Every finding on record at Mary Anna Nursing Home

Based on record reviews and interviews, the facility failed to protect the resident's right to be free from neglect for 1 (#26) of 1 sampled resident reviewed for neglect. S4CNA failed to provide and follow required safety procedures when transporting Resident #26 in the facility van. This deficient practice resulted in an Immediate Jeopardy situation on 01/06/2026 at approximately 1:30 p.m. when Resident #26 was returning from a physician appointment. S4CNA failed to properly secure Resident #26 with the restraining seatbelt in the facility van. Resident #26 verbalized to S4CNA during return transportation that she was sliding out of her wheelchair. S4CNA failed to stop the vehicle and assist Resident #26 with repositioning. S4CNA continued to drive to her personal residence and left Resident #26 alone in the van. Resident #26 slipped out of the wheelchair onto the floor of the van while alone in the van. S4CNA returned to the van, found resident on the floor of the van and continued to drive approximately 15.3 miles to the nursing home without notifying the facility of the fall. Upon arrival to the facility, S4CNA failed to notify the facility of when the fall occurred and how long Resident #26 had been on the floor. Although Resident #26 was assessed with no injuries upon return to the facility, the deficient practice had the likelihood of a serious injury, serious harm, serious impairment or death to occur. The facility implemented corrective actions which were completed prior to State Agency's investigation entry on 03/16/2026. It was determined to be a Past Noncompliance Citation. Findings:Review of the facility's Freedom from Abuse, Neglect, and Exploitation policy revised 07/31/2025 revealed in part:Purpose:Ensure each resident's right to be free from abuse, neglect, and corporal punishment of any type by anyone.Procedure:1. The resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation.2. The facility does not tolerate abuse, neglect, or exploitation of any kind.3. Staff includes employees, the Medical Director, consultants, contractors, volunteers.Definitions: Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of S4CNA's annual training including the abuse and neglect policy revealed S4CNA completed her training on 10/01/2025. Review of the facility's Post - Fall Management and Transport policy dated 08/16/2023 revealed, in part: III. Procedure: 1. Safety and Assessment: do not move the resident until a comprehensive assessment is done, if the resident hit their head, is on anticoagulants, or the fall was unwitnessed, treat as a potential high risk injury and call 911 immediately. 2. Notification: notify the Charge Nurse/DON immediately. Review of the facility's Safe Procedures for Transporting People Who Use Wheelchairs policy (Transportation Policy) dated 03/24/2023 revealed, in part:It is the policy of the facility to ensure adequate training of all personnel responsible for transporting out residents. We are specifically addressing transporting those who use wheelchairs. Safety is our #1 goal.As part of our training, employees will be taught passenger assistive techniques. Each employee transporting residents will be required by management to attend this training course prior to transporting any resident in a wheelchair.An outline of the training will include what to do when: Entering the vehicle, Exiting the vehicle, Transporting the passenger, and Operating the lift.We will be using 2 online videos which outline the proper way to safely secure the wheelchairs throughout the process. Both videos will be viewed by transporting employees. The videos are:Safe Transportation of people who use wheelchairs and Strapping Clients/Wheelchair in vans (YouTube)Our training will also include: Recommended guidelines for safe wheelchair transportation, Safe loading and unloading procedures, How to operate a vehicle lift, How to properly tie down a wheelchair, and what to do if someone falls. Review of the Transportation Training Checklist - Competency Checklist revealed the following: resident fall procedure, vehicle attendance with resident presence and facility transportation policy. S4CNA acknowledged the checklist and policy/procedure by signature and date of 07/16/2025. Review of the undated Passenger Assistive Techniques procedure revealed the following: always use a seat belt for you and your passengers, use passenger restraints and ensure the passenger restraint belts fit securely. S4CNA acknowledged the procedure by signature and date of 07/16/2025. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; hemiplegia, affecting left nondominant side; chronic systolic (congestive) heart failure; type 2 diabetes mellitus with diabetic autonomic (poly) neuropathy; chronic pain due to trauma; spinal stenosis, cervical region; and chronic obstructive pulmonary disease.Review of the quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #26 was cognitively intact. Further review of the MDS revealed Resident #26 was dependent on a wheelchair for mobility and staff for transfers utilizing a lift.On 03/16/2026 at 9:35 a.m., an interview with Resident #26 revealed she sustained a fall from her wheelchair in the facility's transportation van when returning from an appointment. Resident #26 stated when she left her appointment on 01/06/2026, S4CNA failed to attach the van's restraining seatbelt across Resident #26's lap. Resident #26 stated while in route back to the facility, she informed S4CNA she felt like she was sliding down in her wheelchair. Resident #26 stated S4CNA did not stop the van to reposition her, but continued to drive until they reached S4CNA's personal residence. Resident #26 stated S4CNA went inside her personal residence and left her unattended without repositioning her in the wheelchair. Resident #26 stated she slid out of her wheelchair to the transportation van's floor while S4CNA was inside her personal residence. Resident #26 stated when S4CNA returned, she was not assisted off the floor and S4CNA did not call the facility for assistance. Resident #26 stated S4CNA drove her back to the facility while she was on sitting on the transportation van's floor. Resident #26 denied any other instances of not being secured in the transportation van without a seat belt.On 03/17/2026 at 3:05 p.m., an interview with S2DON revealed she was informed Resident #26 fell in the wheelchair van upon the resident's return to the facility, but assumed she sustained a fall when exiting the van at the facility. S2DON stated she was not made aware that Resident #26 fell at S4CNA's personal residence until the following morning when she interviewed Resident #26.On 03/17/2026 at 3:20 p.m., an interview with S4CNA confirmed she did not utilize the van's restraining lap belt when transporting Resident #26 back from her appointment. S4CNA confirmed she had received transportation safety training but did not provide an answer as to why she did not follow policy. S4CNA also confirmed she did not reposition Resident #26 in her wheelchair when Resident #26 informed her she was sliding down in her wheelchair. S4CNA stated she did stop at her personal residence to use the restroom and left Resident #26 unattended in the facility's transportation van. S4CNA confirmed Resident #26 was sitting on the floor of the transportation van when she returned and she did not call the facility for assistance to transfer Resident #26 off the floor. S4CNA confirmed she drove Resident #26 back to the facility from her personal residence while the resident was sitting on the floor of the van due to being unable to lift the resident off of the floor by herself. On 03/18/2026 at 7:45 a.m., an interview with S2DON confirmed S4CNA should have secured Resident #26 properly with the facility's van's restraining belt, S4CNA should have repositioned Resident #26 when she was notified by the resident, she was sliding down in her wheelchair, S4CNA should have not left Resident #26 unattended in the van while she went inside her personal residence, S4CNA should have notified the facility immediately when Resident #26 fell in the transportation van and S4CNA should not have driven the facility van to the nursing home with Resident #26 on the floor of the van. S2DON reported S4CNA had been previously trained prior to the 01/06/2026 incident on transportation safety, the fall policy and the abuse and neglect policy.On 03/18/2026 at 8:15 a.m., an interview with S1Administrator confirmed S4CNA should have properly secured Resident #26 by applying the facility's van's restraining belt, S4CNA should have assisted Resident #26 with repositioning when she was notified by the resident, she was sliding down in her wheelchair, S4CNA should have not left Resident #26 unattended in the van when she went inside her personal residence, S4CNA should have notified the facility immediately when Resident #26 fell in the transportation van and S4CNA should not have driven the facility van to the nursing home with Resident #26 on the floor of the van. S1Administrator reported S4CNA had been previously trained prior to the 01/06/2026 incident on transportation safety, the fall policy, and the abuse and neglect policy.A review of the facility investigation dated 01/07/2026 revealed the facility substantiated neglect in their findings.During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions to correct the deficient practice with a completion date of 01/08/2026:1. Immediately assessed Resident #26 upon return to the facility on [DATE].2. Terminated the employment of S4CNA on 01/07/2026.3. DON updated the facility's policy on transportation to notate change stating to call the facility in the event of a fall if non-emergent or to call 911 if it is an emergency on 01/08/2026.4. On 01/08/2026, in-service performed with transportation drivers at this time to make aware of policy changes and to perform competency checks on loading and unloading resident in wheelchair. In-service done by DON and Maintenance Supervisor. Transport drivers counseled on the importance of never leaving resident unsupervised. Counseled on notifying nursing immediately in the event of a fall.5. On 01/08/2026, mandatory monitoring being done by DON or designee as follows 3x per week until 04/08/2026. This monitoring consists of checks upon arrival and departure to ensure resident is safely anchored in van and that resident is properly seated to ensure safety while being transported. Upon each assessment by DON, upon departure/arrival transport driver will be quizzed on who to call in the event of a fall while transporting. Will also speak with residents about their trip.6. On 01/08/2026, monitoring compliance and situation weekly at our staff meetings. Will monitor and address at quarterly QAPI meetings and other intervals as needed to ensure compliance.Facility is in compliance as of 01/08/2026. Validation of plan of correction:The facility corrective actions were confirmed through onsite interviews, observations and record reviews.On 03/16/2026 at 10:00 a.m., record review revealed that Resident #26 was assessed by S2DON.On 03/17/2026 at 8:45 a.m., an interview with S8CNA revealed she was the main transportation driver for the facility. S8CNA stated she began transporting for the facility in January 2026 when S4CNA was terminated from employment. S8CNA confirmed she had received transportation safety training and proper restraining of residents in the van. S8CNA stated if a resident were to have a fall in the transportation van, she would stop the van and call 911 if the resident was injured or notify the facility immediately if no obvious injuries were sustained by the resident.On 03/17/2026 at 9:30 a.m., observation of S8CNA loading a wheelchair dependent resident in the facility's transportation van revealed the proper loading and securing of the resident without issues. On 03/17/2026 at 2:15 p.m., an interview with S2DON and review of employee files confirmed S4CNA's employment was terminated on 01/07/2026.On 03/18/2026 at 7:45 a.m., an interview with S2DON and review of facility's trainings confirmed CNA/Transport staff were in-serviced on updated transportation safety policies that included competency checks. The trainings included instruction to not leave residents unattended and properly securing residents in the transportation van.On 03/18/2026 at 10:34 a.m., an interview with S9CNA confirmed she is one of the facility's transportation drivers. S9CNA stated she was in-serviced in January on transportation safety and stated she would stop the van immediately and notify the facility if a resident were to fall. S9CNA stated she was in-serviced on not leaving residents unattended while in the transport van.On 03/18/2026 at 11:00 a.m., an interview with S2DON confirmed she had been conducting random checks 3 times weekly beginning the week of 01/11/2026 and randomly interviewing staff about transportation safety policy.On 03/18/2026 at 11:30 a.m., review of the facility's plan of correction revealed documentation of S2DON's audits of resident transports and monitoring of staff securing of residents.On 03/18/2026 at 11:45 a.m., review of the facility's QAPI revealed the interventions for transportation safety were added to the facility's QA.On 03/18/2026 at 3:20 p.m., an interview with S13Laundry employee confirmed she has received an in-service on fall protocol and stated if she discovered a resident had fallen, she would call the nurses station immediately to alert staff.On 03/18/2026 at 3:30 p.m. through 3:40 p.m., interviews conducted with S10CNA, S11CNA, and S12CNA confirmed they were in-serviced on fall protocol and stated they would notify a nurse immediately if a resident fell.

Based on record reviews and interviews, the facility failed to provide adequate supervision and properly secure the resident with the facility van's restraining seatbelt to prevent accidents for 1 (Resident #26) of 5 sampled residents reviewed for accidents.This deficient practice resulted in an Immediate Jeopardy situation on 01/06/2026 at approximately 1:30 p.m. when S4CNA failed to properly secure Resident #26 (who was wheelchair dependent) with the transportation van's restraining seatbelt. S4CNA left Resident #26 in the transportation van unsupervised while S4CNA stopped at her personal residence. This resulted in Resident #26 slipping out of her wheelchair onto the van floor while she was unsupervised. Although Resident #26 was assessed with no injuries upon return to the facility, the deficient practice had the likelihood of a serious injury, serious harm, serious impairment or death to occur.The facility implemented corrective actions which were completed prior to State Agency's investigation entry on 03/16/2026. It was determined to be a Past Noncompliance Citation.Findings:Review of the facility's Safe Procedures for Transporting People Who Use Wheelchairs policy (Transportation Policy) dated 03/24/2023 revealed, in part:It is the policy of the facility to ensure adequate training of all personnel responsible for transporting out residents. We are specifically addressing transporting those who use wheelchairs. Safety is our #1 goal.As part of our training, employees will be taught passenger assistive techniques. Each employee transporting residents will be required by management to attend this training course prior to transporting any resident in a wheelchair.An outline of the training will include what to do when: Entering the vehicle, Exiting the vehicle, Transporting the passenger, and Operating the lift.We will be using 2 online videos which outline the proper way to safely secure the wheelchairs throughout the process. Both videos will be viewed by transporting employees. The videos are: Safe Transportation of people who use wheelchairs and Strapping Clients/Wheelchair in vans (YouTube)Our training will also include: Recommended guidelines for safe wheelchair transportation, Safe loading and unloading procedures, How to operate a vehicle lift, How to properly tie down a wheelchair, and what to do if someone falls. Review of the Transportation Training Checklist - Competency Checklist revealed the following: resident fall procedure, vehicle attendance with resident presence and facility transportation policy. S4CNA acknowledged the checklist and policy/procedure by signature and date of 07/16/2025. Review of the undated Passenger Assistive Techniques procedure revealed the following: always use a seat belt for you and your passengers, use passenger restraints and ensure the passenger restraint belts fit securely. S4CNA acknowledged the procedure by signature and date of 07/16/2025. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; hemiplegia, affecting left nondominant side; chronic systolic (congestive) heart failure; type 2 diabetes mellitus with diabetic autonomic (poly) neuropathy; chronic pain due to trauma; spinal stenosis, cervical region; and chronic obstructive pulmonary disease.Review of the quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #26 was cognitively intact. Further review of the MDS revealed Resident #26 was dependent on a wheelchair for mobility and staff for transfers utilizing a lift.On 03/16/2026 at 9:35 a.m., an interview with Resident #26 revealed she sustained a fall from her wheelchair in the facility's transportation van when returning from an appointment. Resident #26 stated when she left her appointment on 01/06/2026, S4CNA failed to attach the van's restraining seatbelt across Resident #26's lap. Resident #26 stated while in route back to the facility, she informed S4CNA she felt like she was sliding down in her wheelchair. Resident #26 stated S4CNA did not stop the van to reposition her but continued to drive until they reached S4CNA's personal residence. Resident #26 stated S4CNA went inside her personal residence and left her unattended without repositioning her in the wheelchair. Resident #26 stated she slid out of her wheelchair to the transportation van's floor while S4CNA was inside her personal residence. Resident #26 stated when S4CNA returned, she was not assisted off the floor and S4CNA did not call the facility for assistance. Resident #26 stated S4CNA drove her back to the facility while she was on sitting on the transportation van's floor.On 03/17/2026 at 3:20 p.m., an interview with S4CNA confirmed she did not utilize the van's restraining lap belt when transporting Resident #26 back from her appointment. S4CNA also confirmed she did not reposition Resident #26 in her wheelchair when Resident #26 informed her she was sliding down in her wheelchair. S4CNA stated she did stop at her personal residence to use the restroom and left Resident #26 unattended in the facility's transportation van. S4CNA confirmed Resident #26 was sitting on the floor of the transportation van when she returned and she did not call the facility for assistance to transfer Resident #26 off the floor. S4CNA confirmed she drove Resident #26 back to the facility from her personal residence while the resident was sitting on the floor of the van. S4CNA confirmed she had received transportation safety training.On 03/18/2026 at 7:45 a.m., an interview with S2DON confirmed S4CNA failed to properly secure Resident #26 into the transportation van with the restraining seatbelt and S4CNA left Resident #26 in the transportation van unsupervised while S4CNA stopped at her personal residence. Further interview confirmed Resident #26 slipped out of her wheelchair onto the van floor while the resident was not secure with a seatbelt and unsupervised in the facility van. S2DON reported S4CNA had been previously trained prior to the 01/06/2026 incident on transportation safety and the fall policy.On 03/18/2026 at 8:05 a.m., interview with S5LPN confirmed Resident #26 was sitting on the floor of the facility's transportation van upon return and assisted in assessing and lifting the resident off of the van's floor.On 03/18/2026 at 8:15 a.m., an interview with S1Administrator confirmed S4CNA failed to properly secure Resident #26 into the transportation van with the restraining seatbelt and S4CNA left Resident #26 in the transportation van unsupervised while S4CNA stopped at her personal residence. Further interview confirmed Resident #26 slipped out of her wheelchair onto the van floor while the resident was not secure with a seatbelt and unsupervised in the facility van.During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions to correct the deficient practice with a completion date of 01/08/2026:1. Immediately assessed Resident #26 upon return to the facility on [DATE].2. Terminated the employment of S4CNA on 01/07/2026.3. DON updated the facility's policy on transportation to notate change stating to call the facility in the event of a fall if non-emergent or to call 911 if it is an emergency on 01/08/2026.4. On 01/08/2026, in-service performed with transportation drivers at this time to make aware of policy changes and to perform competency checks on loading and unloading resident in wheelchair. In-service done by DON and Maintenance Supervisor. Transport drivers counseled on the importance of never leaving resident unsupervised. Counseled on notifying nursing immediately in the event of a fall.5. On 01/08/2026, mandatory monitoring being done by DON or designee as follows 3x per week until 04/08/2026. This monitoring consists of checks upon arrival and departure to ensure resident is safely anchored in van and that resident is properly seated to ensure safety while being transported. Upon each assessment by DON, upon departure/arrival transport driver will be quizzed on who to call in the event of a fall while transporting. Counseled on notifying nursing immediately in the event of a fall.6. On 01/08/2026, monitoring compliance and situation weekly at our staff meetings. Will monitor and address at quarterly QAPI meetings and other intervals as needed to ensure compliance.Facility is in compliance as of 01/08/2026. Validation of plan of correction:The facility corrective actions were confirmed through onsite interviews, observations and record reviews.On 03/16/2026 at 10:00 p.m., record review revealed that Resident #26 was assessed by S2DON with no injuries documented.On 03/17/2026 at 8:45 a.m., interview with S8CNA revealed she was the main transportation driver for the facility. S8CNA stated she began transporting for the facility in January 2026 when S4CNA was terminated from employment. S8CNA confirmed she had received transportation safety training and proper restraining of residents in the van. S8CNA stated if a resident were to have a fall in the transportation van, she would stop the van and call 911 if the resident was injured or notify the facility immediately if no obvious injuries were sustained by the resident.On 03/17/2026 at 9:30 a.m., an observation was conducted of S8CNA loading a resident into the transportation van in a wheelchair. S8CNA was observed to properly secure the wheelchair and place the restraining seatbelt on the resident.On 03/17/2026 at 2:15 p.m., an interview with S2DON and review of employee files confirmed S4CNA's employment was terminated on 01/07/2026On 03/18/2026 at 7:45 a.m., an interview with S2DON and review of facility's trainings confirmed CNA/Transport staff were in-serviced on updated transportation safety policies that included competency checks. The trainings included instruction to not leave residents unattended and properly securing residents in the transportation van.On 03/18/2026 at 10:34 a.m., an interview with S9CNA confirmed she is one of the facility's transportation drivers. S9CNA stated she was in-serviced in January on transportation safety and stated she would stop the van immediately and notify the facility if a resident were to fall. S9CNA stated she was in-serviced on not leaving residents unattended while in the transport van.On 03/18/2026 at 11:00 a.m., an interview with S2DON confirmed she has been conducting random checks 3 times weekly beginning the week of 01/11/2026 and randomly interviewing staff about transportation safety policy.On 03/18/2026 at 11:30 a.m., review of the facility's plan of correction revealed documentation of S2DON's audits of resident transports and monitoring of staff securing of residents.On 03/18/2026 at 11:45 a.m., review of the facility's QAPI revealed the interventions for transportation safety were added to the facility's QA.On 03/18/2026 at 3:20 p.m., an interview with S13 Laundry employee confirmed she has received an in-service on fall protocol and stated if she discovered a resident had fallen, she would call the nurses station immediately to alert staff and remain with the resident.On 03/18/2026 at 3:30 p.m. through 3:40 p.m., interviews conducted with S10CNA, S11CNA, and S12CNA confirmed they were in-serviced on fall protocol and stated they would notify a nurse immediately if a resident fell and not leave resident unattended.

Based on observations, interviews, and record reviews, the facility failed to implement a person-centered care plan for each resident to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (#1) of 18 sampled residents. The facility failed to ensure care-planned interventions for falls were implemented. Findings:Resident # 1 Review of the record for Resident #1 revealed an admission date of 08/08/2024 with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, gastroesophageal reflux disease, vitamin D deficiency, osteoarthritis, dementia, hypertension, hyperlipidemia, and history of falling. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated Resident #1 had severe cognitive impairment with daily decision making. Further review revealed Resident #1 required supervision/touch assist with chair to chair and bed to chair transfers. Review of the quarterly fall risk assessment dated [DATE] revealed a score of 18 which indicated Resident #1 was a high fall risk. Review of the plan of care to address falls for Resident #1 revealed an intervention dated 02/09/2026 to encourage Resident #1's use of a reacher and ensure the device is within reach. On 03/17/2026 at 9:38 a.m., observation revealed Resident #1 did not have a reacher plainly visible.On 03/17/2026 at 12:53 p.m., Resident #1 was observed without a reacher. Interview with Resident #1 revealed she did not have the device and asked for surveyor to get her one.On 03/17/2026 at 12:56 p.m., S8CNA did not identify the reacher as a fall intervention for Resident #1.On 03/17/2026 at 1:53 p.m., S15LPN did not identify the reacher as a fall intervention for Resident #1. S15LPN reported being unaware of the reacher being a fall intervention.On 03/17/2026 at 12:27 p.m., S2DON was informed of the findings and confirmed there was no documentation to support a reacher was in place per the plan of care.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to follow their policy and procedure when a significant weight loss was identified for 1 (#2) of 3 residents reviewed for nutrition. Findings:Review of the facility undated Policy and Procedure: Weight Loss Management revealed the following, in part:III. Definitions:Significant Weight Loss: 1 month: >5% loss of body weightIV. ProcedureC. Identification of Weight Loss:1. If a significant weight loss is identified, nursing staff must notify the dietitian, attending physician, and the responsible party within 24 hours.2. Place the resident on the facility's High Risk /Weight Management List for closer monitoring.D. Evaluation and Intervention:2. IDT Meeting: Within 72 hours of identifying significant weight loss, the IDT (Dietician, Nurse, Physician, and Activity Director) will meet to review the plan of care.3. Interventions: Implement appropriate actions, which may include: Offering food substitutions, providing therapeutic diets as ordered, increasing protein/calorie density of meals, initiating nutritional supplements, assistance with feeding or adaptive feeding devices, and medication review by the pharmacist to identify drugs causing anorexia.E. Follow-up:1. Weekly weights will be taken until weight stabilizes for at least 3 months2. The IDT will review the effectiveness of interventions at least monthly.Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of pylorus, dysphagia following cerebral infarction, and Type 2 diabetes mellitus with chronic kidney disease.Review of the Significant Change 5 day MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 13, which indicated no cognitive impairment and he was independent with eating.Review of Resident #2's weights revealed:12/01/2026 - 180.801/05/2026 - 182.802/03/2026 - 169.803/02/2026 - 169.2Record review revealed Resident #2 was hospitalized from [DATE] - 02/03/2026 for diabetic ketoacidosis and a gastrointestinal bleed. His prehospitalization weight was 182.8 on 01/05/2026, and the resident's re-admit weight to the facility was 169.8 on 02/03/2026. This resulted in a 7.11% weight loss in 1 month. Review of S2DON's nurses' note dated 02/05/2026 at 6:34 p.m. revealed Resident #2 was in the hospital for 2 weeks and returned with a 13 pound weight loss. She noted before the resident was sent out to the hospital his weight was 182.8 pounds and since the resident returned, he had been eating 75-100% of all meals.Record review revealed after S2DON identified the resident's significant weight loss on 02/05/2026, there was no documentation of the following: notification of the dietician, physician, and responsible party within 24 hrs; IDT meeting within 72 hours; appropriate interventions for weight loss; weekly weights; and IDT follow-up on effectiveness of interventions at least monthly per the facility policy.Record review revealed there was no documentation the dietician assessed Resident #2 in February 2026. Review of Resident #2's February 2026 orders revealed there was no order for nutritional supplements or an appetite stimulant.Review of Resident #2's current care plan revealed he had a possible nutritional deficit related to diabetes mellitus and he was non-compliant with his diet. Further review revealed there were no new interventions for the resident's significant weight loss that was identified by S2DON on 02/05/2026.Review of S6Registered Dietician notes' dated 03/12/2026 at 4:48 p.m. revealed Resident #2's current weight was 169.2 pounds (03/02/2026) and he had a weight loss of 13.6 pounds in the past 2 months. S6Registerd Dietician recommended sugar free health shakes with meals for weight maintenance.Observations of Resident #2 on 03/16/2026 at 12:00 p.m., and 03/17/2026 at 12:05 p.m. revealed he was eating lunch in the dining room. Further observation revealed the resident did not receive any sugar free health shakes on his lunch trays.Interview with S7Cook on 03/18/2026 at 10:35 a.m. confirmed Resident #2 had not received sugar free health shakes with his meals on 03/16/2026 or 03/17/2026. S7Cook reported they do not keep sugar free health shakes on hand, and they had not received any for Resident #2.An interview with S2DON on 03/18/2026 at 1:45 p.m., revealed she was responsible for following up on the dietician's recommendations. She confirmed Resident #2 had not received any health shakes since the 03/12/2026 dietician's recommendation.Interviews with S1Administrator and S2DON on 03/18/2026 at 2:40 p.m., confirmed the facility failed to comply with the following areas of the facility weight loss management policy regarding Resident #2: notify the dietician, physician, and responsible party within 24 hours of identifying a significant weight loss; IDT meeting within 72 hours of identifying significant weight loss; implement appropriate interventions for weight loss; follow-up with weekly weights until weight stabilizes; and IDT will review the effectiveness of interventions at least monthly.

Based on observations, interviews, and record reviews, the facility failed to ensure that nurses have specific competencies and skill sets necessary to care for residents' needs by not: 1) clarifying the correct dosage of a medication for 2 (#1, #16) of 5 residents observed for medication administration and 2) notifying the physician with changes in condition for 1 (#37) of 2 residents reviewed for hospitalization. Findings:Resident #1Review of the record for Resident #1 revealed an admission date of 08/08/2024 with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, gastroesophageal reflux disease, vitamin D deficiency, osteoarthritis, dementia, hypertension, hyperlipidemia, and history of falling. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 7 which indicated Resident #1 had severe cognitive impairment with daily decision makingReview of the record for Resident #1 revealed a physician's order dated 12/11/2025 for Voltaren 1% external gel topical apply to bilateral hands topically two times a day related to osteoarthritis. On 03/18/2026 at 8:15 a.m. S5LPN confirmed Resident #1 received Voltaren 1% gel without the dosage ordered by the physician. Further review of the record revealed Resident #1 received Voltaren 1% external gel topically twice daily from 01/01/2026-03/17/2026, except for the morning dose 01/09/2026 which was refused. On 03/18/2026 at 5:47 p.m., S1Administrator was informed of findings. Resident #16Review of the record for Resident #16 revealed an admission date of 01/30/2023 with diagnoses that included coronary artery disease, heart failure, hypertension, gastroesophageal reflux disease, renal insufficiency, and arthritis.Review of the comprehensive MDS dated [DATE] revealed a BIMS score of 11 which indicated Resident #16 had moderate cognitive impairment with daily decision making.Review of the record for Resident #16 revealed a physician's order dated 04/03/2025 for Voltaren 1% external gel topical apply to bilateral lower extremities topically two times a day related to pain.On 03/18/2026 at 8:01 a.m. S5LPN prepared to administer Voltaren 1% external gel topically to Resident #16. Upon interview, S5LPN confirmed Resident #16 received Voltaren 1% gel topically without the dosage ordered by the physician.Further review of the record revealed Resident #16 received Voltaren 1% external gel topically twice daily from 01/01/2026- 03/17/2026, except for the morning doses on: 01/02/2026, 01/03/2026, 01/08/2026, 01/09/2026, 01/15/2026, and 01/20/2026.On 03/18/2026 at 5:47 p.m., S1Administrator was informed of findings. Resident #37Review of the record for Resident #37 revealed an admission date of 02/11/2026 with diagnoses that included occlusion and stenosis of unspecified carotid artery, heart failure, hypertension, cardiomegaly, cerebral ischemia, stage 3 chronic kidney disease, dysuria, wedge compression fracture of first lumbar vertebra, history of falling, traumatic hemorrhage of right cerebrum without loss of consciousness, sequela, dyspnea, fracture of nasal bones and anxiety.Review of the comprehensive MDS dated [DATE] revealed Resident #37 had severely impaired cognitive skills for daily decision making skills. Resident #37 was noted to have an unplanned discharge to a short-term general hospital on [DATE].Review of the plan of care to address Resident #37's stage 3 chronic kidney disease, revealed an intervention to monitor, document, and report as needed signs and symptoms that included edema, weight gain of over 2 lbs a day, difficulty breathing, level of consciousness, and breath sounds. Review of the nurses note dated 02/26/2026 at 6:43 a.m. revealed, in part, Resident #37 had 4+ edema in lower extremities. Further review revealed no documentation to support the physician was notified of the edema per the interventions in the plan of care.Review of the nurses note dated 03/03/2026 at 10:18 p.m. revealed, in part, medication held per family due to resident is incoherent. Further review revealed no documentation to support the physician was notified of Resident #37's level of consciousness per the interventions in the plan of care. Review of the nurses note dated 03/03/2026 at 10:31 p.m., revealed Resident #37 was administered ipratropium-albuterol inhalation solution via nebulizer due to wheezing and congestion noted to lung sounds. Further review revealed an order to perform a post nebulizer assessment. There was no documentation to support the post-nebulizer assessment was completed as ordered or breath sounds monitored per the plan of care. Review of Resident #37's weights revealed weight of 202.6 lbs on 02/16/2026 and 212 lbs on 03/03/2026. Interview with S2DON revealed no other weights were obtained, and Resident #37 was being weighed weekly instead of daily per the plan of care. S2DON confirmed being responsible for weights.During an interview on 03/18/2026 at 12:32 p.m., S2DON was unable to provide documentation to support the physician was notified of Resident #37's edema and weight gain and S2DON was unable to provide documentation to support a post nebulizer assessment was performed on 03/03/2026. Further interview revealed S2DON confirmed the physician should have been notified of Resident #37's level of consciousness on 03/03/2026 per the interventions in the plan of care.

Based on interviews the facility failed to ensure residents received mail on Saturdays. This deficient practice had the potential to affect 35 residents residing in the facility. Findings,During a resident council interview on 03/16/2026 at 12:45 p.m., Resident #19 reported they receive mail Monday through Friday. Resident #19 reported they do not receive mail on Saturdays. On 03/16/2026 at 1:10 p.m. an interview with S14Office Manager revealed she goes to the post office Monday through Friday and picks up all of the facility's mail and the residents' mail from the post office box. S14Office Manager reported she passes out the residents' mail to them Monday through Friday after she returns from the post office. S14Office Manager reported she does not go to the post office to pick up mail on Saturdays. On 03/16/2026 at 1:15 p.m. an interview with S1Administrator reported the facility's mail and the residents' mail are both delivered to the provider's post office box at the post office. S1Administrator reported S14Office Manager has the key to the post office box and goes to the post office and collects the mail Monday through Friday. S1Administrator reported they do not have a dedicated staff member that checked the post office box on Saturdays. S1Administrator confirmed residents were not able to receive mail on Saturdays.

Based on record review, interviews and observations, the facility failed to provide the care and services that is in accordance with professional standards of practice for 1 (#5) of 1 resident reviewed for respiratory care. The facility failed to date nebulizer tubing and properly store nebulizer tubing and face mask in a plastic bag when not in use. Findings:Review of the provider's nursing procedure for compliance with changing oxygen/nebulizer tubing/humidifier policy, undated policy, revealed in part: Policy: to aid in the prevention of the spread of infection and the buildup of bacteria on the tubing over time. Oxygen and nebulizer tubing will be changed two times per month on the 1st and 15th. Tubing will be dated at this time. LPN will check upon each shift that tubing is still in designated bag and labeled properly and document it on EMAR for that shift. If tubing is not properly stored it should be replaced and dated at this time.Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic systolic congestive heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellitus without complications, aftercare following joint hip replacement surgery, presence of right artificial hip joint, presence of coronary artery angioplasty implant and graft, ischemic cardiomyopathy, acute embolism and thrombosis of deep vein of right upper extremity, anxiety disorder, and fracture of the neck of right femur sequela.Review of current March 2026 physician orders revealed the following orders: 1) 03/12/2026: Ipratropium-albuterol solution (0.5-2.5 (3) mg/3ml. 1 vial inhale orally every 6 hours x 3 days; 2) 02/27/2026 albuterol sulfate inhalation solution (2.5 mg/3ml) 0.083%. 1 vial inhale orally every 6 hours as needed for wheezing or shortness of breath. Review of the March 2026 EMAR revealed documentation Resident #5 received Ipratropium-albuterol solution (0.5-2.5 (3) mg/3ml 1 vial inhale orally every 6 hours x 3 days as ordered.Observations of Resident #5's room on 03/16/2026 at 9:00 a.m. and 03/17/2026 at 8:20 a.m. revealed a nebulizer machine sitting on dresser beside Resident #5's bed. The nebulizer tubing and face mask were connected to the side of the nebulizer machine. The nebulizer tubing and face mask were not dated and were not properly stored in a plastic bag. On 03/17/2026 at 8:27 a.m. an observation of Resident #5's room with S2DON revealed a nebulizer machine sitting on dresser beside bed. The nebulizer tubing and face mask were connected to the side of the nebulizer machine. The nebulizer tubing and face mask were not dated. The nebulizer tubing and face mask were not properly stored in a plastic bag. S2DON confirmed the nebulizer tubing should be dated and the nebulizer tubing and face mask should be stored in a plastic bag when not in use.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to implement the EBP policy for 2 (#14, #5) of 2 residents reviewed for EBP. Findings: Resident #5 Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, pain in right hip, aftercare following joint hip replacement surgery, presence of right artificial hip joint, fracture of the neck of right femur sequela, and chronic venous hypertension (idiopathic) with ulcer and inflammation of unspecified lower extremity. Review of current March 2026 Physician Orders included the following: 1) 02/11/2026: Cleanse incision to right hip daily with hydrogen peroxide, apply thin layer of bactroban, cover with 4x4 and tape daily and as need for soilage/dislodgement; 2) 02/12/2026: Cleanse unstageable pressure ulcer to left great toe with wound cleanser, pat dry with gauze, apply iodine, cover with dressing daily until healed; and 3) 02/12/2026: Cleanse DTI to right heel with wound cleanser, pat dry with gauze, apply iodine, cover with dressing daily until healed. Review of admission MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated Resident #5 was cognitively intact for activities of daily decision making. Further review revealed Resident #5 had a surgical wound and unstageable wounds present on admission. On 03/16/2026 at 9:00 a.m. an interview with Resident #5 reported she has a surgical wound to her right hip area that still has a slight drainage. Resident #5 reported she also has a wound on her left great toe and right heel. Observation revealed there was no signage posted outside Resident #5's door indicating she was on EBP. On 03/17/2026 at 8:20 a.m. an observation revealed there was no signage posted outside Resident #5's door that indicated EBP were in place. On 03/17/2026 at 8:25 a.m. observation and interview with S2DON revealed there was no signage posted outside Resident #5's door indicting she was on EBP. S2DON revealed Resident #5 should be on EBP related to her wounds. S2DON confirmed there should have been a sign posted outside Resident #5's door indicating EBP were in place. Resident #14 Review of the facility's, undated, Enhanced Barrier Precautions in Nursing Homes Policy revealed the following, in part: EBP will be used when performing high-contact resident care activities for the below list: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. Review of the record for Resident #14 revealed an admission date of 10/01/2029 with diagnoses that included traumatic brain injury, aphasia, post-traumatic seizures, hemiplegia, and gastrostomy status. Review of the quarterly MDS dated [DATE] revealed Resident #14 was severely impaired with daily decision making. Further review revealed Resident #14 had a feeding tube. Review of Resident #14's physician's orders revealed an order dated 11/18/2024 for EBP: use hand sanitizer when entering and before leaving room, must wear gown and gloves while performing the following with resident: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: feeding tube. On 03/16/2026 at 1:30 p.m., S3LPN administered medications per PEG tube without donning a gown. S3LPN was unable to confirm donning a gown prior to PEG use was required. On 03/16/2026 at 1:30 p.m., an observation of S3LPN revealed she administered medications per peg tube to Resident #14 and failed to don a gown. S3LPN was unable to confirm if she should have donned a gown prior to administering medications per peg tube to Resident #14. On 03/16/2026 at 1:45 p.m., S3LPN reviewed Resident #14's physician's order for EBP and confirmed she should have donned a gown prior to administering medications to Resident #14 per her peg tube. On 03/16/2026 at 2:03 p.m., S2DON was informed EBP was not implemented as ordered for Resident #14. S2DON confirmed S3LPN should have donned a gown while administering medications via PEG tube for Resident #14.

Based on observations, record reviews and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 4 (#11, #20, #24, and #29) of 5 (#11, #15, #20, #24 and #29) residents reviewed for restraints. The facility failed to 1) obtain a consent, 2) have a physician's order and 3) failed to appropriately assess residents prior to placing the bolsters on the bed. Findings: Review of the facility's Respect and Dignity Policies and Procedures dated 03/02/2023 revealed ____ ____ Nursing Home will ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Should ____ ____ staff decide to use a restraint, it must be the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. It is our intent at ____ ____ for each resident to attain and maintain his/her highest practical well-being in an environment that: Prohibits the use of physical restraints for discipline or convenience; Prohibits the use of physical restraint to unnecessarily inhibit a resident's freedom of movement or activity; and limits physical restraint use to circumstances in which the resident has medical symptoms that may warrant the use of restraints. ____ ____ Nursing Home staff will document the symptoms being treated, and a physician's order for the use of the specific type of restraint will be obtained. A resident will be appropriately assessed prior to the use of any restraint. The care plan interdisciplinary team will be involved and documentation of the medical symptoms and use of the physical restraint for the least amount of time possible will be noted. Ongoing re-evaluation is necessary to be in compliance with regulatory requirements. Resident 20 Review of the medical record for resident #20 revealed an admitted [DATE]. Resident #20 had diagnoses including diabetes mellitus, osteomyelitis, open angle glaucoma, gastrostomy, aphasia, metabolic encephalopathy, peripheral vascular disease, pain, embolism, and heart failure. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive skills for daily decision making, was totally dependent on staff and required two person assistance with bed mobility and transfers. Observations of resident #20 on 01/27/2025 at 8:35 a.m., 01/27/2025 at 3:20 p.m., and on 01/28/2025 at 10:10 a.m., revealed the resident was lying in the bed with bilateral bolsters attached to the bottom half of the bed. Review of the care plan revealed resident #20 had a potential for falls due to decreased mobility and she had a roll control bolster on the bed, monitor every 2 hours with incontinent checks and turning and as needed contact. Review of the medical record revealed no documented evidence of an assessment prior to the use of roll control bolsters, no consent from the resident or the Responsible Party and there was no physician's order for the use of the roll control bolsters. An interview on 01/28/2025 at 12:00 p.m. with S1Administrator confirmed the facility failed to obtain a consent and a physician's order prior to the use of the bolsters, and they failed to assess resident #20 prior to the use of bolsters. Resident 24 Review of the medical record for resident #24 revealed an admitted [DATE]. Resident #24 had diagnoses including bradycardia, lack of coordination, cognitive communication deficit, pain, Parkinson's disease, and macular degeneration. Review of the Quarterly MDS assessment dated [DATE] revealed the facility was unable to determine resident #24's Brief Interview for Mental Status (BIMS) score due to cognitive impairment. Resident #24 required extensive assistance with bed mobility and was totally dependent on staff with transfers. Observations of resident #24 on 01/27/2025 at 9:15 a.m., and 01/28/2025 at 9:00 a.m. revealed the resident was observed lying in the bed with bilateral bolsters attached to the bottom half of the bed. Review of the current care plan revealed resident #24 had the potential for falls and an intervention was noted for a roll control bolster, monitor every 2 hours with incontinent checks and turning and as needed. Review of the medical record revealed no documented evidence of an assessment prior to the use of roll control bolsters, no consent from the resident or the Responsible Party and there was no physician's order for the use of the roll control bolsters. An interview on 01/28/2025 at 12:00 p.m. with S1Administrator confirmed the facility failed to obtain a consent and a physician's order prior to the use of the bolsters, and they failed to assess resident #20 prior to the use of bolsters. 43405 Resident #11 Review of resident #11's record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, wedge compression fracture of thoracic 11 and 12 vertebra, paroxysmal atrial fibrillation, glaucoma, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, unspecified protein calorie malnutrition, displaced fracture of base of neck of left femur, presence of left artificial hip joint, and osteoarthritis. Review of resident #11's January 2025 Physician's Orders revealed an order dated 07/21/2024 for quarter side rails on each side of bed up at all times as enabler in turning/repositioning. Review of the Significant Change/5 day MDS assessment dated [DATE] revealed a BIMS score of 99 indicating unable to determine. Further review of the MDS revealed resident had severely impaired cognitive skills for daily decision making and dependent on staff for activities of daily living. Review of resident #11's current care plan revealed a need for bed rails related to a history of falls. Observations of resident #11 on 01/27/2025 at 9:05 a.m., 01/27/2025 at 3:24 p.m., and 01/28/2025 at 8:10 a.m. revealed resident was lying in bed with bilateral bolsters attached to the bottom half of the bed. Review of the medical record revealed no documented evidence of an asessment prior to the use of roll control bolsters, no consent from the resident or the responsible party, and no physician's order for the use of bed bolsters for resident #11. An interview on 01/28/2025 at 3:55 p.m. with S1Administrator confirmed the facility failed to obtain a consent and a physician's order prior to the use of the bolsters, and they failed to assess resident #11 prior to the use of bolsters. Resident #29 Review of resident #29's record revealed an admitted [DATE] with diagnoses including pressure ulcer of sacral region stage 3, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Alzheimer's disease, atrial fibrillation, other seizures, type 2 diabetes mellitus, and gastrostomy status, Review of resident #29's Quarterly MDS assessment dated [DATE] revealed unable to determine a BIMS score due to cognitive impairment. Further review of the MDS revealed resident dependent on staff for activities of daily living. Observations of resident #29 on 01/27/2025 at 8:50 a.m. and 01/28/2025 at 8:20 a.m. revealed resident was lying in bed with bilateral bed bolsters in place Review of the medical record revealed no documented evidence of an assessment prior to the use of roll control bolsters, no consent from the resident or the responsible party, and there was no orders for the use of the roll control bolsters. An interview on 01/28/2025 at 3:55 p.m. with S1Administrator confirmed the facility failed to obtain a consent and a physician's order prior to the use of the bolsters, and they failed to assess resident #29 prior to the use of bolsters.

Based on record review and interview, the facility failed to ensure a resident was free of accident hazards as is possible by failing to ensure appropriate interventions were attempted after each fall for 1 (#11) of 1 residents sampled for falls. Findings: Review of resident #11's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, wedge compression fracture of Thoracic 11 and 12 vertebra, paroxysmal atrial fibrillation, glaucoma, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, unspecified protein calorie malnutrition, displaced fracture of base of neck of left femur, presence of left artificial hip joint, and osteoarthritis. Review of resident #11's January 2025 Physician's Orders revealed an order dated 07/21/2024 for quarter side rails on each side of bed up at all times as enabler in turning/repositioning. Review of resident #11's Significant Change/5 day Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 99 indicating unable to determine. Further review of the MDS revealed resident had severely impaired cognitive skills for daily decision making and dependent on staff for activities of daily living. Review of resident #11's Incident/Accident report dated 10/12/2024 revealed resident was ambulating in the front lobby with her walker and fell . Resident reported her feet got tangled in her walker and she fell and hit her head on the floor. Review of resident #11's Incident/Accident report dated 11/12/2024 revealed resident #11 found lying on the floor in her room on right side and had a hematoma to the back of head. Review of resident #11's Incident/Accident report dated 12/15/2024 revealed resident #11 was found on the floor in her room. Resident reported she was going to the bathroom and slipped in her own urine, no complaints of pain at this time. Review of the current care plan for resident #11 revealed she had a potential for falls related to history of fall, right hip replacement, osteoarthritis, dementia with history of behavior disturbance, and depression. Further review of resident's fall care plan revealed the following interventions were implemented for the falls listed as follows: 10/12/2024 intervention- encourage/remind resident when standing to get her balance before moving her feet or her walker; 11/12/2024 intervention- remind to wear well fitted shoes; and 12/15/2024 intervention- therapy to evaluate Review of the Fall Risk Evaluations dated 11/08/2024 and 12/27/2024 revealed resident #11 at risk for falls. An interview on 01/28/2025 at 3:30 p.m. with S2Director of Nursing (DON) confirmed the interventions the facility documented for these falls were not appropriate to help prevent falls for resident #11.

Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to installation for 3 (#11, #15, and #20) of 4 (#11, #15, #20, and #29)residents reviewed for accident hazards. Findings: Review of the facility's Bed Rails and Non-Restraint Measures Policy and Procedures revised date 10/11/2024 revealed: Intent: Prior to the installation of bed rails, ____ _____ Nursing Home will attempt to use alternatives. When alternatives are not adequate to meet the resident's needs, the resident will be assessed for the use of bed rails: which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative. Resident #15 Review of resident #15's record revealed an admitted [DATE] with diagnoses including chronic systolic (congestive) heart failure, hypoxemia, moderate protein-calorie malnutrition, major depressive disorder, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, mood disturbance, and anxiety. Review of the January 2025 physician's orders for resident #15 revealed an order dated 07/01/2024 for quarter side rails on each side of bed up at all times as enabler for turning/repositioning. Review of resident #15's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive skills for daily decision making and required total assistance with activities of daily living. Observations of resident #15 on 01/27/2025 at 3:05 p.m. and 01/28/2025 at 3:45 p.m. revealed resident lying in bed with quarter bilateral bed rails in place. Review of the current care plan revealed resident #15 needed bed rails related to muscle weakness as an enabler for turning/repositioning within the bed. Review of the medical record revealed no documentation of the facility assessing the risk for entrapment prior to the installation of bed rails for resident #15. An interview on 01/28/2025 at 3:55 p.m. with S1Administrator confirmed the facility failed to assess the risk for entrapment prior to installation of bed rails on resident #15. Resident #11 Review of resident #11's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, wedge compression fracture of Thoracic 11 and 12 vertebra, paroxysmal atrial fibrillation, glaucoma, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, unspecified protein calorie malnutrition, displaced fracture of base of neck of left femur, presence of left artificial hip joint, and osteoarthritis. Review of resident #11's January 2025 physician's orders revealed an order dated 07/21/2024 for quarter side rails on each side of bed up at all times as enabler in turning/repositioning. Review of the Significant Change/5 day MDS assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 99 indicating unable to determine. Further review of the MDS revealed resident had severely impaired cognitive skills for daily decision making and dependent on staff for activities of daily living. Review of resident #11's current care plan revealed a need for bed rails related to a history of falls. Observations of resident #11 on 01/27/2025 at 9:05 a.m., 01/27/2025 at 3:24 p.m., and 01/28/2025 at 8:10 a.m. revealed resident was lying in bed with quarter bilateral bed rails in the up position. Review of the medical record revealed no documentation of an assessment for the risk of entrapment prior to the installation of bed rails for resident #11. An interview on 01/28/2025 at 3:55 p.m. with S1Administrator confirmed the facility failed to assess the risk for entrapment prior to the installation of bed rails on resident #11. 18118 Resident #20 Review of the medical record for resident #20 revealed an admitted [DATE]. Resident #20 had diagnoses including diabetes mellitus, osteomyelitis, open angle glaucoma, gastrostomy, aphasia, metabolic encephalopathy, peripheral vascular disease, pain, embolism, and heart failure. Review of the January 2025 physician's orders for resident #20 revealed an order dated 07/01/2024 for quarter rails on each side of bed up at all times as enabler in turning and repositioning. Review of resident #20's quarterly minimum data [NAME] (MDS) dated [DATE] revealed the resident had severe cognitive skills for daily decision making and was totally dependent on staff and required two person assistance with bed mobility and transfers. On 01/27/2025 at 8:35 a.m., 01/27/2025 at 3:20 p.m., and on 01/28/2025 at 10:10 a.m., resident #20 was observed lying in the bed with bilateral quarter rails raised at the top of the bed. Review of the medical record revealed no documented evidence of the facility assessing the risk for entrapment prior to the installation of bed rails. An interview on 01/28/2025 at 12:00 p.m. with S1Administrator confirmed the facility failed to assess the risk for entrapment prior to the installation of bed rails for resident #20.

Based on record reviews and interviews, the facility failed to ensure the nursing staff had appropriate competencies and skills sets to provide nursing care and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (#14, #33 ) of 5 (#11, #14, #17, #26, #33) residents investigated for unnecessary medications. The facility failed practice was evidenced by nurses' failing to 1). document injections sites for Insulin and 2). follow parameters for Insulin Sliding Scale. Findings: Review of resident #14's medical record revealed he was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. Review of resident #14's physician order dated 04/22/2022 revealed the following: Monitor and record blood sugar before meals and at bedtime. Notify physician if blood sugar (BS) is <60 or >400. Further review of resident #14's physician order dated 02/21/2023 revealed the following: Humalog 100 Units/Milliliters (ML) Kwikpen administer following Sliding Scale (SS): 0-90 = 0 Units 91-150 = 6 Units 151-200 = 10 Units 201-250 = 12 Units 251-300 = 15 Units >300 = 18 Units Review of resident #14's November 2023 and December 2023 Medication Administration Records (MARs) revealed the nurses failed to document any injection sites (before meals and at HS) for the Humalog Insulin SS that was administered to resident #14 for the months of November and December 2023. Review of resident #14's November 2023 and December 2023 MARs revealed the following: 1). for November 2023, S3Licensed Practical Nurse (LPN) failed to notify resident #14's physician 8 times when his blood sugar was >400; and 2). for December 2023, S3LPN failed to notify resident #14's physician 5 times when his blood sugar was >400. On 12/13/2023 at 2:40 p.m., an interview with S3LPN confirmed she failed to document any of the injection sites for the Humalog Insulin SS that was administered to resident #14 for November and December 2023. S3LPN also confirmed she failed to notify resident #14's physician each time his blood sugar was greater than 400 for November 2023 and December 2023. On 12/13/2023 at 3:30 p.m., S2Director of Nursing (DON) confirmed that the nurses failed to document resident # 14's injection sites for Humalog SS for November 2023 and December 2023. S2DON also confirmed S3LPN failed to follow parameters for Humalog Insulin SS for November and December 2023 as evidenced by no documentation that S3LPN notified resident #14's physician each time his blood sugar was >400. 32231 Resident #33 Review of the medical record revealed resident #33 was admitted to the facility on [DATE] with diagnoses including in part, Type 2 diabetes with foot ulcer, cerebral vascular disease, left side,peripheral vascular disease, hemiplegia following cerebral infarction. Review of the December 2023 physician's orders revealed in part, the following orders dated 09/29/2023 for accu checks with meals and at bedtime and Humalog 100 unit/milliliter vial per sliding scale. Further review of the Humalog order revealed sliding scale insulin as 151-200 mg/dl (Milligrams per deciliter) =3 units, 201-250 mg/dl=6 units, 251-300 mg/dl=8 units, 301-350=12 units, 351-400 mg/dl=16 units, and greater than 400=20 units. Review of the November 2023 MAR (Medication Administration Record) revealed resident #33 had blood glucose levels of 441 mg/dl on the date of 11/10/2023 at 6:00 a.m., 581 mg/dl on the date of 11/17/2023 at 6:00 a.m. Review of the December 2023 physician's orders revealed there was no documented evidence of parameters to indicate at what level of the blood glucose results the nurse was to report to the physician. Review of the November 2023 MAR revealed resident #33 received Humalog insulin per sliding scale 56 times and 30 times as documented on the December 2023 MAR. Review of the November 2023 and December 2023 MARs and nurse's notes revealed resident #33 had received the Humalog insulin injections, but there was no documented evidence of the insulin injection sites. Further review revealed there was no documented parameters in the physician's orders to indicate when the blood glucose level should be reported to the physician. On 12/13/2023 at 2:20 p.m., S3LPN (Licensed Practical Nurse) was notified of the findings regarding there being no documented evidence on November 2023 and December 2023 MARs of the Humalog insulin sites for resident #33. After completing a review of the MARs, S3LPN confirmed the insulin sites had not been documented on the MARs, after administration. After completing a review of the November 2023 and December 2023 MARs and nurse's notes on 12/13/2023 at 2:30 p.m. with S2DON (Director of Nursing), she confirmed the sites of the insulin injections for resident #33 had not been attached to the medication orders within the special requirements section of the electronic health records and not available for nursing staff documentation. S2DON further confirmed there was no documented evidence in the physician's orders and the facility's standing orders to indicate when the blood glucose level should be reported to the physician.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored and labeled properly in accordance with currently accepted professional principles. The facility failed to have multiple use medications and biologicals labeled with the date of opening and stored per professional standards. Findings: On 12/11/2023 at 8:30 a.m., an observation of the Medication Cart A revealed there was one Novolog FlexPen and one Levemir FlexPen. Further observation revealed the FlexPens had been opened and were not labeled with an open date. S5LPN (Licensed Practical Nurse) was present during the observations. S5LPN confirmed the Novolog and Levemir FlexPens (Pre-Filled Insulin Pens) were currently being used for resident #3. She further confirmed they had not been labeled with an opened date. On 12/11/2023 at 12/11/2023 at 8:45 a.m., an observation of the Medication Cart B revealed there were four individual Humalog KwinPens (Pre-Filled Insulin Syringes). Further observation revealed they had been opened and were not labeled with an opened date. S4LPN was present during the observations and confirmed the Humalog KwinPens were currently being used for residents #5, #9, #14, and #33. She further confirmed the prefilled insulin syringes had not been labeled with an opened date. On 12/11/2023 at 9:15 a.m., an observation of the medication room revealed there were 3 vials of Lidocaine 1% and one vial of Lidocaine 2% that was stored inside of a drawer. Further observation revealed the vials had been opened and were not labeled with an opened date. S5LPN was present during the observations. She reported the vials of Lidocaine had previously been used for residents #3, #18, and #24. S5LPN further reported the residents no longer required the medication Further interview with S5LPN revealed that one of the vials of Lidocaine 1% belonged to a resident who was no longer residing in the facility. S5LPN confirmed the vials of Lidocaine should not have been stored in the medication storage room and be available for further resident use. On 12/13/2023 at approximately 2:45 p.m., S2DON was notified of the findings during the observations of Medication Cart A, Medication Cart B, and the medication storage room. S2DON confirmed the resident medications should have been labeled with an opened date and the vial of Lidocaine 1% should have been discarded when the resident was discharged and not be available for further resident use. On 12/13/2023 at 4:15 p.m., S1Administrator was notified of the findings during the observations of Medication Cart A, Medication Cart B, and the medication storage room.

Based on record review and interview, the provider failed to ensure each resident's medication regimen was free from unnecessary medications for 1 (#17) of 5 (#11, 14, 17, 26 and 33) residents reviewed for unnecessary medications. The facility failed to have documented evidence of parameters or justification for resident #17's as needed medications administered. Findings: Review of the medical record for sampled resident #17 revealed an admitted [DATE] with diagnoses including insomnia, hypertension, hyperlipidemia, pain, hypothyroidism, hypokalemia, and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment for daily decision making and required assistance with activities of daily living. Review of the current care plan revealed resident #17 was at risk for cardiovascular complications related to diagnoses of hypertension and cardiomyopathy. Further review of the care plan revealed the interventions were to obtain and evaluate blood pressure two times a day, notify the physician of changes, monitor the effectiveness of the medications, and to monitor for a headache and dizziness. Review of the physician's orders dated 11/02/2023 revealed an order for Bumetanide 1 milligram (mg) two times a day as needed, and Coreg 12.5 mg every day as needed. Review of the Medication Administration Record (MAR) for December 2023 revealed the resident received Bumetanide 1 mg on 12/07/2023 at 11:37 p.m., 12/08/2023 at 2:16 p.m., and on 12/11/2023 at 3:15 p.m. Further review of the MAR revealed the resident received Coreg 12.5 mg on 12/07/2023 at 11:37 p.m. Review of the record revealed no documented evidence of parameters or justification for the as needed medications administerd to resident #17. On 12/13/2023 at 11:50 a.m. an interview with S6Registered Nurse revealed there was no documentation in the nurses notes or the MAR for the reason or parameters for the as needed medications administered to resident #17. On 12/13/2023 at 1:30 p.m. S2Director of Nursing (DON) was notified that the nurses did not document the justification for the medications administered to resident #17. On 12/13/2023 at 2:30 p.m. an interview with S2DON revealed the facility did not have parameters for when to administer the as needed medications to resident #17. On 12/13/2023 at 3:00 p.m. S1Administrator was notified that resident #17 received as needed medications and there was no justification for the reason the medications were given.

Based on observations, recorded reviews, and interviews, the facility failed to provide necessary care and services that is in accordance with professional standards of practice for 2 (#4 and #9) of 2 residents reviewed for respiratory care. The facility failed to 1) properly change the nasal cannula (#4 and #9) and the nebulizer facemask (#9) and label them with the date it was changed and 2) store the nasal cannula and the nebulizer face mask in plastic bag when not in use per their policy. Findings: Review of the facility policy and procedure for Oxygen/Tubing/Humidifier Tubing Change revealed: All oxygen and nebulizer tubing/equipment will be changed every 14 days - on the 1st and 15th of each month by the infection control nurse. Nurse will date tubing at this time. PRN (when necessary) oxygen/nebulizers are to be changed monthly. Oxygen and nebulizers are to be stored in bag when not in use. Resident #4 On 10/31/2022 at 6:46 a.m. resident #4 stated he uses his oxygen every now and then, only when he needs it. Resident #4 further stated that he last wore oxygen on Saturday night, 10/29/2022, and Sunday night, 10/30/2022. Observation at this time of the oxygen tubing revealed it was lying on the floor with the nasal cannula directly touching the floor. Further observation of the oxygen tubing revealed it was not dated. On 10/31/2022 at 12:43 p.m. review of the physician orders dated 10/21/2022 revealed oxygen via nasal cannula at 2 lpm (liters per minute) every evening. On 11/01/2022 at 8:17 a.m., observation revealed the oxygen tubing continued with no date or label, and not stored in a protective bag. On 11/01/2022 at 12:55 p.m., interview with S5LPN (Licensed Practical Nurse) confirmed the oxygen tubing was not dated, labeled or stored per the facility's policy. On 11/01/2022 at 1:18 p.m., interview with S6LPN revealed she was in charge of changing oxygen tubing monthly. S6LPN confirmed the current oxygen tubing was not stored properly, not in a bag and not labeled. Resident #9 Observation on 10/31/2022 at 10:00 a.m. revealed resident #9's oxygen tubing and facemask nebulizer were not dated and were not in the protective bag. The protective bag was dated 07/31/2022. Observation on 11/01/2022 at 9:15 a.m. revealed the oxygen tubing and facemask nebulizer continued with no date or label and not stored in a protective bag. Review of the physician orders for October 2022 revealed the following orders: 02/11/2020 - change oxygen and nebulizer tubing on the 1st and 15th of each month, 07/07/2019 - oxygen therapy at 2 lpm (liters per minute) per mask if oxygen saturation is below 92% as needed for dyspnea related to anxiety and other health related diagnoses, and 05/13/2019 - [MEDICATION(S)] - [MEDICATION(S)] 0.5 - 3 (2.5) milligrams/3 milliliters administer 1 vial per inhalation every 6 hours as needed. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 11/01/2022 at 12:40 p.m. with S4LPN (Licensed Practical Nurse) confirmed the oxygen tubing and nebulizer were not dated and not in a protective bag. S4LPN confirmed the bag was dated 07/31/2022. During an interview with S2DON (Director of Nursing) on 11/01/2022 at 1:15 p.m., S2DON was notified that the oxygen tubing and nebulizer were not dated and not in a protective bag. During an interview with S1Administrator on 11/02/2022 at 1:00 p.m., S1Administrator was notified that the oxygen tubing and nebulizer were not dated and not in a protective bag.

Based on record reviews and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary medication by failing to ensure a resident was adequately monitored for signs and symptoms of bleeding while receiving an anticoagulant medication for 1 (#5) of 5 (#1, #4, #5, #19, #21) sampled residents reviewed for unnecessary medications. Findings: Record review revealed Resident #5 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] is an anticoagulant medication. Review of the August, September, October, and November 2022 EMAR (Electronic Medication Administration Record) revealed Resident #5 received [MEDICATION(S)] 2.5 mg po twice a day as ordered. There was no documentation of monitoring for signs and symptoms of bleeding noted. Further record review revealed there was no documentation for the daily monitoring for signs and symptoms of bleeding. On 11/02/2022 at 10:00 a.m. an interview conducted with S2DON (Director of Nursing) was notified of the findings regarding no documentation of the daily monitoring of Resident #5 for signs and symptoms of bleeding. S2DON confirmed there was no documentation of the daily monitoring for signs and symptoms of bleeding. S2DON further confirmed Resident #5 should be monitored for signs and symptoms of bleeding daily while receiving an anticoagulant medication.

Based on record reviews and interview, the pharmacist failed to identify and report irregularities to the physician and DON (Director of Nursing) for 1 (#5) of 5 (#1, #4, #5, #19, #21) residents reviewed for unnecessary medications. The pharmacist failed to address that the resident was not adequately monitored while receiving an anticoagulant. Findings: Record review revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses include but not limited to the following: essential hypertension, [CONDITION(S)] unspecified, unspecified dementia without behavioral disturbance, memory deficit following subarachnoid hemorrhage, pure [CONDITION(S)] and [CONDITION(S)]/flutter. Review of the November 2022 physician orders revealed an active order [MEDICATION(S)] 2.5 mg (milligram) tablet give one tablet po (by mouth) twice a day that was originally ordered on 08/08/2022. [MEDICATION(S)] is an anticoagulant medication. Review of the August, September, October, and November 2022 EMAR (Electronic Medication Administration Record) revealed Resident #5 received [MEDICATION(S)] 2.5 mg po twice a day as ordered. There was no documentation of monitoring for signs and symptoms of bleeding noted. Further record review revealed there was no documentation for the daily monitoring for signs and symptoms of bleeding. Review of Resident #5's monthly medication regimen review for August, September, and October 2022 completed by the consultant pharmacist revealed there was no recommendation for the monitoring of bleeding related to receiving the anticoagulant medication ([MEDICATION(S)]). On 11/02/2022 at 10:00 a.m. an interview conducted with S2DON(Director of Nursing) was notified of the findings regarding no documentation for the daily monitoring of Resident #5 for signs and symptoms of bleeding. S2DON confirmed there was no documentation of the daily monitoring for signs and symptoms of bleeding. S2DON further confirmed Resident #5 should be monitored for signs and symptoms of bleeding daily while receiving an anticoagulant medication. On 11/02/2022 at 10:05 a.m. an interview conducted with S2DON confirmed that the consultant pharmacist failed to identify that Resident #5 was receiving an anticoagulant medication without being monitored daily bleeding.

Based on record review and interview, the facility failed to ensure that a resident had the right to be free from physical abuse by a staff member for 1 (#1) of 5 (#1, 2, 3, 4, 5) sampled residents. Findings: Review of the facility's current Resident Abuse and Neglect Policy revealed residents in the facility are to be treated with dignity and respect at all times. Mistreatment in the form of verbal, physical, sexual, or emotional abuse of any nature will not be tolerated. Review of resident #1's medical record revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #1's Minimum Data Set, dated dated dated [DATE] revealed he had a BIMS (Brief Interview for Mental Status) of 10, indicating he was moderately cognitively impaired. Further review revealed he required supervision/set-up help for most activities of daily living, but required moderate assistance for dressing, bathing, and toileting. Review of resident #1's most recent care plan revealed the facility had identified he had mental health concerns and had a long history of behaviors (cursing, disruptive, socially inappropriate, and resisting care). Review of resident #1's nurse's note dated 03/15/2022 at 11:28AM revealed at 8:05AM S1RN/MDS Coordinator (Registered Nurse/Minimum Data Set Coordinator) informed S2SSD (Social Services Director) that S3DON (Director of Nurses) hit resident #1 in the mouth. S1RN/MDS Coordinator reported that S3DON came and told her I'm gonna let you know before he does that I slapped resident #1 in the mouth. At 8:10AM, S2SSD went to resident #1's room and he informed her S3DON hit him in the mouth. At 8:17AM, S2SSD went to S4Administrator's office where S3DON, S5Office Manager, and S1RN/MDS Coordinator were present. S2SSD asked S3DON what happened with resident #1 today? S3DON replied I popped him in the mouth. S2SSD informed S3DON that you know you cannot do that. S3DON replied, Nobody is gonna call me a F_ _ _ B _ _ _! (nurse's note was signed by S2SSD). Further review of resident #1's nurse's note revealed on 03/17/2022 at 8:09AM, S2SSD phoned the local sheriff's office and spoke with an investigator. S2SSD reported to him the incident that happened on 03/15/2022 between S3DON & resident #1. The investigator informed S2SSD that he would complete a report. (nurse's note was signed by S2SSD). On 03/31/2022 at 9:45AM, an interview with S2SSD revealed her above documentation in the nurses' notes was accurate regarding the incident that occurred on 03/15/2022 involving S3DON and resident #1. She confirmed that S3DON did physically abuse resident #1 on 03/15/2022 by hitting him in the mouth. On 03/29/2022 at 10:56AM, an interview with Resident #1 revealed he had a speech impairment and it was difficult to understand him and his words were unintelligible at times. When the surveyor questioned him about the incident that recently occurred with the S3DON, he reported she hit him in the mouth because he cussed at her. Resident #1 also revealed S3DON was trying to get him to go to his room and make him be quiet. He confirmed she pushed him in the back at that time. When asked how he felt about her hitting him he said it upset me. Resident #1 reported he was okay now because she was gone. The surveyor attempted to call S6 House Keeper several times but she was unavailable for interview. Review of S6House Keeper's signed witness statement dated 03/15/2022 revealed that she witnessed S3DON get very upset on 03/15/2022 and she was pushing resident #1 while trying to make him go to his room. S3DON was getting very aggressive and pushed him hard three times and he almost fell . He seemed to say quit B_ _ _ I'm going to fall. When resident #1 cursed her, S3DON hit him in his back. S6House Keeper went straight to the office and reported what she saw. Review of S7Activity Director's signed witness statement dated 03/15/2022 revealed she was in the hall talking with another staff member. She witnessed S3DON coming out of office and demanding resident #1 to get up and go to his room because the resident was cursing loudly. S3DON was forcing resident #1 to walk faster to his room by poking him in his back. On 03/31/22 at 12:35PM, an interview with S7AD revealed she was working the day of the above incident with S3DON and resident #1. On the morning of 03/15/22 the resident was in the lobby and was cursing loudly. S7AD was near the lobby writing on the dry erase board and S3DON was in S5Office Manager's office. S3DON came out of the office demanding that resident #1 get up and go to his room. Resident #1 refused at first and continued to curse but he did eventually stand up. S3DON made him walk faster by poking him in the back. S7AD reported resident #1 walks slow and shuffles his feet. Resident #1 continued to curse and S3DON kept saying get to your room resident #1, get to your room. S7AD confirmed her above witness statement was accurate. S7AD revealed she did not see S3DON hit resident #1. When the surveyor asked her what the staff normally do when resident #1's curses or has other behaviors, she reported they calmly redirect him to his room and he usually goes. Staff will turn on his music in his room because it calms him down. S7AD confirmed she has used this many times with resident #1 with success. On 03/31/2022 at 1:25PM, an interview with S8LPN revealed she has worked at the facility for 6 years. S8LPN routinely takes care of resident #1 and she was working the 7AM - 3PM shift the day that the above incident occurred. S8LPN heard the resident cursing in his room that morning around 8:00AM but she did not go in his room because S3DON was in there. S8LPN confirmed she did not witness the incident. S8LPN revealed after the incident she was sitting at the nurses' station and S3DON passed by the nurses' station and told them she just hit resident #1 in the mouth. S8LPN confirmed resident #1 has a long history of cursing and other behaviors. S8LPN revealed she usually just asks him to go to his room when he is cursing or being disruptive. She revealed that she doesn't have a problem redirecting him. 03/31/2022 at 1:45PM, an interview with S9CNA revealed she has worked at facility for 3 years and works with resident #1. S9CNA confirmed she was taking care of resident #1 on the day of incident. She was in the dining room during the incident so she did not witness the incident. S9CNA revealed resident #1 curses every day, that's just him and she's used to it. S9CNA revealed she ignores him and does what she needs to do. S9CNA reports that when he's upset, she talks to him and plays music to calm him down. Review of S1RN/MDS Coordinator's signed witness statement dated 03/15/2022 revealed she was at the nurses' station when S3DON walked by and stated that before he tells you, I just hit resident #1 across the mouth. S3DON had taken resident #1 to his room because he was cursing loudly in the lobby. S3DON said nobody is going to call me a f_ _ _ b_ _ _. S1RN/MDS Coordinator informed S2SSD of the situation so they could decide the best course of action. On 03/31/2022 at 10:00AM, an interview with S1RN/MDS Coordinator revealed her above documentation in the witness statement was accurate. She also confirmed S3DON did physically abuse resident #1 on 03/15/2022 by hitting him in the mouth.

Based on record review and interviews, the facility failed to report allegations of staff to resident physical abuse to the State Survey Agency no later than 2 hours after the allegation was made for 1 (#1) of 1 (#1) sampled residents reviewed for abuse incidents in a total of 5 (#1, 2, 3, 4, 5) sampled residents. Findings: Review of the facility's current Resident Abuse and Neglect Policy revealed any cases of suspected abuse or neglect shall be reported to the Director of Nurses and to the Nursing Facility Administrator. A complete investigation shall be conducted and the abuse/neglect will be reported to the State Office within 24 hours of occurrence or discovery of the incident. Review of resident #1's medical record revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #1's Minimum Data Set, dated dated dated [DATE] revealed he had a BIMS (Brief Interview for Mental Status) of 10, indicating he was moderately cognitively impaired. Further review revealed he required supervision/set-up help for most activities of daily living, but required moderate assistance for dressing, bathing, and toileting. Review of resident #1's most recent care plan revealed the facility had identified he had mental health concerns and a long term history of behaviors (cursing, disruptive, socially inappropriate, and resisting care). Review of resident #1's nurse's note dated 03/15/2022 at 11:28AM revealed at 8:05AM S1RN/MDS Coordinator (Registered Nurse/Minimum Data Set Coordinator) informed S2SSD (Social Services Director) that S3DON (Director of Nurses) hit resident #1 in the mouth. S1RN/MDS Coordinator reported that S3DON came and told her I'm gonna let you know before he does that I slapped resident #1 in the mouth. At 8:10AM, S2SSD went to resident #1's room and he informed her S3DON hit him in the mouth. At 8:17AM, S2SSD went to S4Administrator's office where S3DON, S5Office Manager, and S1RN/MDS Coordinator were present. S2SSD asked S3DON what happened with resident #1 today? S3DON replied I popped him in the mouth. S2SSD informed S3DON that you know you cannot do that. S3DON replied, Nobody is gonna call me a F_ _ _ B _ _ _! (nurse's note was signed by S2SSD). Further review of resident #1's nurse's note revealed on 03/17/2022 at 8:09AM, S2SSD phoned the local sheriff's office and spoke with an investigator. S2SSD reported to him the incident that happened on 03/15/2022 between S3DON & resident #1. The investigator informed S2SSD that he would complete a report. (nurse's note was signed by S2SSD). On 03/31/2022 at 9:45AM, an interview with S2SSD revealed her above documentation in the nurses' notes was accurate regarding the incident that occurred on 03/15/2022 involving S3DON and resident #1. She confirmed the allegation of abuse was substantiated for resident #1. S2SSD also confirmed that the facility failed to enter the allegation of abuse for resident #1 in the Statewide Incident Management System (SIMS) within the required 2 hour time frame. On 03/29/2022 at 10:56AM, an interview with Resident #1 revealed he had a speech impairment and it was difficult to understand him and his words were unintelligible at times. When the surveyor questioned him about the incident that recently occurred with the S3DON, he reported she hit him in the mouth because he cussed at her. Resident #1 also revealed S3DON was trying to get him to go to his room and make him be quiet. He confirmed she pushed him in the back at that time. When asked how he felt about her hitting him he said it upset me. Resident #1 reported he was okay now because she was gone. Review of S7Activity Director's signed witness statement dated 03/15/2022 revealed she was in the hall talking with another staff member. She witnessed S3DON coming out of office and demanding resident #1 to get up and go to his room because the resident was cursing loudly. S3DON was forcing resident #1 to walk faster to his room by poking him in his back. On 03/31/22 at 12:35PM, an interview with S7AD revealed she was working the day of the above incident with S3DON and resident #1. On the morning of 03/15/22 the resident was in the lobby and was cursing loudly. S7AD was near the lobby writing on the dry erase board and S3DON was in S5Office Manager's office. S3DON came out of the office demanding that resident #1 get up and go to his room. Resident #1 refused at first and continued to curse but he did eventually stand up. S3DON made him walk faster by poking him in the back. S7AD reported resident #1 walks slow and shuffles his feet. Resident #1 continued to curse and S3DON kept saying get to your room resident #1, get to your room. S7AD confirmed her above witness statement was accurate. S7AD revealed she did not see S3DON hit resident #1. When the surveyor asked her what the staff normally do when resident #1's curses or has other behaviors, she reported they calmly redirect him to his room and he usually goes. Staff will turn on his music in his room because it calms him down. S7AD confirmed she has used this many times with resident #1 with success. Review of S1RN/MDS Coordinator's signed witness statement dated 03/15/2022 revealed she was at the nurses' station when S3DON walked by and stated that before he tells you, I just hit resident #1 across the mouth. S3DON had taken resident #1 to his room because he was cursing loudly in the lobby. S3DON said nobody is going to call me a f_ _ _ b_ _ _. S1RN/MDS Coordinator informed S2SSD of the situation so they could decide the best course of action. On 03/31/2022 at 10:00AM, an interview with S1RN/MDS Coordinator revealed her above documentation in the witness statement was accurate. She confirmed the allegation of abuse was substantiated for resident #1. S1RN/MDS Coordinator also confirmed that the facility failed to enter the abuse allegation for resident #1 in the Statewide Incident Management System (SIMS) within the required time frame of 2 hours.

Based on record review and interview, the facility failed to ensure a resident receiving a [CONDITION(S)] medication was monitored for behaviors and side effects for 1 (#88) of 5 (#1, #9, #15, #29, #88) residents reviewed for unnecessary medications. Findings: Review of the medical record for resident #88 revealed the resident was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, [CONDITION(S)], [CONDITION(S)], hypertension, overactive bladder, reflux, constipation, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and joint pain. Review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. The resident required one person extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the physician orders for December 2021 revealed an order for [MEDICATION(S)] 50 milligrams every hs (at bedtime). Review of the record from admit to current revealed there was no documented evidence of the facility monitoring for behaviors or side effects of the [CONDITION(S)] medication for resident #88. An interview with S3Licensed Practical Nurse on 12/09/2021 at 9:45AM revealed they were not monitoring her behaviors or side effects. S3LPN reported they should be monitoring her behaviors and side effects since she is on a [CONDITION(S)] medication. S3LPN revealed when the resident was admitted , the nurse should have entered orders for behavior monitoring and side effects since the resident was receiving a [CONDITION(S)] medication. An interview with S2Director of Nursing on 12/09/2021 at 10:00AM revealed the nurses should be monitoring behaviors and side effects on resident #88. S2DON reported when a resident is receiving [CONDITION(S)] medications, the nurse should automatically order to monitor for specific behaviors and side effects.

I. Based on observation, record review and interview, the facility failed to ensure that the residents environment remains as free of accident hazards as is possible by 1) not having a system to monitor water temperatures, 2) having water temperatures exceeding 120 degrees, 3) not being aware of the water heater settings, 4) not assessing residents potentially at risk for accessibility to water exceeding 120 degrees, and 5) not assessing three wandering residents (#8, 28, and 34) for the capability of turning water on and regulating the water temperature. There were a total of 49 residents in the facility according to the resident census and condition form. This failed practice led to an Immediate Jeopardy Situation for the facility on 01/09/12 at 12:00PM, when sampled resident #16's water in her bathroom was checked and the thermometer revealed it was 128 degrees; and one of the three wandering residents (#8) had the ability to turn the water on but not regulate the temperature of the water. The Immediate Jeopardy Situation continued until the facility put a system in place to ensure that hot water temperatures were monitored for safety for all residents. The facility's Administrator #S1, was informed of the Immediate Jeopardy at this time. The " Time and Temperature Relationship to Severe Burns " table on the American Burn Association website shows that at 127 degrees Fahrenheit a third degree burn can occur at 1 minute; at 133 degrees Fahrenheit a third degree burn can occur at 15 seconds; and at 140 degrees Fahrenheit a third degree burn can occur at 5 seconds (www.ameriburn.org/Preven/ScaldInjuryEducatorsGuide.pdf). A third degree burn is defined as the destruction of the entire skin; deep third degree burns extend into subcutaneous fat, muscle, or bone and often cause much scarring according to Stedman ' s Medical Dictionary, 25th Edition Illustrated, 1990, Williams & Wilkins. The Immediate Jeopardy was removed on 01/09/12 at 4:18PM when surveyors determined that the Plan of Removal was implemented. S1 Adm was notified of the removal of the IJ at that time. The deficient practice continued at a scope and severity of second level pattern after the Plan of Removal had been implemented. The following was implemented as a Plan for Removal: 1) all residents were identified to be at risk, 2) hot water heaters were turned down to proper setting, the maintenance supervisor bled the system to remove hot water, maintenance supervisor rechecked temperatures in residents rooms, 3) log was established to monitor hot water temperatures in all resident rooms, 4) water temperatures will be checked daily for one week, and rooms will be randomly checked each week and as needed thereafter, 5) a policy regarding proper temperatures was being written, 6) the maintenance supervisor was trained verbally concerning proper water temperature settings, and 7) Administrator will monitor temperature logs randomly to ensure that logs and water temperatures are meeting regulations. Findings: On 01/09/12 at 12:00PM, observations of the following rooms revealed the following hot water temperatures: room a - 132 degrees room b - 132 degrees room c - 122 degrees room d - 122 degrees room e - 134 degrees room f - 134 degrees room g - 128 degrees room h - 138 degrees room i - 128 degrees room j - 138 degrees room k - 126 degrees room l - 126 degrees room m - 134 degrees On 01/09/12 at 12:15PM, resident in room m reported to the surveyor that her water was very hot. On 01/09/12 at 12:40PM during an interview, #S4 Maintenance Supervisor confirmed that he has been working at the facility for the past four years, and he has never kept a water temperature log. #S4 Maintenance Supervisor further reported if one of the CNAs complain that the water is too hot, then he will adjust the water heater. On 01/09/12 at 12:42PM, observation of hot water heater room #1 (off of hall 2) revealed there were 4 hot water heaters. Observation revealed hot water heaters #1 and #3 were both set at 130 degrees. Further observation revealed hot water heaters #2 and #4 were both set on B. At this time an Interview #S4 Maintenance Supervisor confirmed he was unsure of what the "B" setting of the hot water heater meant. Further observation of the hot water heater room revealed there was no owner's manual for this hot water heater that was set to "B". At this time, #S4 Maintenance Supervisor adjusted the hot water heaters #1 and #3's temperature down to 120 degrees. On 01/09/12 at 12:47PM, observation of hot water heater room #2 (off of hall 2) revealed there were 2 hot water heaters set at 130 degrees. At this time, #S4 Maintenance Supervisor adjusted the temperature of the hot water heaters down to 120 degrees. On 01/09/12 at 12:50PM, observation of hot water heater room #3 (off hall 1) revealed there were 2 hot water heaters set on "B" Further observation of the hot water heater room revealed there was no manual to indicate what "B" setting was for this type of hot water heater. On 01/09/12 at 2:00PM, #S4 Maintenance Supervisor informed the surveyor the he had called the company for the hot water heaters that were set on "B". He further reported that the following temperatures were associated with the following settings: "A" setting - 140 degrees "B" setting - 150 degrees "C" setting - 160 degrees Triangle setting - 120 degrees On 01/09/12 at 2:00PM, #S4 Maintenance Supervisor confirmed that all the hot water heaters that were set on "B" have now been set to the triangle setting. He further reported he had bled the system to remove all of the hot water. Hot water was rechecked in random resident rooms and was noted to be 115 degrees. An interview with #S2 DON on 01/09/12 at 1:00PM revealed the facility had three wandereing residents (#8, 28, and 34). She further stated that one of the three wandering residents (#8) was capable of turning the water on, but was unable to regulate the temperature of the water. On 01/09/12 at 1:30PM during an interview, #S1 Adm. confirmed the facility did not have a policy regarding monitoring of proper water temperatures. Further interview revealed #S4 Maintenance Supervisor was not trained on maintaining proper water temperatures in the facility. II. Based on observation and interview, the facility failed to ensure the residents' environment remains free of accident hazards as evidence by: 1) having a bottle of glass cleaner stored in a resident's bathroom 2) having two mop buckets full of water unattended during initial tour, 3) having a beauty shop left unlocked with environmental hazards, 4) having scissors stored in a resident's bathroom, 5) having a metal framed bed with the springs exposed, and 6) having an employee bathroom left unlocked that did not have a emergency call bell. Findings: On 01/09/12 at 11:40 AM observation of sampled resident #16's bathroom revealed a bottle of Windex cleaner in a wash basin on the floor. On 01/09/12 at 10:00AM during initial tour, observation revealed on hall 100 and hall 200 there were two mop buckets full of water that were left unattended in the hallway. On 01/09/12 at 2:00PM observation revealed the beauty shop on the 200 hall was unlocked. Further observation revealed a pair of scissors soaking in sanitizer, and a disposable razor and an electric razor were stored in a bin in a cabinet that was unlocked. On 01/12/12 at 3:00PM observation of room n during an environmental tour revealed a pair of scissors lying on the edge of the bathtub. On 01/09/12 at 2:00PM observation of room q revealed a metal frame bed with exposed springs. On 01/10/12 at 11:30AM observation of the employee's bathroom off of hall 200 revealed it was unlocked. Further observation revealed there was no emergency call bell. On 01/09/12 at 1:00PM during an interview, #S2 DON revealed there were three residents in the facility that wandered. On 01/13/12 at 11:00PM, #S1 Adm. was informed of the above environmental hazards.

Based on observation, record review and interview, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable wellbeing of each resident by failing to ensure that the residents environment remains as free of accident hazards. The facility: 1) did not have a system to monitor water temperatures, 2) had water temperatures exceeding 120 degrees, 3) was not aware of the water heater settings, 4) had not assessed the residents potentially at risk for accessibility to water exceeding 120 degrees, and 5) not assessing three wandering residents (#8, 28, and 34) for the capability of turning water on and regulating the water temperatures. There were a total of 49 residents in the facility according to the resident census and condition form. This failed practice led to an Immediate Jeopardy Situation for the facility on 01/09/12 at 12:00PM when sampled resident # 16's water in her bathroom was checked and the thermometer revealed it was 128 degrees; and one of the three wandering residents (#8) had the ability to turn the water on but not regulate the temperature of the water. The Immediate Jeopardy Situation continued until the facility put a system in place to ensure that hot water temperatures were monitored for safety for all residents. The facility's Administrator #S1, was informed of the Immediate Jeopardy at this time. The " Time and Temperature Relationship to [MEDICAL CONDITION]" table on the American Burn Association website shows that at 127 degrees Fahrenheit a third degree burn can occur at 1 minute; at 133 degrees Fahrenheit a third degree burn can occur at 15 seconds; and at 140 degrees Fahrenheit a third degree burn can occur at 5 seconds (www.ameriburn.org/Preven/ScaldInjuryEducatorsGuide.pdf). A third degree burn is defined as the destruction of the entire skin; deep third [MEDICAL CONDITION] into subcutaneous fat, muscle, or bone and often cause much scarring according to Stedman ' s Medical Dictionary, 25th Edition Illustrated, 1990, Williams & Wilkins. The Immediate Jeopardy was removed on 01/09/12 at 4:18PM when surveyors determined that the Plan of Removal was implemented. S1 Administrator was notified of the removal of the IJ at that time. The deficient practice continued at a scope and severity of second level pattern after the Plan of Removal had been implemented. The following was implemented as a Plan for Removal: 1) all residents were identified to be at risk, 2) hot water heaters were turned down to proper setting, the maintenance supervisor bled the system to remove hot water, maintenance supervisor rechecked temperatures in residents rooms, 3) log was established to monitor hot water temperatures in all resident rooms, 4) water temperatures will be checked daily for one week and, rooms will be randomly checked each week and as needed thereafter, 5 )a policy regarding proper temperatures was being written, 6) the maintenance supervisor was trained verbally concerning proper water temperature settings, 7) Administrator will monitor temperature logs randomly to ensure that logs and water temperatures are meeting regulations. Observations revealed the Plan of Removal had been implemented and was functioning. The deficient practice continued at a scope and severity of a second level pattern. Findings: On 01/09/12 at 12:00PM, observations of the following rooms revealed the following hot water temperatures: room a - 132 degrees room b - 132 degrees room c - 122 degrees room d - 122 degrees room e - 134 degrees room f - 134 degrees room g - 128 degrees room h - 138 degrees room i - 128 degrees room j - 138 degrees room k - 126 degrees room l - 126 degrees room m - 134 degrees On 01/09/12 at 12:15PM, resident in room m reported to the surveyor that her water was very hot. On 01/09/12 at 12:40PM during an interview, #S4 Maintenance Supervisor confirmed that he has been working at the facility for the past four years, and he has never kept a water temperature log. #S4 Maintenance Supervisor further reported if one of the CNAs complain that the water is too hot, then he will adjust the water heater. . On 01/09/12 at 12:42PM, observation of hot water heater room [ROOM NUMBER] (off of hall 2) revealed there were 4 hot water heaters. Observation revealed hot water heaters #1 and #3 were both set at 130 degrees. Further observation revealed hot water heaters #2 and #4 were both set on B. At this time an Interview #S4 Maintenance Supervisor confirmed he was unsure of what the "B" setting of the hot water heater meant. Further observation of the hot water heater room revealed there was no owner's manual for this hot water heater that was set to "B". At this time, #S4 Maintenance Supervisor adjusted the hot water heaters #1 and #3's temperature down to 120 degrees. . On 01/09/12 at 12:47PM, observation of hot water heater room [ROOM NUMBER] (off of hall 2) revealed there were 2 hot water heaters set at 130 degrees. At this time, #S4 Maintenance Supervisor adjusted the temperature of the hot water heaters down to 120 degrees. On 01/09/12 at 12:50PM, observation of hot water heater room [ROOM NUMBER] (off hall 1) revealed there were 2 hot water heaters set on "B" Further observation of the hot water heater room revealed there was no manual to indicate what "B" setting was for this type of hot water heater. On 01/09/12 at 2:00PM, #S4 Maintenance Supervisor informed the surveyor the he had called the company for the hot water heaters that were set on "B". He further reported that the following temperatures were associated with the following settings: "A" setting - 140 degrees "B" setting - 150 degrees "C" setting - 160 degrees Triangle setting - 120 degrees On 01/09/12 at 2:00PM, #S4 Maintenance Supervisor confirmed that all the hot water heaters that were set on "B" have now been set to the triangle setting. He further reported he had bled the system to remove all of the hot water. Hot water was rechecked in random resident rooms and was noted to be 115 degrees. An interview with #S2 DON on 01/09/12 at 1:00PM revealed the facility had three wandering residents (#8, 28, and 34). She further stated that one of the three wandering residents (#8) was capable of turning the water on, but was unable to regulate the temperature of the water. On 01/09/12 at 1:30PM during an interview, #S1 Administrator confirmed the facility did not have a policy regarding monitoring of proper water temperatures. Further interview revealed S4 Maintenance Supervisor was not trained on maintaining proper water temperatures.