostatic blood pressure she would have notified the APRN. LPN #1 further identified the values she had obtained for Resident #64's orthostatic blood pressures on 6/13/25 had looked okay to her, she had not notified the APRN of any blood pressure changes, and that the blood pressures were being done because Resident #64 had started a new medication (Olanzapine). Interview with APRN #1 on 6/17/25 at 12:38 PM identified when obtaining orthostatic blood pressures, if there was a drop of 20 mmHg in the systolic blood pressure with position changes, it signified a positive orthostatic blood pressure and she should be notified. APRN #1 identified she had not been notified of a positive orthostatic blood pressure for Resident #64. After reviewing the blood pressures obtained on 6/13/25, APRN #1 identified Resident #64 had positive orthostatic blood pressures changes, that she should have been notified of the orthostatic blood pressures, and that if she had been notified she would have done additional monitoring for Resident #64. Additionally, APRN #1 noted she would have had the psychiatry provider evaluate Resident #64's medications. APRN #1 further identified Resident #64 had recently started on a new antipsychotic medication (Olanzapine) which may require changes if it was determined the medication resulted in orthostatic blood pressure changes for Resident #64. Review of the Psychotropic Medication Use policy directed, in part, residents receiving psychotropic medications are monitored for adverse consequences, including cardiovascular effects such as orthostatic hypotension. The policy directed, if psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication should be continued, and document the rationale for this decision.

Based on staff interviews, review of the clinical record, facility documentation, and facility policy for one sample resident (Resident #24) reviewed for mistreatment, the facility failed to notify the State Agency in a timely manner of an injury of unknown origin. The findings include: Resident #24's diagnoses hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, heart disease, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 was severely cognitively impaired, required maximal assistance for toileting, and bathing. Also identified Resident #24 required moderate assistance with eating, transfers and personal hygiene. The Resident Care Plan (RCP) dated 2/20/25 identified Resident #24 had cognitive dementia or impaired thought process related to a cerebral vascular accident (CVA) with interventions that included to provide Resident #24 with supervision and assistance with all decisions, and to use task segmentation to support short term memory deficits. Also identified Resident #24 had a communication problem related to CVA with interventions that included Resident 24's ability to express and comprehend language, memory, reasoning ability, and problem solving. Further identifying Resident #24 had a self-care deficit with intervention included to provide assistance of 1 for meals and transfers. The nursing note dated 2/21/25 at 5:04 PM and written by the Assistant Director of Nursing (ADNS) identified that Nurse Aide (NA) #8 reported at 3:45 PM that Resident #24 had a large ecchymotic (bruise) area measuring 5.5 centimeters (cm) by 5.0 cm to Resident #24's left upper buttocks. Also identifying Resident #24 was unable to recall how the bruise occurred. Further identifying that Resident #24 was advised to sit down slowly, during transfers to the bathroom or wheelchair, as an impact during transfers may have caused the ecchymosis. A facility Reportable Event Form dated 2/21/25 identified that Resident #24 was unable to recall how the bruise occurred, needed moderate assistance with transfers, and there was not a witness to the injury to the left upper buttocks. An investigation statement dated 2/21/25 from NA #7 identified that Resident #24 had the bruise to his/her left buttocks for a week and it had gotten bigger. An investigation statement dated 2/21/25 from NA #8 identified that she had taken Resident #24 to the bathroom to change him/her and noticed the bruise to his/her left buttocks. An interview with the Director of Nursing (DNS) on 6/16/25 at 11:00 AM indicated the ADNS managed the Accident and Injury reports and the bruise on Resident #24 left buttocks was not reported to the State Agency when NA #7 first observed the bruise a week prior to 2/21/25 and subsequent to NA #8 observing the bruise on 2/21/25. An interview with the ADNS on 6/16/25 at 11:03 AM identified that the injury of unknown origin to Resident #24's left buttocks was not reported to the state, she had spoken to the resident and physician identifying that Resident #24 sits abruptly and sometimes hits the armrest of the chair. Further identifying that Resident #24 was confused and the story changes and goes in a different direction. Also identifying that the DNS was responsible for reporting the injury of unknown origin to the state agency. Further identifying that it was an unwitnessed injury, and the policy was to investigate first and then report the incident to the state agency. An interview with NA #7 on 6/16/25 at 3:35 PM identified that she assists other residents even if they were not on her assignment and the bruise to Resident #24's left upper buttocks was there approximately a week before 2/21/25. Also, identifying that she had reported the bruise to the nurse on the unit a week ago, it was not reported to management or the State Agency for over a week, but that nurse she reported it to no longer works at the facility. Further identifying that Resident #24 was not capable of explaining how he/she obtained the bruise. An interview with NA #8 on 6/16/25 at 3:50 PM identified that Resident #24 was confused and not capable of explaining how he/she obtained the bruise to his/her left buttocks. Review of the facility's Abuse Prevention policy identified that reporting of all alleged violations to the Administrator, state agency, and to all other required agencies.

Based on observations, interviews and record review for 1 of 1 resident (Resident #310) reviewed for positioning, the facility failed to offload heels for a resident at high risk for pressure ulcer development. The findings include: Resident #310's diagnoses included atrial fibrillation, essential hypertension and hearing loss. The admission Norton Scale Predicting Risk of Pressure Ulcer Assessment completed 5/30/25 identified Resident #310 was a high risk for pressure ulcer development. The Resident Care Plan dated 5/30/25 identified Resident #310 had the potential for pressure injury development related to incontinence, and decreased mobility. Interventions included to monitor dressing placement as ordered to ensure it was intact and adhering, educate the resident/family/caregivers as to causes of skin injury including repositioning/positioning requirements and offloading both feet with pillows while in bed starting at calves down to the heels. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #310 was severely cognitively impaired, dependent on staff for dressing, toileting and transfers. A physician's order dated 6/9/25 directed to offload both feet with pillows while Resident #310 was in bed, starting from the calves down to the heels every shift. Observations on 6/10/25 at 12:16 PM, 6/10/25 at 9:42 AM, 6/11/25 at 6:28 AM, and 6/11/25 at 8:57 AM identified Resident #310 sitting in bed, barefoot, legs extended, heels flat on the bed without the benefit of the heels being off loaded from the bed. Interview and observation with Registered Nurse (RN) #1 on 6/16/25 at 8:40 AM identified Resident #310 in bed, legs extended flat on the bed without the benefit of offloaded heels. RN #1 identified it was facility policy to have an offload heel order for new admissions. Additionally, RN #1 identified it was a collective effort to ensure that heels were offloaded, and staff could refer to the Resident Care Card for directions on how to care for residents. Review of Resident #310's care card with RN #1 identified it was located on the inside of the closet door, instructing to offload feet on pillow in bed, calves to heels. Subsequent to surveyor inquiry RN#1 placed a pillow under Resident #310's calves to offload heels off the bed. Interview with Nurse Aide (NA) #3 on at 6/16/25 at 8:49 AM identified she offloads heels for all residents and when instructed by the nurse. Additionally, NA #3 identified she did not offload Resident #310's heels because she was not familiar with him/her, so she did not know that was a care need. NA #3 failed to identify that there were resident care instructions written or located anywhere to refer to. Review of the Skin Management Program directed in part that once at risk residents are identified, interventions for risk reduction are implemented. Measures to protect the residents against adverse effects of external mechanical forces included to protect the heels if needed with appropriate/ordered devices.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 4 residents (Resident #64) reviewed for falls, the facility failed to prevent a fall for a resident at risk for falls who required assistance with ambulation. The findings include: Resident #64's diagnoses included dementia with agitation, anxiety, and rheumatoid arthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 was severely cognitively impaired, required setup or clean-up assistance with eating, and supervision or touching assistance with transfers and ambulation. Additionally, the MDS identified Resident #64 had no falls since admission. The Resident Care Plan (RCP) in effect 1/29/25 identified Resident #64 was at risk for falls related to confusion, deconditioning, medications, decline in health on hospice, refusal of care at times, and Resident #64 was very self-determined to do what he/she wanted independently despite ongoing assistance. Interventions included encourage Resident #64 on appropriate use of assistive devices, offer Resident #64 toileting every 2 hours or less, and ensure Resident #64's wearing appropriate footwear when ambulating or mobilizing. A nursing note written by Registered Nurse (RN) #8 on 2/25/25 at 6:30 PM identified Resident #64 had a witnessed fall. The note identified Resident #64 was ambulating with a rolling walker and accompanied by a staff member (Nurse Aide #5) when his/her walker got stuck and Resident #64 fell sideways onto his/her side. The note identified there were no injuries to Resident #64. Review of a fall assessment dated [DATE] identified Resident #64 was walking with a rolling walker and staff member. The assessment identified the staff member walked into Resident #64's room with Resident #64 following behind the staff member when the walker got stuck and Resident #64 fell sideways onto his/her side. A fall investigation statement written by Licensed Practical Nurse (LPN) #2 and dated 2/25/25 identified at approximately 6:20 PM a NA #5 was assisting Resident #64 with ambulating to his/her room. The statement identified the NA #5 walked ahead while Resident #64 followed behind using a rolling walker. The statement identified as Resident #64's walker became stuck, Resident #64 lost his/her balance and fell to the side. The statement identified LPN #2 observed the incident and immediately intervened and assisted Resident #64 to the floor. The statement further identified there were no visible injuries observed, and Resident #64 denied pain or discomfort. Review of the facility Accident/Incident report documentation for Resident #64's fall on 2/25/25 at 6:20 PM identified the fall was witnessed by LPN #2 and NA #5. The documentation identified Resident #64 required assistance of 1 staff member and a rolling walker for ambulation. Review of a Staff Inservice Sheet signed by NA #5 on 2/28/25 identified on 2/25/25 at 6:20 PM a resident fell during ambulation when the NA walked ahead of the resident while assisting with the rolling walker. The Inservice sheet identified the walker got stuck and the resident lost their balance resulting in a fall. The Inservice sheet identified this incident highlighted the critical need for consistent and direct supervision during ambulation. The Inservice sheet identified when a resident was assist of one staff member with ambulation, always walk alongside the resident ensuring you remain within arms reach, and never leave the resident behind you or walk ahead of them. The Inservice sheet further identified staff were to ensure the resident's path was clear of obstacles or hazards such as rugs, furniture or clutter which could cause the walker to get stuck, and by following these guidelines staff could ensure the safety of the residents and reduce the risk of falls. Interview with Assistant Director of Nursing Services (ADNS) on 6/17/25 at 1:00 PM identified nursing staff should walk along the side of Resident #64 when ambulating him/her, and nursing staff should not walk in front of Resident #64. Interview with NA #5 on 6/17/25 at 1:25 PM identified she was walking with Resident #64 on 2/25/25 when Resident #64 fell. NA #5 said she was walking with Resident #64 and when they reached the doorway of the room she went in front of Resident #64 to move an item out of their path, and as she was moving the item, one of Resident #64's walker legs got stuck in the door jamb and Resident #64 slowly lowered him/herself to the floor. NA #5 identified that when a resident required assistance of 1 staff member when ambulating, the staff member was supposed to walk side by side with the resident or behind the resident following with a wheelchair. NA #5 identified she received education after Resident #64's fall and further identified she should have been walking next to Resident #64 on 2/25/25 because Resident #64 required assistance of 1 staff member for ambulation with a rolling walker. Review of the Fall Prevention and Management policy directed, in part, a fall is an unintended landing on the floor or lower position not caused by a sudden major health event such as a stroke. The policy directed fall prevention safety precautions and interventions may include assisting with ambulation as needed. The policy directed an investigation into the circumstances of the fall is conducted in an effort to determine causative or contributing factors.

Based on interview, facility documentation, and policy review for medication storage , the facility failed to ensure bi-monthly audits of controlled medications were completed. Review of the facilities bi-monthly narcotic audit sheets for [NAME], C1 South, C2 South, and C2 North medication carts identified they were not completed for May 2025 and June 2025. Interview and facility documentation review with the Director of Nurses (DNS) on 6/16/25 at 12:34 PM identified that the bi-monthly audits of controlled medications for [NAME], C1 South, C2 South, and C2 North medication carts were not completed for May 2025 and June 2025. It was identified that it was the responsibility of the DNS to ensure they were completed and although she knew they should be completed, she had forgotten to complete. Review of the Controlled Substance Storage facility policy and procedures by Woodmark Pharmacy, revised November 2011, identified that medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. Additionally, it identified the DNS, in collaboration with the consultant pharmacist, maintains the facilities compliance with federal and state laws and regulations in the handling of controlled substances.

Based on review of the clinical record, facility policy and interviews for 1 of 5 residents (Resident #64) reviewed for unnecessary medication, the facility failed to change or discontinue a psychotropic medication after extended nonuse of the medication, failed to document the duration and rationale for extension of an as needed (PRN) psychotropic medication extended beyond 14 days. The findings include: Resident #64's diagnoses included dementia with agitation, anxiety, and left femur fracture repair. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 was severely cognitively impaired, received hospice care, had no physical or behavioral symptoms directed towards others (hitting, kicking, grabbing, screaming/cursing at others, threatening others), had no behavior symptoms not directed towards others (pacing, rummaging, screaming or hitting/scratching self), and was receiving an antianxiety medication. The MDS assessment further identified Resident #64 required setup or clean-up assistance with eating, was independent with bed mobility, and required supervision or touching assistance with transfers. A nursing progress note written by Registered Nurse (RN) #3 on 2/3/25 at 1:40 PM identified a collaboration meeting was held with the facility interdisciplinary team and the hospice team. The note identified that Resident #64's clinical condition, history of falls, medications and refusal of care were discussed and identified the hospice provider was discontinuing the scheduled Lorazepam (antianxiety medication). An Advanced Practice Registered Nurse (APRN) order dated 2/4/25 directed to discontinue the order to administer Lorazepam 0.5 milligrams (mg) by mouth 2 times a day and directed to administer Lorazepam 0.5 mg by mouth every 12 hours PRN for anxiety for 30 days. The Resident Care Plan (RCP) dated 2/26/25 identified Resident #64 had a behavior problem related to anxiety, delusions, agitation with care, aggression, combativeness, and refusal of care. Interventions included to provide Resident #64 with a program of activities that were of interest and accommodated his/her needs, anticipate and meet Resident #64's needs, administer medications as ordered and monitor/document effectiveness and side effects. A physician order dated 3/30/25 directed to administer Lorazepam 0.5 mg by mouth every 6 hours PRN for anxiety/restlessness and directed to administer Lorazepam 0.5 mg by mouth one time daily for anxiety/restlessness. A physician order dated 5/27/25 directed to administer Lorazepam 0.5 mg by mouth every 6 hours PRN for anxiety/restlessness for 3 months and directed to administer Lorazepam 0.5 mg by mouth one time daily for anxiety/restlessness for 3 months. Interview with RN #2 on 6/17/25 at 9:45 AM identified he had entered a telephone order from Medical Doctor (MD) #1 on 5/27/25 for PRN Lorazepam with a duration of 3 months. RN #2 identified when medications were due for reevaluation, MD #1 asked for information on the status of the resident, if the resident was being followed by the psychiatry provider, and MD #1 used that information to determine the need for renewal or if the medication should be discontinued. RN #2 identified criteria for discontinuation of a medication was decreased behaviors and/or symptoms and that the resident usage was reviewed upon renewal of the order. RN #2 identified Resident #64 was not on his unit, and he couldn't recall specifics but identified PRN psychotropic orders were usually entered with a duration of 14-30 days, but that MD #1 must have told him to put the order in for 3 months. Interview with MD #1 on 6/17/25 at 10:27 AM identified he had given a telephone order for PRN Lorazepam with a duration of 3 months for Resident #64 but he did not recall specifically the circumstances for giving the order. MD #1 identified there were many residents who required PRN medications and having a stop date of 1 month can create extra work for the staff so he would offer longer durations. MD #1 identified he was not aware Resident #64 had not utilized the PRN Lorazepam order from 2/4/25 through 5/27/25 and that he wished he had known because he would have either reduced or discontinued the Lorazepam PRN order. Review of the Medication Administration Record (MAR) for February 2025, March 2025, April 2025, May 2025, and June 2025 within the electronic medical record (EMR) failed to identify Lorazepam 0.5 mg was administered PRN to Resident #64. Review of the APRN and MD progress notes from February 2025 through June 2025 failed to identify Resident #64 required a PRN order for Lorazepam extended beyond 14 days with inclusion of the rationale for the appropriateness of the extended duration and what the ordered duration was. Interview with MD #1 on 6/17/25 at 10:27 AM identified he was not aware of the Centers for Medicare and Medicaid Services (CMS) guidelines that required documentation in the medical record of the rationale with the ordered duration when a resident was appropriate for extension of a psychotropic medication beyond 14 days, and that going forward he would complete that documentation and make sure anyone covering him was also aware. Review of the Psychotropic Medication Use policy directed, in part, anti-anxiety medications are considered psychotropic medications. The policy directed PRN orders for psychotropic medications are limited to 14 days. The policy directed for psychotropic medications that are not antipsychotics, if the prescriber believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.

Based on observations, interviews, review of the clinical record, and facility policy for 1 of 5 residents reviewed for nutrition, the facility failed to provide adaptive equipment per the physician's order for a resident with dysphagia and malnutrition. The findings include: Resident #106's diagnosis included dysphagia (difficulty swallowing), protein-calorie malnutrition, and dementia. An Occupational Therapy progress note dated 5/14/25 identified Resident #106 was observed for breakfast and lunch and was made an assist of 1 for feeding and required a blue covered mug with a straw for all meals. A physician's order dated 5/14/25 directed to provide a blue handled cup with lid and straw for all meals. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #106 was severely cognitively impaired and was dependent with transfers, toileting, eating and bed mobility. The MDS indicated Resident #106 required a mechanically altered and therapeutic diet. A Nutrition Assessment written by the Dietician and dated 5/17/25 identified Resident #106 was at nutritional risk due to dysphagia and mild protein-calorie malnutrition with a modified consistency diet and the resident required assistance with meals. The Resident Care Plan dated 5/21/25 identified Resident #106 had a nutritional problem with diet restrictions (due to dysphagia) and an activities of daily living self-performance deficit. Interventions included to provide adaptive equipment for feeding and assist resident to completion with meals. Review of the Nurse Aide (NA) care card for Resident #106 directed use of a blue handled cup with a lid and straw for all meals. Observations on 6/9/25 at 12:40 PM and 6/11/25 at 8:15 AM identified Resident #106 was served a meal without the benefit of a blue handled mug with a lid and straw for his/her beverage. The resident was observed with clear cups without a handle, lid or straw for his/her beverages at both meals. Observation, interview, and review of the clinical record with NA #4 on 6/16/25 at 12:48 PM identified Resident #106 was in his/her room and was being served his/her lunch meal without the benefit of a blue handled mug with a lid and straw for a beverage. A clear cup without a handle, lid or straw, which was ¾ full and contained a clear/pink liquid in it, had been placed by NA #4 on the resident's tray table. NA #4 indicated she did not know that Resident #106 needed a blue handled mug with a lid and straw for a beverage with all meals because she had not reviewed the NA care card. Review of the NA care card with NA #4 identified the resident required a blue handled mug with a lid and straw for every meal. NA #4 indicated she had made a mistake and proceeded to locate a blue handled mug with a lid and straw on the unit and filled it with a new beverage for Resident #106. Observation, interview, and review of the clinical record with the unit manager (RN #2) on 6/16/25 at 12:50 PM identified Resident #106 was served and assisted with the lunch meal by NA #4 without the benefit of a blue handled mug with a lid and straw for her beverage. RN #2 indicated adaptive equipment cups were kept on the unit and it was the responsibility of the NA's to locate and provide adaptive cups for the residents. RN #2 identified NA #4 should have reviewed the NA care card for Resident #106 and provided the resident with a blue handled mug for his/her meal. Review of the clinical record for Resident #106 with RN #2 indicated both the physician's orders and the NA care card directed a blue handled mug with a lid and straw for every meal. RN #2 indicated he would provide further education to NA staff regarding Resident #106's need for adaptive equipment. Review of the facility policy, Adaptive Feeding Equipment, dated 4/24/25, directed adaptive feeding equipment enables residents to maintain the ability to feed themselves and preserve their dignity and respect. The policy further directed standard of practice included writing a physician's order for adaptive feeding equipment. Review of the facility policy, Activities of Daily Living (ADL's), Supporting, undated, directed residents who are unable to carry out ADL's independently will receive support and services to maintain good nutrition and resident's will be provided with treatment and services to ensure that their ADL's do not diminish. The policy further directed, in accordance with the plan of care, residents will receive the appropriate support and assistance with dining (meals and snacks).

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for restraints, the facility failed to ensure the resident was free of a physical restraint. The findings include: Resident #1 had diagnoses that included dementia with behavioral disturbance and adjustment disorder with disturbance of conduct. The nursing admission assessment dated [DATE] at 9:13 A.M. completed by RN #7 identified for Resident #1 restraints were not being used. The functional abilities and goals assessment dated [DATE] identified Resident #1 requires substantial assistance with ADLs and transfers, independent with bed mobility, and uses a manual wheelchair. The initial social history assessment dated [DATE] at 2:25 P.M. identified Resident #1's family reports h/she has had increased confusion over the past few months. The social history assessment identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of two (2) indicative of severely impaired cognition. The care plan dated 1/17/25 identified Resident #1 uses psychotropic antipsychotic medications related to delirium, restlessness, and agitation with interventions directing to monitor/record potential target behavior symptoms that would justify either elimination of or continued use of antipsychotics, administer medications as ordered and monitor for side effects and effectiveness. The physician's order dated 1/17/25 directed to administer escitalopram oxide (a medication used for depression and anxiety) oral tablet 5 milligrams one time a day, olanzapine (a medication used for agitation) 2.5 milligrams one time per day for agitation, and monitor for the following behaviors delirium, restlessness, and agitation and document every shift. The nurse's note dated 1/18/25 at 12:13 A.M. written by LPN #3 identified Resident #1 was sitting up in the wheelchair, restless at times, trying to get out of the wheelchair. LPN #2 indicated Resident #1 was able to be redirected from trying to get up from the wheelchair. The nurse's note dated 1/19/25 at 12:48 P.M. written by LPN #4 identified Resident #1 was noted removing dressing to lower extremities and dressing were re-done. LPN #4 identified Resident #1 was out of bed to the wheelchair for a short time, but insisted on going back to bed to rest this afternoon. The nurse's note dated 1/19/25 at 11:53 P.M. written by LPN #3 identified Resident #1 is restless at times, out of bed at 9:30 P.M. placed in wheelchair near the entrance of h/her door and monitored. The care card dated 1/20/25 identified Resident #1 self-propels in wheelchair for mobility. Review of Resident #1's Medication Administration Record dated 1/20/25 identified RN #1 documented for the night shift (11 PM- 7 AM) Resident #1 had behaviors of hitting and kicking. Review of the facility's accident and incident report dated 1/21/25 identified at approximately 8:00 A.M. RN #2 reported Resident #1 was found in the dayroom seated in h/her wheelchair with a sheet positioned around h/her waist and then tied to the wheelchair. RN #2 immediately removed the sheet, assessed Resident #1 for any injury, and no injuries were found. NA #1 and RN #1 who were on the floor were removed immediately pending investigation. The police, family, and MD #1 were notified. The nurse's note dated 1/21/25 at 8:25 A.M. written by RN #2 identified that Resident #1 was in the dining room seated in the wheelchair appearing very agitated. RN #2 identified a staff member who speaks Portuguese was communicating with Resident #1 and Resident #1 appeared to be more agitated. RN #2 indicated she notified APRN #1 new orders obtained to give trazodone 12.5 milligrams (mg) now. RN #2 identified Resident #1 received trazodone and appeared calmer. Interview with RN #2 on 2/5/25 at 7:35 A.M. identified on 1/21/25 between 7:45 A.M. and 8:00 A.M. when she entered the dining room RN #1 was standing up next to Resident #1 who was seated in h/her wheelchair with a white sheet draped from h/her waist to h/her upper legs. RN #2 identified she went over to see Resident #1 at which time she noted that Resident #1 is tied to the chair. RN#2 identified she immediately untied the sheet that was tied in a bow behind the back of Resident #1's wheelchair and removed the sheet. RN #2 identified RN #1 indicated she did not know who tied the sheet and she had just noticed that the sheet was tied when RN #2 walked into the dining room. RN #2 identified she assessed Resident #1 for any injuries and Resident #1 had no injuries, skin was intact without any redness or bruising. RN #2 identified she notified the on-call APRN and the DNS. Interview with RN #1 on 2/5/25 at 11:25 A.M. identified on 1/21/25 at approximately 2:45 A.M. Resident #1 was taking off h/her socks and pants off so she placed a fitted white sheet over h/her legs. RN #1 indicated she brought Resident #1 who was seated in the wheelchair over near the nurse's station in the hallway and kept Resident #1 with her. RN #1 identified at approximately 5:30 A.M. she started passing morning medications and Resident #1 was still in the wheelchair in the hallway. RN #1 indicated while she was passing medications as she entered and exited other residents' rooms, she could see Resident #1 and she kept checking on Resident #1 to ensure h/she was not attempting to stand up without assistance. RN #1 indicated at approximately 6:30 A.M. she noted that Resident #1 was becoming restless, so she wheeled Resident #1 to the dining room. RN #1 indicated she planned on sitting in the lounge with Resident #1 because when she sat with Resident #1 h/she would calm down. RN #1 indicated she left the lounge for a few minutes and then returned to sit with Resident #1. RN #1 indicated she noticed Resident #1 had a flat white sheet draped h/her not white fitted sheet she had placed on Resident #1 earlier in the shift. RN #1 indicated she stood up as she noticed the sheet was tied in a bow behind Resident #1's wheelchair RN #2 walked into the dining room. RN #1 identified she and RN #2 immediately untied the sheet. RN #1 indicated when she wheeled Resident #1 into the dining room, she did not see any sheet tied behind Resident #1's wheelchair and thought the staff from day shift tied the sheet. RN #1 indicated NA #1 did not ask her or notify her that he had tied a sheet around Resident #1. RN #1 indicated she did not assist NA #1 in tying the sheet around Resident #1. Interview with NA #1 on 2/5/25 at 12:30 P.M. identified on 1/21/25 during the 11 PM - 7 AM shift he attempted to put Resident #1 into bed three times, but Resident #1 was restless and would not stay in bed. NA #1 identified Resident #1 was a fall risk. NA #1 indicated Resident #1 stayed up all night in h/her wheelchair and made several attempts to stand up without assistance. NA #1 identified at approximately 4:30 A.M. he called RN #1 to inform her that he was putting a sheet around Resident #1 because he needed to start his last rounds and if he left Resident #1 h/she would fall. NA #1 identified with Resident #1 seated in the wheelchair he placed a flat white sheet around Resident #1's waist and loosely tied it in a bow behind the back of the wheelchair. NA #1 identified he was supposed to untie the sheet around Resident #1's wheelchair before he left but forgot. NA #1 identified although he was aware that he is not supposed to physically restrain residents he felt it was the only way to prevent Resident #1 from falling out of the wheelchair. Interview with MD #1 on 2/5/25 at 2:17 P.M. identified when NA #1 placed the sheet around Resident #1's waist and tied it behind the back of the wheelchair although it was unethical, he believes NA #1 was attempting to prevent Resident #1 from falling not trying to harm Resident #1. MD #1 indicated Resident #1 was not at risk for injuries when h/she was tied with a sheet in the wheelchair because the sheet was tied around Resident #1's waist. Interview with the DNS on 2/5/25 at 2:24 P.M. identified on 1/21/25 when RN #2 reported she found Resident #1 seated in h/her wheelchair with a sheet tied around h/her an investigation was immediately initiated. The DNS identified on 1/21/25 that NA #1 and RN #1 were the staff assigned to Resident #1 when RN #2 found Resident #1 tied with a sheet and they were suspended pending the outcome of the investigation. The DNS identified on 1/21/25 during an interview with RN #1 reported during the 11 PM - 7 AM shift Resident #1 was disrobing so she covered Resident #1's bare legs with a sheet that was not tied, at the end of shift she was sitting with Resident #1 in the lounge when RN #2 walked in she noticed the sheet was tied. The DNS identified RN #1 indicated at the same time RN #2 walked in she noticed the sheet tied behind Resident #1's wheelchair and RN #1 reported she had not seen the sheet tied before then. The DNS identified on 1/21/25 during an interview with NA #1 he reported on 1/21/25 Resident #1 had been up all night was uncooperative and couldn't stay still for even a moment and NA #1 was worried Resident #1 would fall so right before the last rounds started NA #1 put a sheet around Resident #1's waist and tied it loosely behind the wheelchair. The DNS identified the facility does not use sheets to physically restrain residents. The DNS identified NA #1 should have never placed the sheet around Resident #1's waist and tied the sheet behind the wheelchair. Review of the facility's use of restraint policy identified physical restraints are defined as any manual, physical, mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement, and practices that inappropriately utilize equipment to prevent residents mobility are considered restraints and are not permitted including tucking sheets so tightly that a resident cannot move.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for behaviors, the facility failed to ensure the physician was notified when the resident was restless and agitated. The findings include: Resident #1 had diagnoses that included dementia with behavioral disturbance and adjustment disorder with disturbance of conduct. The nursing admission assessment dated [DATE] at 9:13 A.M. completed by RN #7 identified for Resident #1 restraints were not being used. The functional abilities and goals assessment dated [DATE] identified Resident #1 requires substantial assistance with ADLs and transfers, independent with bed mobility, and used a manual wheelchair. The initial social history assessment dated [DATE] at 2:25 P.M. identified Resident #1's family reports h/she has had increased confusion over the past few months. The social history assessment identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of two (2) indicative of severely impaired cognition. The care plan dated 1/17/25 identified Resident #1 used psychotropic antipsychotic medications related to delirium, restlessness, and agitation with interventions directing to monitor/record potential target behavior symptoms that would justify either elimination of or continued use of antipsychotics, administer medications as ordered and monitor for side effects and effectiveness. The physician's order dated 1/17/25 directed to administer escitalopram oxide (a medication used for depression and anxiety) oral tablet 5 milligrams one time a day, olanzapine (a medication used for agitation) 2.5 milligrams one time per day for agitation, and monitor for the following behaviors delirium, restlessness, and agitation and document every shift. The nurse's note dated 1/18/25 at 12:13 A.M. written by LPN #3 identified Resident #1 was sitting up in the wheelchair, restless at times, trying to get out of the wheelchair. The nurse's note dated 1/19/25 at 12:48 P.M. written by LPN #4 identified Resident #1 was noted removing dressing to lower extremities and dressing had to be re-done. The nurse's note dated 1/19/25 at 11:53 P.M. written by LPN #3 identified Resident #1 is restless at times. LPN #3 identified Resident #1 was out of bed at 9:30 P.M. placed in wheelchair near the entrance of h/her door and monitored. The care card dated 1/20/25 identified Resident #1 is agitated at times. If Resident #1 is exhibiting behaviors, guide the resident away from the source of distress offer me a snack or drink and notify the nurse. Review of Resident #1's Medication Administration Record dated 1/20/25 identified RN #1 documented for the night shift (11 PM- 7 AM) Resident #1 had behaviors of hitting and kicking. Interview with RN #1 on 2/5/25 at 11:25 A.M. identified on 1/21/25 during the 11 PM - 7 AM shift Resident #1 had intermittent agitation and was restless. RN #1 identified Resident #1 sat in the wheelchair all night, did not sleep, and she tried to keep an eye on Resident #1 throughout the shift. RN #1 identified Resident #1 did not have any as needed medications ordered for insomnia, restlessness, or agitation. RN #1 identified she did not think it was necessary to call the on-call provider to get an as needed medication order because when she sat with Resident #1 h/she usually calmed down. RN #1 identified around 7:00 AM Resident #1 became more agitated, restless, and combative so she sat with Resident #1. Interview with NA #1 on 2/5/25 at 12:30 P.M. identified on 1/21/25 during the 11 PM - 7 AM shift he attempted to put Resident #1 into bed three times, but Resident #1 was restless and would not stay in bed. NA #1 identified Resident #1 stayed up all night in the wheelchair, Resident #1 would not stay still, and Resident #1 was restless, agitated, and made several attempts to stand up without assistance. NA #1 indicated RN #1 was aware that Resident #1 was restless and agitated. Interview with MD #1 on 2/5/25 at 2:17 P.M. identified on 1/21/25 when Resident #1 was agitated, restless, and could not sleep RN #1 should have called the on-call provider to report Resident #1's behaviors. MD #1 indicated the on-call provider would have ordered an as needed medication for Resident #1's behaviors. Interview with the DNS on 2/5/25 at 2:24 P.M. identified her expectation is if a resident is agitated, restless, unable to sleep and does not have an as needed medication order the nurse will call the physician and obtain an as needed order to address the behavior. The DNS identified on 1/21/25 when Resident #1 was restless, agitated, and could not sleep RN #1 should have notified the physician and obtained an as needed order to address Resident #1's behaviors. Review of the facility's change in resident's condition or status policy direct the nurse will notify the attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition.

Based on review of the clinical record, facility documentation, interviews and facility policy for one resident reviewed for abuse (Resident #1), the facility failed to ensure the resident was treated with dignity and respect. The findings include: Resident #1 was admitted with diagnoses that included dementia with behavioral disturbance, and anxiety. The RCP dated 8/13/2024 identified Resident #1 had impaired cognition, communication and impaired thought process due to dementia. Interventions directed to approach resident in a slower pace, and to stop and return if the resident was agitated or upset, when unable to redirect, have staff to sit with resident to provide emotional support, do not touch her/him, do not rush and report the behavior issues to the nurse. The quarterly MDS assessment dated [DATE] identified Resident #1 had severely impaired cognition and was supervision for self-care, moderate assist for toileting, transfer and walk with a walker. Resident #1 was independent for bed mobility. The facility incident report dated 9/3/2024 at 11:45 AM identified an allegation of staff to resident abuse without injury on 8/30/2024 at 6:30 PM. NA #2 alleged she had witnessed NA #1 press Resident #1's shoulders down to sit him/her on the toilet as Resident #1 made vulgar statements to NA #1. NA #1 then responded with curse words back to Resident #1 and NA #1 then took the resident #1's rag doll and hit Resident #1 with the rag doll on each side of her/his face. Resident assessment identified no injuries, NA #1 was removed from the schedule pending investigation. The incident summary dated 9/6/2024 identified on 9/3/2024, at approximately 11:45 AM, NA #2 reported to the DON and Administrator that on 8/30/2024 between 6:30 and 7:30 PM NA #2 responded to Resident #1 yelling and observed Resident #1 was in the bathroom with NA #1. NA #2 observed Resident #1 start to stand up from the toilet and NA #1 put her hands on the Resident #1's shoulders and pressed down to sit the resident back down on the toilet, and then held Resident #1's hands down to her/his lap. Resident #1 was using foul language/cursing, and NA #1 responded back to Resident #1 with cursing. NA #2 assisted the resident to stand up and ambulated her/him to bed. Resident #1 would not lie down so NA #1 placed her hands on the resident's shoulders and again pressed down to cause Resident #1 to sit on the bed, while Resident #1 continued cursing and striking out at NA #1. Resident #1 then stated he/she was going to hit NA #1 and NA #1 responded if Resident #1 was going to hit her, she would hit back. NA #1 then picked up Resident #1's rag doll and hit Resident #1 once on each side of the face with it, while Resident #1 was leaning back attempting to kick NA #1. NA #2 then asked NA #1 to leave the room. NA #1 denied that allegations. Resident #1 and the roommate could not answer questions due to cognitive status, and the allegation was not substantiated. Interview with NA #1 on 9/23/2024 at 11:45 AM identified that she was assigned to Resident #1 on 8/30/2024 she toileted Resident #1, provided incontinent care, and Resident #1 was yelling out during the care and NA #2 entered the bathroom to assist with care. NA #1 stated she assisted Resident #1 to sit back down on the toilet by putting her right arm under Resident #1's right arm and her left arm on Resident #1's back to guide her to sit on the toilet (she denied pushing on Resident #1's shoulders), and Resident #1 began to hit, pinch and tried to stand up. NA #1 asked the resident to stop swearing at her and NA #2 assisted Resident #1 out of the bathroom and to sit on the side of the bed. NA #1 then lifted Resident #1's legs into the bed when Resident #1 kicked her in the stomach. NA #1 continued that she had become frustrated that Resident #1 continued to be agitated and she picked up the soft plush doll that was on the foot of the bed. She continued that she was so frustrated at that point that she picked up the doll and threw it, and she did not intend to throw it at Resident #1. NA #1 stated the doll landed on the pillow near Resident #1's head but did not hit the resident. NA #1 stated she then left the room at that point, realizing that she lost control and NA #2 stayed with the resident. NA #1 added that she should have left the room earlier but was concerned that Resident #1 was a fall risk; she indicated she should have left when NA #2 entered to provided help. Further, NA #1 denied using foul language, pressing on Resident #1 to make the resident sit down, and although NA #1 stated she threw the doll because she lost control, she denied hitting Resident #1 with the doll. NA #1 stated she should have notified the nurse that Resident #1 was agitated, as Resident #1 may have needed medication to calm him/her. Interview with NA #2 on 9/23/2024 at 12:14 PM identified Resident #1 was known to yell and become combative with care and when she heard yelling from Resident #1's room on 8/30/2024 at around 6:30 PM, she went to assist. When she entered the room, she saw NA #1 in the bathroom with Resident #1 assisting with toileting. NA #1 was trying to calm the Resident as she changed her and provided Resident #1 care. Resident #1 was swinging her/his arms, struggling against NA #1, yelling and calling NA #1 names. NA #1 began to yell and swear back, forcing Resident #1's hands down, yelling back to Resident #1 to just stop and Resident #1 continued to be combative. She assisted Resident #1 back to the wheelchair and wheeled her/him to the bedside. NA #2 continued that she talked very calmly, and Resident #1 seemed to settle. When they got to the bedside, Resident #1 stood and as NA #2 was cueing Resident #1 to move and sit on the bed, NA #1 grabbed both Resident 1's hands. NA #2 stated that touching Resident #1 will sometimes cause Resident #1 to become agitated. Resident #1 sat and then started to stand again. NA #1 was annoyed and put both her hands on Resident #1's shoulders, pushing her/him back to a seated position on the bed. Resident #1 threatened to hit NA #1 and NA #1 responded if you hit me, I'll hit you. NA #1 then grabbed Resident #1's doll that was at the foot of the bed and gently hit Resident #1 on each check. Resident #1 then began to kick and kicked NA #1 in the stomach. NA #1 then kicked the bed and NA #2 told NA #1 that that was enough and to leave the room. NA #2 stayed with Resident #1, talking to her/him calmly until the resident was calm and resting. NA #2 stated when she and NA #1 were in the hallway, NA #1 asked her not to report the incident, as she had been a NA for a long time, and this was the first time she had ever lost control when interacting with a resident. NA #2 stated she worked the remainder of the shift and did not report the event to the nurse that evening as NA #1 had requested. She continued that she was off the next few days and realized that the interaction between NA #1 and Resident #1 was wrong and reported the incident to the DON on her next working day, 9/3/2024. Interview with the DON on 9/23/2024 at 2:00 PM identified that the allegation of abuse was unsubstantiated. There were no witnesses other than NA #2 and NA #1 had denied the allegation. The DON stated that residents should be treated with dignity and respect, and NA #1 should have left the room when she was upset and gone back later. The DON stated NA #1 was provided with education regarding the facility abuse policy. The facility Abuse Prevention Program Policy dated 11/9/2022 directed in part, that all employees are responsible for identifying and reporting immediately to their supervisor any witnessed abuse or allegation of abuse. The policy defined verbal abuse as the use of oral or gestured language that will fully included disparaging and derogatory terms to resident, that included threats of harm. Physical abuse is defined as hitting or slapping.

Based on review of the clinical record, facility documentation, interviews and facility policy for one resident reviewed for abuse (Resident #1), the facility failed to ensure staff reported an allegation of abuse timely. The findings include: Resident #1 was admitted with diagnoses that included dementia with behavioral disturbance, and anxiety. The RCP dated 8/13/2024 identified Resident #1 had impaired cognition, communication and impaired thought process due to dementia. Interventions directed to approach resident in a slower pace, and to stop and return if the resident was agitated or upset, when unable to redirect, have staff to sit with resident to provide emotional support, do not touch her/him, do not rush and report the behavior issues to the nurse. The quarterly MDS assessment dated [DATE] identified Resident #1 had severely impaired cognition and was supervision for self-care, moderate assist for toileting, transfer and walk with a walker. Resident #1 was independent for bed mobility. The facility incident report dated 9/3/2024 at 11:45 AM identified an allegation of staff to resident abuse without injury on 8/30/2024 at 6:30 PM. NA #2 alleged she had witnessed NA #1 press Resident #1's shoulders down to sit him/her on the toilet as Resident #1 made vulgar statements to NA #1. NA #1 then responded with curse words back to Resident #1 and NA #1 then took the resident #1's rag doll and hit Resident #1 with the rag doll on each side of her/his face. Resident assessment identified no injuries, NA #1 was removed from the schedule pending investigation. The incident summary dated 9/6/2024 identified on 9/3/2024, at approximately 11:45 AM, NA #2 reported to the DON and Administrator that on 8/30/2024 between 6:30 and 7:30 PM NA #2 responded to Resident #1 yelling and observed Resident #1 was in the bathroom with NA #1. NA #2 observed Resident #1 start to stand up from the toilet and NA #1 put her hands on the Resident #1's shoulders and pressed down to sit the resident back down on the toilet, and then held Resident #1's hands down to her/his lap. Resident #1 was using foul language/cursing, and NA #1 responded back to Resident #1 with cursing. NA #2 assisted the resident to stand up and ambulated her/him to bed. Resident #1 would not lie down so NA #1 placed her hands on the resident's shoulders and again pressed down to cause Resident #1 to sit on the bed, while Resident #1 continued cursing and striking out at NA #1. Resident #1 then stated he/she was going to hit NA #1 and NA #1 responded if Resident #1 was going to hit her, she would hit back. NA #1 then picked up Resident #1's rag doll and hit Resident #1 once on each side of the face with it, while Resident #1 was leaning back attempting to kick NA #1. NA #2 then asked NA #1 to leave the room. NA #1 denied that allegations. Resident #1 and the roommate could not answer questions due to cognitive status, and the allegation was not substantiated. Interview with NA #1 on 9/23/2024 at 11:45 AM identified that although she observed the incident on 8/30/2024, she did not report the allegation until she returned to work on 9/3/2024. She continued that she was off the few days after the incident, and realized that the interaction between NA #1 and Resident #1 was wrong and reported the incident to the DON on her next working day, 9/3/2024. Interview with the DON on 9/23/2024 at 2:00 PM identified that the allegation of abuse was unsubstantiated. There were no witnesses other than NA #2 and NA #1 had denied the allegation. The DON stated that NA #2 should have reported the allegation at the time of her observations on 8/30/2024 and she did not know why NA #2 did not report the event until 9/3/2024, and NA #2 was provided with education regarding timely reporting allegations of abuse. The facility Abuse Prevention Program Policy dated 11/9/2022 directed in part, that all employees are responsible for identifying and reporting immediately to their supervisor any witnessed abuse or allegation of abuse. The policy defined verbal abuse as the use of oral or gestured language that will fully included disparaging and derogatory terms to resident, that included threats of harm. Physical abuse is defined as hitting or slapping. Facility documentation review identified staff education was initiated on 9/3/2024 and included education on the facility abuse policy, reporting requirements and care of the resident with combative behaviors was completed after the incident. Further, NA #1 and NA #2 received one (1) to one (1) education. Random audits of staff and audits of other residents who were cared for by NA #1 were initiated on 9/3/2024 and included on all shifts to identify possible allegations of abuse and reporting of those allegations, and a QAPI meeting was held on 9/8/2024. The facility alleged completion and compliance on 9/20/2024. Based on review of facility documentation, past non-compliance was identified with a date of 9/20/2024.

Based on clinical record reviews and observation, for one of two sampled residents reviewed for pressure ulcers (R#25) the facility failed to provide care and services to prevent the development of a pressure ulcer. The findings included: Resident # 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified the resident as moderately cognitively impaired, requiring extensive assistance for dressing, bed mobility and transfers and at risk for pressure ulcers. The RCP updated on 10/11/12 identified the resident at risk for skin breakdown related to decreased mobility. Interventions included to provide a pressure relief mattress, cushion for the bed and wheelchair, to turn, reposition and toilet every two hours as needed. Review of a Twenty-Four Hour, Nursing Admission/Re-Admission Form dated 10/02/12 identified the resident with intact skin and/or dry heels. Although a review of the resident's weekly body audit during the period of 11/06/12 to 12/04/12 identified the resident's skin as clear and intact, a review of the Skin/Wound Healing Record dated 11/30/12 identified the resident with a stage 2 pressure ulcer to the left heel measuring 0.5 cm by 0.5 cm by 0.2 cm in depth. Interview with RN #3 on 5/16/13 at 11:53 A.M. and review of the clinical record and facility documentation, identified that the resident acquired the pressure ulcer from a pair of ill-fitting slippers that rubbed against his/her Achilles area (posterior ankle) of the resident's left heel. RN #3 indicated that nursing staff should have noticed the condition of the resident's skin during care and reported it.

Based on review of clinical records and interview for one of three sampled residents reviewed for accidents (R#3), the facility failed to provide adequate supervision and assistive devices to prevent an accident. The findings included: Resident #3's [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident as severely cognitively impaired, total dependence on staff for ADL's and was non-ambulatory. A RCP dated 11/01/12 identified a problem with functional mobility related to arthritis. Interventions included transfer with the assistance of two and a sit and stand lift. physician's orders [REDACTED]. A nurse's note dated 12/02/12 identified that at 6:15 PM while NA#1 was transferring the resident from the wheelchair to bed, the resident complained of pain. The supervisor was notified and a large hematoma was noted on the right anterior lower extremity. The resident indicated that she/he had pain all over and grimaced when the right leg was manipulated. The APRN was notified and an order for [REDACTED]. At 1:15 AM the x-ray results where available and identified a minimally displaced oblique fracture through the right tibial diaphysis. The APRN was updated and directed the administration of Ultram 50 mg, every six hours as needed for pain, ice to the area for 24 hours, elevate the right leg and schedule an Orthopedic Consult in the morning. On 12/3/12 at 2:15 PM the resident was transported to the Orthopedic Physician and returned to the facility at 5:00 PM with, an above the knee hard cast in place on the right leg. Interview and review of the clinical record and facility documentation on 5/14/13 at 10:30 with the DNS and ADN'S identified that although the Resident Care Plan directed the use of a sit and stand lift with the assistance of two, NA#1 reported that she transferred the resident without the use of a lift and/or the assistance of another staff member. Facility documentation identified that during the transfer, NA#1 stated that the resident was unable to bear weight and his/her leg got stuck in the wheelchair. Once in bed, the resident complained of pain and NA#1 notified the charge nurse. Subsequently, NA#1 resigned her position at the facility.

Based on observations, record review and staff interviews for one of forty-eight residents on a mechanically altered diet (Resident #115), the facility failed to serve the appropriate diet which resulted in the resident choking and subsequent death. The findings include: Resident 115 ' s [DIAGNOSES REDACTED]. A quarterly Minimum (MDS) data set [DATE] identified a cognitive impairment and required total assistance of two staff members for activities of daily living and setup help only for eating. Physician orders [REDACTED]. Physician orders [REDACTED]. The care plan dated 3/20/12 identified dysphagia and a risk for aspiration with interventions that included to remain upright for meals, provide a mechanical soft diet with ground meat, thin liquids as ordered and to report any symptoms of aspiration to the physician. The care plan further noted a self-care deficit with interventions to set up and cue with meals and provide assistance as needed. On 4/18/12 at 1:30PM, Resident #115 was observed seated in a high back customized wheelchair in the dining room. During the course of eating, the resident started to cough and clear frothy liquid was noted coming from the mouth. RN#5 removed the resident to the hallway outside of the dining room. RN#5 called RN#4 for assistance as Resident #115 was wheeled into the clean utility room for privacy. Interview with RN#5 on 4/18/12 at 4:10PM identified that the resident began coughing in the dining room and appeared to be trying " to spit up. " RN#5 noted the resident looked better after RN#5 cleaned the inner mouth with the clothing protector and was at " baseline. " During the interview RN#5 stated that she remained with the resident. R#115 began coughing again and was noted to have difficulty breathing. RN#5 summoned RN#4 and requested that she call for assistance. RN#5 indicated she brought R#115 into the clean utility room and the resident was still trying to cough and became red in the face. RN#5 further identified that she was going to suction the resident when R#115 vomited. RN#5 was unable to find anything in the resident ' s mouth and began to administer " frontal abdominal thrusts " rather than the [MEDICATION NAME] maneuver because she could not get her arms around and behind the resident due to the high back customized wheelchair. NA #7 was present and RN#5 requested he perform the [MEDICATION NAME] maneuver because he had a longer arm reach. RN#5 indicated R#115 ' s color became white after NA# 7 attempted the [MEDICATION NAME] maneuver from behind. RN#5 stated the back of the wheelchair was released and the [MEDICATION NAME] maneuver was again attempted without success. RN #5 directed RN#4 to call emergency 911 and to get additional help. RN#5 continued to perform the [MEDICATION NAME] maneuver until the DNS arrived who was notified by telephone rather than an emergency communication method. The DNS attempted to perform the [MEDICATION NAME] maneuver but RN#5 stated R#115 vital signs had ceased and the pupils were fixed and dilated. R#115 was pronounced dead at 1:40PM by RN#5 prior to the arrival of the emergency 911 medical staff. Observation by the Surveyor on 4/18/12 at 1:30PM of the resident ' s meal tray identified a diet slip that indicated to provide a modified soft diet with ground meat and half portions. Observation of the meal tray at that time identified ham that was cut into ? inch pieces, cooked diced carrots, potatoes and a hard cookie. Interview with NA# 6 on 4/18/12 at 1:35PM identified the resident received a whole piece of ham on the food tray that she cut up for the resident. NA#6 further identified she thought the resident was on a regular diet and was unaware the resident required ground meat. NA#6 noted that she did not check the diet slip prior to serving the resident the meal. NA#6 indicated she sat next to the resident to provide supervision during the meal and R#115 was eating independently when she began to cough. Interview with the DNS and ADNS on 4/18/12 at 4:00PM identified that NA ' s are not in-serviced to check the diet slip with the meal prior to serving a resident because it should be part of the Nurse Aide certification training. Observation of R#115 ' s meal tray and interview with the Dining Service Manager on 4/18/12 at 1:53PM identified the pieces of ham on the food tray were too large to be served to a resident who required a ground diet. Additionally, the Dining Service Manager indicated a mechanical soft diet directs to provide a softer dessert and not a hard cookie. On 4/18/12 at 2:20PM an interview with Dietary Aide (DA) #1 identified he was aware the resident was to receive ground meat, however, indicated he plated a whole piece of ham for the resident because he thought it was soft enough to eat. DA#1noted that there was a ground meat available on the steam table, (knockwurst) but he did not know if the resident had any allergies [REDACTED]. Review of the resident death certificate dated 4/18/12 identified that the resident ' s cause of death was [MEDICAL CONDITION] secondary to aspiration.

Based on observation, record review and staff interview for one of forty eight residents on a mechanically altered diet (Resident #115), the facility failed to serve the appropriate diet and/or failed to ensure the facility developed a policy for responding to medical emergencies and/or failed to ensure staff were in-serviced on facility expectations for responding to medical emergencies. The findings include: Resident 115 ' s [DIAGNOSES REDACTED]. A quarterly Minimum (MDS) data set [DATE] identified a cognitive impairment and required total assistance of two staff members for activities of daily living and setup help only for eating. Physician orders [REDACTED]. Physician orders [REDACTED]. The care plan dated 3/20/12 identified dysphagia and a risk for aspiration with interventions that included to remain upright for meals, provide a mechanical soft diet with ground meat, thin liquids as ordered and to report any symptoms of aspiration to the physician. The care plan further noted a self-care deficit with interventions to set up and cue with meals and provide assistance as needed. On 4/18/12 at 1:30PM, Resident #115 was observed seated in a high back customized wheelchair in the dining room. During the course of eating, the resident started to cough and clear frothy liquid was noted coming from the mouth. RN#5 removed the resident to the hallway outside of the dining room. RN#5 called RN#4 for assistance as Resident #115 was wheeled into the clean utility room for privacy. Interview with RN#5 on 4/18/12 at 4:10PM identified that the resident began coughing in the dining room and appeared to be trying " to spit up. " RN#5 noted the resident looked better after RN#5 cleaned the inner mouth with the clothing protector and was at " baseline. " During the interview RN#5 stated that she remained with the resident. R#115 began coughing again and was noted to have difficulty breathing. RN#5 summoned RN#4 and requested that she call for assistance. RN#5 indicated she brought R#115 into the clean utility room and the resident was still trying to cough and became red in the face. RN#5 further identified that she was going to suction the resident when R#115 vomited. RN#5 was unable to find anything in the resident ' s mouth and began to administer " frontal abdominal thrusts " rather than the [MEDICATION NAME] maneuver because she could not get her arms around and behind the resident due to the high back customized wheelchair. NA #7 was present and RN#5 requested he perform the [MEDICATION NAME] maneuver because he had a longer arm reach. RN#5 indicated R#115 ' s color became white after NA# 7 attempted the [MEDICATION NAME] maneuver from behind. RN#5 stated the back of the wheelchair was released and the [MEDICATION NAME] maneuver was again attempted without success. RN #5 directed RN#4 to call emergency 911 and to get additional help. RN#5 continued to perform the [MEDICATION NAME] maneuver until the DNS arrived who was notified by telephone rather than an emergency communication method. The DNS attempted to perform the [MEDICATION NAME] maneuver but RN#5 stated R#115 vital signs had ceased and the pupils were fixed and dilated. R#115 was pronounced dead at 1:40PM by RN#5 prior to the arrival of the emergency 911 medical staff. a. Observation by the Surveyor on 4/18/12 at 1:30PM of the resident ' s meal tray identified a diet slip that indicated to provide a modified soft diet with ground meat and half portions. Observation of the meal tray at that time identified ham that was cut into ? inch pieces, cooked diced carrots, potatoes and a hard cookie. Interview with NA# 6 on 4/18/12 at 1:35PM identified the resident received a whole piece of ham on the food tray that she cut up for the resident. NA#6 further identified she thought the resident was on a regular diet and was unaware the resident required ground meat. NA#6 noted that she did not check the diet slip prior to serving the resident the meal. NA#6 indicated she sat next to the resident to provide supervision during the meal and R#115 was eating independently when she began to cough. Interview with the DNS and ADNS on 4/18/12 at 4:00PM identified that NA ' s are not in-serviced to check the diet slip with the meal prior to serving a resident because it should be part of the Nurse Aide certification training. Observation of R#115 ' s meal tray and interview with the Dining Service Manager on 4/18/12 at 1:53PM identified the pieces of ham on the food tray were too large to be served to a resident who required a ground diet. Additionally, the Dining Service Manager indicated a mechanical soft diet directs to provide a softer dessert and not a hard cookie. On 4/18/12 at 2:20PM an interview with Dietary Aide (DA) #1 identified he was aware the resident was to receive ground meat, however, indicated he plated a whole piece of ham for the resident because he thought it was soft enough to eat. DA#1noted that there was a ground meat available on the steam table, (knockwurst) but he did not know if the resident had any allergies [REDACTED]. b. On 4/19/12 at 9:17AM, a review of the facility medical emergency policy with the Assistant Director of Nurses lacked a mechanism and/or process to follow to alert facility personnel to respond to a medical emergency. Interview with RN#4 on 4/19/12 at 9:00AM identified that she did not use the intercom to summon assistance because RN#5 told her to call 911 and the DNS. Further interview with RN#4 noted that she began employment at the facility in February 2012 and could not ascertain if he/she was oriented on a procedure for alerting staff to respond to a medical emergency specific to the facility. Subsequent to surveyor inquiry, the facility developed a policy to utilize the " EMER PAGE " on the telephone, and announce clearly " STAT " and the location where the emergency is taking place. Review of the resident death certificate dated 4/18/12 identified that the resident ' s cause of death was [MEDICAL CONDITION] secondary to aspiration.

Based on record review and staff interview, for one of two sampled residents reviewed for injuries of unknown origin (Resident #13), the facility failed to provide adequate supervision to prevent an injury. The findings include: Resident #13's [DIAGNOSES REDACTED]. A significant change Minimum (MDS) data set [DATE] identified the resident had short and long term memory problems and required total assistance with activities of daily living. A care plan dated 3/15/12 identified a problem with self care deficit/totally dependant on nursing for all aspects of activities of daily living with interventions to provide care with 2 care givers at all times due to resistive behaviors, bed rest related to diarrhea, alternating air pressure mattress, and utilize 4 1/2 siderails at all times. physician's orders [REDACTED].(INR) of 3.3 (0.8-3.0 normal range). Review of Nurses notes dated 3/27/12 at 2:00AM noted the resident had a 8cm by 4 cm bruise to the top of the left foot, dorsal area. There was no swelling and no pain/discomfort. The physician was notified on 3/27/12 at 2:00AM and directed to monitor the top of the left foot and document. Nurses notes dated 3/28/12 at 3:00AM noted the bruise persists to the top of the left foot, and a 9cm by 5cm bruise was noted to the right foot, dorsal area, with complaints of discomfort. The left shoulder was also noted to have a 8cm by 4cm bruise. The physician was notified on 3/28/12 and directed to obtain blood work including a Prothrombin Time and an International Normalized Ratio, hold the evening Coumadin and re-start Coumadin 5mg daily on 3/29/12. The INR on 3/29/12 was 3.5. Nurses notes dated 3/30/12 at 1:00PM identified the resident complained of severe pain to the right leg with movement and positioning. The right lower anterior leg was noted to be eccymotic with redness and heat noted. The Advanced Practice Registered Nurse was notified and directed a portable x-ray of the right leg and foot. Review of the portable x-ray report dated 3/30/12 identified an impacted right lower leg fracture. The physician was notified and directed to tranfer the resident to the emergency room for evaluation at 5:45PM. The resident was transferred back to the facility on [DATE] at 3:00AM with a [DIAGNOSES REDACTED]. There was also noted to be a fracture of the distal tibia throught the medial malleolus. The resident was in a right lower extremity splint with the toes exposed. Review of the Nurse Aide flow sheets from 3/25/12 to 3/31/12 noted the resident was on bedrest except for 3/29/12. On 4/23/12 at 2:20PM interview with NA#10 identified that he had R#13 on his assigment on 3/29/12 and only got the resident up in the wheelchair to obtain the residents weekly weight (via hoyer lift and another staff member) and returned the resident to bed. On 4/20/12 at 2:18PM an interview with Radiologist #3 identified that an oblique fracture is the type of injury sustained by a twist and fall. On 4/23/12 at 3:15PM an interview with Radiologist #4 identified that an impacted fracture is caused by some type of trauma and did not spontaneously occur. Radiologist #4 further noted certain causes to be from a twisting outward of the lower leg from trauma and can even be caused by legs tangled in the side rails. The facility failed to ensure that the resident was free from injury.

Based on review of the clinical record, facility documentation, facility policies and procedures and interviews for one of 5 residents reviewed for accidents (Resident #120), the facility failed to provide care and/or services following a fall that caused a head injury with an [MEDICAL CONDITION]. The findings included: Resident #120's [DIAGNOSES REDACTED]. A significant change assessment dated [DATE] identified the resident was severely cognitively impaired, wandered daily, was independent with bed mobility, transfers and ambulation both on and off the unit, continent of bowel, had no swallowing or chewing problems, and no history of falls. Review of the clinical record and facility documentation dated 3/24/11 at 10:45 A.M. identified that after hearing a loud bang, Recreation Aide #1 (RA #1), who was in the dining room, found Resident #120 lying on the floor in the dining room. Nurse's notes documented the following changes in the resident's condition: 3/24/11 at 8:30 AM: ambulating ad lib. 3/24/11 at 12 noon: found on floor in dining room. Eyes open. Pale color. Vomited small amount. Oxygen administered. Put back to bed. Vomited again and incontinent of large amount of stool. Hematoma of occiput approximately 5 cm noted. APRN (#1) assessed. Continue neurological checks . 3/24/11: 3-11 shift: Opens eyes occasionally, no food taken. Opens eyes only when called. 3/25/11: Unsteady gait. Brought back to bed. 3/26/11: Non-ambulatory. Eyes closed all day. Pureed food ordered. Poor lunch. [MEDICATION NAME] on hold. 3/27/11: Blood pressure 190/100. APRN (#2) notified. Eyes closed most of time. Not ambulating. Ate bites of food. 3/28/11: Keeps eyes closed. Slept most of time. Slightly lethargic. 3/29/11: Doesn't keep eyes open. Refused breakfast. Ambulated with 2 staff. On 3/28/11, the resident was observed seated in a chair in the hallway throughout the day with his/her eyes closed and head down. On 3/29/11, the resident was observed in the same condition, and staff were observed having difficulty waking the resident for breakfast. On 3/29/11, MD#1 via APRN #1, directed a CT of the head be scheduled. The physician later called back and directed the resident be sent to the emergency department immediately. On 3/30/11 and 4/1/11 at 2:15 P.M. and 10:52 A.M., interviews and review of the clinical record with LPN#4 identified that upon observing the resident right after the fall, the resident was noted to be unresponsive. LPN#4 noted that it had taken 15 minutes to get him/her stabilized. On 3/30/11 and 3/31/11 at 10:45 A.M. and 9:10 A.M. interviews and reviews of the clinical record with APRN#1 indicated that following the resident's fall, the practitioner opted not to send Resident #120 out for emergent care because she assessed that the resident was alert, responsive, eyes were opened and the resident was not in respiratory distress. The practitioner further indicated that generally, residents aren't sent out for emergent care following a fall based on the APRN Practice Group's philosophy of treating in place. Review of nurse's notes, APRN #1's progress note, and the neurological monitoring report dated 3/24/11 with APRN #1 identified that following the fall, Resident #120 was noted as unresponsive, pale in color, with cyanosis to the lips, requiring oxygen, had vomited a small amount of undigested food, was incontinent of feces and had sustained a 5 centimeter (cm) hematoma to the occiput. APRN #1 further indicated that she informed the covering APRN (APRN #2) of the resident's fall and change of condition when she reported off to her on 3/25/11. Interview with APRN #2 on 4/1/11 at 12 noon noted that she had received a call from the facility (on 3/27/11) regarding the resident's elevated blood pressure, but had not been informed that the resident was unable to ambulate, that the [MEDICATION NAME] was being held for lethargy, or that the resident was not eating. On 3/29/11, five days after the resident's fall and due to a deterioration in the resident's condition (i.e. refusing medications and food, increased lethargy, episodes of increased blood pressure, non-ambulatory and sleeping most of time), a review of the clinical record identified that the resident was transferred to an acute care facility via 911 emergency and was subsequently diagnosed with [REDACTED]. Due to the resident's family declining surgical interventions for the resident's condition related to the head trauma, the resident was transferred back to the facility and placed on comfort measures and/or palliative care. On 3/30/11 at 10:15 A.M. an interview with the Medical Director (MD #1) regarding the resident's fall and/or the facility failure to transfer the resident for emergent care, the physician indicated that although he was made aware of the fall on the day of the occurrence, MD #1 noted that "I don't think it's fair for me to comment and/or second guess the APRN's clinical judgement". MD #1 further indicated at the time of the interview that "today" (3/30/11) was his first time assessing the resident after the fall on 3/24/11 and following his/her emergency room visit on 3/29/11. Interview with Person #3 (who was not the resident's next of kin or power of attorney) on 4/1/11 at 10:15 AM, noted that she was notified of the fall on 3/24/11 by APRN #1 and asked APRN#1 if a CT scan of the head was going to be done. Person #3 noted that she was told that the resident had advanced directives in place that included do not resuscitate, and do not hospitalize, and that the resident was stable and being monitored. Review of the clinical record noted that although the resident had DNR orders in place, the resident did not have advanced directives that prohibited hospitalization in place until 3/30/11.

Based on review of the clinical record, facility documentation, facility policies and procedures and interviews for one of 5 residents reviewed for accidents (Resident #120), the facility failed to provide care and/or services in accordance with professional standards following a fall causing a head injury that resulted in an [MEDICAL CONDITION]. The findings included: Resident #120's [DIAGNOSES REDACTED]. A significant change assessment dated [DATE] identified the resident was severely cognitively impaired, wandered daily, was independent with bed mobility, transfers and ambulation both on and off the unit, continent of bowel, had no swallowing or chewing problems, and no history of falls. Review of the clinical record and facility documentation dated 3/24/11 at 10:45 A.M. identified that after hearing a loud bang, Recreation Aide #1 (RA #1), who was in the dining room, found Resident #120 lying on the floor in the dining room. Nurse's notes documented the following changes in the resident's condition: 3/24/11 at 8:30 AM: ambulating ad lib. 3/24/11 at 12 noon: found on floor in dining room. Eyes open. Pale color. Vomited small amount. Oxygen administered. Put back to bed. Vomited again and incontinent of large amount of stool. Hematoma of occiput approximately 5 cm noted. APRN (#1) assessed. Continue neurological checks . 3/24/11: 3-11 shift: Opens eyes occasionally, no food taken. Opens eyes only when called. 3/25/11: Unsteady gait. Brought back to bed. 3/26/11: Non-ambulatory. Eyes closed all day. Pureed food ordered. Poor lunch. [MEDICATION NAME] on hold. 3/27/11: Blood pressure 190/100. APRN (#2) notified. Eyes closed most of time. Not ambulating. Ate bites of food. 3/28/11: Keeps eyes closed. Slept most of time. Slightly lethargic. 3/29/11: Doesn't keep eyes open. Refused breakfast. Ambulated with 2 staff. On 3/28/11, the resident was observed seated in a chair in the hallway throughout the day with his/her eyes closed and head down. On 3/29/11, the resident was observed in the same condition, and staff were observed having difficulty waking the resident for breakfast. On 3/29/11, MD#1 via APRN #1, directed a CT of the head be scheduled. The physician later called back and directed the resident be sent to the emergency department immediately. On 3/30/11 and 4/1/11 at 2:15 P.M. and 10:52 A.M., interviews and review of the clinical record with LPN#4 identified that upon observing the resident right after the fall, the resident was noted to be unresponsive. LPN#4 noted that it had taken 15 minutes to get him/her stabilized. On 3/30/11 and 3/31/11 at 10:45 A.M. and 9:10 A.M. interviews and reviews of the clinical record with APRN#1 indicated that following the resident's fall, the practitioner opted not to send Resident #120 out for emergent care because she assessed that the resident was alert, responsive, eyes were opened and the resident was not in respiratory distress. The practitioner further indicated that generally, residents aren't sent out for emergent care following a fall based on the APRN Practice Group's philosophy of treating in place. Review of nurse's notes, APRN #1's progress note, and the neurological monitoring report dated 3/24/11 with APRN #1 identified that following the fall, Resident #120 was noted as unresponsive, pale in color, with cyanosis to the lips, requiring oxygen, had vomited a small amount of undigested food, was incontinent of feces and had sustained a 5 centimeter (cm) hematoma to the occiput. APRN #1 further indicated that she informed the covering APRN (APRN #2) of the resident's fall and change of condition when she reported off to her on 3/25/11. Interview with APRN #2 on 4/1/11 at 12 noon noted that she had received a call from the facility (on 3/27/11) regarding the resident's elevated blood pressure, but had not been informed that the resident was unable to ambulate, that the [MEDICATION NAME] was being held for lethargy, or that the resident was not eating. On 3/29/11, five days after the resident's fall and due to a deterioration in the resident's condition (i.e. refusing medications and food, increased lethargy, episodes of increased blood pressure, non-ambulatory and sleeping most of time), a review of the clinical record identified that the resident was transferred to an acute care facility via 911 emergency and was subsequently diagnosed with [REDACTED]. Due to the resident's family declining surgical interventions for the resident's condition related to the head trauma, the resident was transferred back to the facility and placed on comfort measures and/or palliative care. On 3/30/11 at 10:15 A.M. an interview with the Medical Director (MD #1) regarding the resident's fall and/or the facility failure to transfer the resident for emergent care, the physician indicated that although he was made aware of the fall on the day of the occurrence, MD #1 noted that "I don't think it's fair for me to comment and/or second guess the APRN's clinical judgement". MD #1 further indicated at the time of the interview that "today" (3/30/11) was his first time assessing the resident after the fall on 3/24/11 and following his/her emergency room visit on 3/29/11. Interview with Person #3 (who was not the resident's next of kin or power of attorney) on 4/1/11 at 10:15 AM, noted that she was notified of the fall on 3/24/11 by APRN #1 and asked APRN#1 if a CT scan of the head was going to be done. Person #3 noted that she was told that the resident had advanced directives in place that included do not resuscitate, and do not hospitalize, and that the resident was stable and being monitored. Review of the clinical record noted that although the resident had DNR orders in place, the resident did not have advanced directives that prohibited hospitalization in place until 3/30/11. According to the Lippincott Manual of Nursing Practice, 8th Edition, 2006, nursing assessment for head trauma includes, in part, assessing motor function, reflexive movement, swallowing and gag reflexes and examine head for sings of trauma. Monitor any change in neurologic status over time and report changes to health care provider. If patient demonstrates deterioration, as evidenced by a change in neurologic checks, notify the health care provider without delay, and reevaluate the neurologic status more often than required by orders based on nursing judgement.

Based on review of the clinical record, facility documentation, facility policies and procedures and interviews for two of five sampled residents reviewed for accidents (Resident #120, 111), the facility failed to provide adequate supervision to prevent an accident resulting in a head injury with an intracranial hemorrhage, and/or failed to assure the resident was supervised during toileting to prevent a resident fall. The findings include: 1. Resident #120's [DIAGNOSES REDACTED]. A significant change assessment dated [DATE] identified the resident was severely cognitively impaired, wandered daily, and was independent for ambulation and transfers. The resident care plan dated 1/11/11 identified the resident at risk for falls due to cognitive loss and/or poor safety awareness. Interventions included transfer and/or ambulate independently, and monitoring and/or checks every 15 minutes secondary to wandering. Review of facility documentation identified that on 3/24/11 at 10:45 A.M., a loud noise was heard by the recreation staff person (RA #1) while involved in a program in the dining room. RA#1 observed Resident #120 lying on the floor and called for help. On 3/30/11 at 1:15 P.M. an interview with RA#1 indicated that on 3/24/11 at or around 10:30 A.M., Resident #120 wandered into the dining room during an activity. RA #1 further indicated that shortly afterwards she heard a loud sound behind her only to find that the resident had fallen and had probably bumped his/her head. RA #1 indicated that an aide from another unit who was not with the resident and happened to be walking through the dining room at that time ran for help. On 3/30/11 at 2:00 P.M. an interview and review of facility documentation with NA #3 identified that she was assigned to care for Resident #120 on 3/24/11 during the 7 A.M. to 3 P.M. shift and was responsible for monitoring and/or documenting the resident's whereabouts every 15 minutes. NA #3 further indicated that although she was on her lunch break at the time of the resident's fall, she left the resident in care of those remaining on the unit. NA#3 noted that she did not specifically report off to another aide to monitor the resident's whereabouts because everyone knows (to watch). On 3/30/11 at 2:15 P.M. LPN #4 identified that at the time of the resident's fall, she was sitting at the nurse's desk, didn't know who was responsible for the resident and that the resident's care was left up to "whoever" was there at the time. On 4/1/11 at 9:45 A.M. an interview with NA #5 identified that at the time of the resident's fall, a third aide (NA#6) was busy toileting a resident and she was busy with a music activity for the resident's seated in the hallway and although Resident #120 was not part of her activity, she believed that the resident was "probably walking around because that's what's he/she is known to do". Review of the facility investigation documentation noted that although NA #3 documented that the resident was observed in the hallway every fifteen minutes on 3/24/11 between the hours of 10:00 A.M. to 12:45 P.M. (which includes the time of the resident's fall at 10:45 A.M.), the documentation was not accurate based on other staff members interviews. Also noted on the 15 minute check form were crossouts and write overs with the resident's location changed. On 3/30/11 at 2:45 P.M. NA #3 was observed seated in the hallway with two other aides completing the entire shift's 15 minute monitoring sheet for a resident all at one time. The aide was observed documenting and filling each line and/or column with information regarding a resident from the start of her shift at 7:00 AM., in it's entirety to the end of her shift at 2:45 P.M. During an interview with NA #3 at that time the surveyor asked NA#3, "Is this how the 15 minute monitoring checks are completed, all at once, at the end of the shift"? NA #3's response was "ah huh". Review of acute care documentation dated 3/29/11 noted the resident was diagnosed with [REDACTED]. 2. Resident # 111's ( R #111) [DIAGNOSES REDACTED]. A minimum data assessment dated [DATE] identified the resident was moderately cognitively impaired, and required extensive assistance with transfers and walking in the room. A fall risk assessment dated 2/23/11 identified a risk score of 12 (10 or above= risk). A care plan dated 2/24/11 identified the risk for falls due to resident noncompliant, shuts off alarms, has impaired safety awareness, and confusion increases in late afternoon. Interventions included personal alarm in chair and bed, wheelchair sensor, and call bell in reach. An additional note on the resident care plan dated 2/28/11 identified a recent fall with an intervention that staff were to be in the bathroom at all times when in bathroom. A physician order [REDACTED]. A nurse's note dated 2/28/11 at 3:15 PM indicated R #111 was found on the floor next to his/her bed. The note indicated that the resident got up from the toilet and walked toward the bed and fell . The resident complained of right shoulder pain and was sent to the emergency room for evaluation. Review of a reportable event form and investigation dated 2/28/11 indicated R #111 got up from the toilet and attempted to walk to the bed without assistance. Resident to have a staff member with him/her at all times. An additional comment dated 3/1/11 indicated x-ray and CT scan were negative. An interview on 3/30/11 at 1:00 PM with RN # 4 indicated the resident was left on the toilet while a nurse aide waited outside the resident's room. She indicated R #111 had unsafe behaviors and would not remember to turn on the call light. She further indicated because an alarm was not used on the toilet, she would have expected the nurse aide to supervise the resident in the bathroom and/or outside the bathroom door. RN # 4 was unable to recall the nurse aide who toileted the resident. An interview with the DNS on 3/31/11 at 10:00 AM indicated she was not aware the resident had been left on the toilet unsupervised. She indicated R #111 was unsafe and any resident with alarms needs to have close supervision during toileting. The DNS indicated she would investigate and provide the nurse aide with appropriate education at that time.