Every finding on record at Mission Point Nursing & Physical Rehabilitation Ce

This citation pertains to Incident 3044880Based on interview and record review, the facility failed to ensure a snack was given in a form consistent with physician diet orders for one (R302) of four residents reviewed for therapeutic diets resulting in R302 choking on a peanut butter sandwich requiring emergency intubation and was hospitalized with extensive hypoxic ischemic brain injury [brain damage due to loss of oxygen]. Findings include:A Facility Reported Incident [FRI] was received by the State Agency [SA] on 6/9/26 that reported in part R302 ate a peanut butter and jelly sandwich, staff performed the Heimlich Maneuver and R302 was transported to the hospital.Review of the closed record revealed R302 was admitted into the facility on 2/2/23 with diagnoses that included: acute respiratory failure with hypoxia, facial weakness following cerebral infarction and Parkinson's Disease. According to the Minimum Data Set [MDS] assessment dated [DATE], R302 had moderate cognitive impairment.Review of R302's physician ordered diet dated 4/15/26 read in part, .6-Soft and bite sized texture. cut up meats.Review of a Nutritional Assessment for R302 dated 5/11/26 read in part, .Resident was recently down graded to 5-minced and moist per his request, then was upset that he could not get the foods he was requesting on that diet and was upgraded to 6-chopped and bite sized 4/15 per SLP [Speech Language Pathologist].Review of a SLP Evaluation and Plan of Treatment dated 4/15/26 read in part, .Eval of oral and pharyngeal swallow function. Oral Motor Structure and Function = Impaired. Oral Phase Impairments characterized by: effortful mastication and oral residue. What modified diet is recommended for the patient to swallow solids safely? = Soft & bite sized.Review of R302's Nutritional Care Plan revealed an intervention initiated 3/25/26 that read in part, .5-minced and moist texture.Review of a Transfer to Hospital Summary progress note by Registered Nurse [RN] 'C' dated 6/8/26 at 11:06 PM read in part, At approximately 2218 [10:18 PM], this nurse responded to a nurse aide calling for assistance. Upon arrival, the resident was seatedon [sic] the floor and being supported by the nurse aide. The nurse aide reported concern that the resident was choking and appeared to be in respiratory distress. Resident appeared to be in acute respiratory distress with labored breathing. Material consistent in appearance and odor with peanut butter was observed in the posterior oral cavity/pharyngeal area. Visible material was removed as able. Following abdominal thrusts, resident appeared to clear a portion of the obstructing material and had some improvement in air movement. At approximately 2228 [10:28 PM], the resident became unresponsive and pulseless. chest compressions were started immediately. EMS [Emergency Medical Services] arrived at approximately 2228. external defibrillator applied. advanced airway placed. ventilations provided through advanced airway.Review of hospital records dated 6/9/26 read in part, .[R302] presented after cardiac arrest. Patient was found at his facility 'blue in the face and with fluid still in his mouth'. CPR [cardiopulmonary resuscitation] was done for approximately 20 minutes. patient is intubated. patient's pupils are fixed and dilated and there is no purposeful movement. Result Entered: CT [computed tomography] HEAD WO [without] CONTRAST IMPRESSION: Diffuse loss of gray-white differentiation and sulcation [grooves and furrows] throughout the brain most suspicious for diffuse cerebral edema likely reflecting extensive hypoxic ischemic brain injury with a provided history of cardiac arrest On 6/23/26 at 9:28 AM, a call was placed to RN 'C' and a text message was sent. No return call was made prior to the end of the survey.On 6/23/26 at 9:30 AM, Licensed Practical Nurse [LPN] 'B' was interviewed by phone and asked about what happened with R302 on 6/8/26. LPN 'B' explained she was R302's assigned nurse, but had just started at 10:00 PM that day, she had just received report when RN 'C' ran down the hall. Certified Nursing Assistant [CNA] 'A' had found R302 choking and they provided care until EMS arrived and took R302 to the hospital. LPN 'B' was asked about R302's diet. LPN 'B' explained R302 had been on a regular diet, but he had asked for his meat to be cut up because he had tremors due to his Parkinson's Disease, so he had weighted silverware and sometimes he needed assistance with eating because the tremors could be severe at times. LPN 'B' was asked if R302's diet had been downgraded due to swallowing issues. LPN 'B' explained R302 did not have swallowing issues that she knew of, but sometimes he would eat too fast and she would tell him to slow down his eating.On 6/23/26 at 9:42 AM, CNA 'A' was interviewed and asked about R302 on 6/8/26. CNA 'A' explained she had asked the nurse if anyone was on a puree diet, the nurse told her no one was, so she asked R302 if he wanted a snack. he told her he wanted a peanut butter sandwich, so she gave him a sandwich. after she passed out snacks to the residents that wanted one she circled back to check on the residents. saw R302 standing in the doorway to his room. she asked him if he was choking, and he indicated he was. she first tried hitting him on the back, then got behind him and performed the Heimlich Maneuver. he started to collapse, so she lowered him to the ground and started compressions. the nurses came and took over, then EMS came and took him to the hospital. CNA 'A' was asked if she had cut up the peanut butter sandwich prior to giving it to R302. CNA 'A' explained she had given R302 a whole sandwich. On 6/23/26 at 10:29 AM, LPN 'D' was interviewed by phone and asked what happened with R302 on 6/8/26. LPN 'D' explained she had punched out and was in the parking lot when she heard screaming, she went back inside and saw R302 lying on the floor with staff around him. went to help. saw a peanut butter sandwich on the table by the bed, there was maybe half of the sandwich left. LPN 'D' was asked what kind of diet was ordered for R302. LPN 'D' explained she knew R302 was on an altered diet, that is why she thought it was strange there was a sandwich on his table.On 6/23/26 at 11:25 AM, Registered Dietician [RD] 'G' was interviewed by phone and asked about R302's diet. RD 'G' explained R302 had been on a regular diet but he saw another resident who had a 5-minced and moist diet, and wanted to have that diet due to his tremors. he then wanted food that was not allowed on that diet so then he wanted to upgrade his diet. had SLP do an evaluation on him and he was upgraded to a 6-chopped and bite size diet.On 6/23/26 at 1:00 PM, the Director of Nursing [DON] was interviewed and asked if R302 should ever have been given a whole peanut butter sandwich when he was on a soft and bite size diet. The DON explained the sandwich should have been cut into pieces to make it easier to eat. The DON further explained they had since changed their process of diets and snacks to make it easier for staff and residents to understand what foods are allowed on altered diets.During the onsite survey, past noncompliance [PNC] was cited after the facility implemented actions to correct the noncompliance which included:An audit of all residents on altered diets.Decreasing the number of altered diets from four (minced and moist, soft and bite sized, mechanical soft and pureed) to two (mechanical soft and pureed).Peanut butter and jelly sandwiches were removed from the snack list.Specific foods for snacks according to the altered diet. Mechanical soft snacks are apple sauce, pudding, yogurt, cottage cheese and oatmeal cream pie. Puree snacks are apple sauce, pudding and yogurt. Residents on altered diets will be assessed on admission, quarterly and when there is a significant change.Dietary and Nursing staff were educated on revised Altered Diet Policy and revised Snack Policy.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation relates to Intake 3020377. Based on interview and record review, the facility failed to transcribe a medication accurately per physician orders for one Resident (R102) of two residents reviewed for medication administration. Findings include:Review of an intake received by the State Agency on 5/21/26 revealed an allegation R102 was administrated medications inaccurately during their stay, resulting in medication errors. It was alleged R102 was administered the wrong dose type of Depakote, used as a mood stabilizer, which resulted in mood swings and atypical behaviors for R102. The complainant reported they did not find out until R102 was discharged that R102 was supposed have received Depakote extended release (medication dose released slowly and continuously over 24 hours) pills. The complainant alleged R102 was given delayed release (medication dose released quickly after two hours), which would have only lasted a couple of hours in R102's system per their reporting. Review of R102's profile revealed they were their own responsible party, with an inactivated Power of Attorney (POA). This was confirmed by the facility management. Review of R102's census revealed R102 was admitted to the facility on [DATE] and discharged on 3/23/26. Review of R102's Minimum Data Set (MDS) assessment, dated 2/03/26, revealed R102 had diagnoses including deep vein thrombosis (blood clot), heart failure, arthritis, wedge compression fracture (back), anxiety, depression, bipolar disorder, schizoaffective disorder, psychotic disorder, schizoaffective disorder, pseudobulbar affect (neurological condition causing sudden uncontrollable episodes of laughing or crying that do not match a person's emotions), spinal stenosis (narrowing of spine), and back pain. Review of R102's hospital discharge medication list, dated 1/30/26, retrieved from the documents section of the Electronic Medical Record (EMR), .Discharge Medication Instructions (continued). These are your home medications, divalproex (generic medication) 500 mg (milligrams) 24 hr (hour) tablet (in bold print), commonly known as: Depakote (mood stabilizer or anti-seizure medication) ER (Extended Release). Take 1,500 mg (milligrams) by mouth at bedtime. Review of R102's hospital discharge summary, by the hospitalist, revealed, .divalproex 500 mg 24 hr (hour) tablet.Commonly known as: Depakote ER. 1,500 mg, Oral. At bedtime. Review of R102's printable discharge hospital referral form, dated 1/26/26, showed R102 was prescribed Depakote Extended Release prior to their admission to the facility on 1/30/26, at the dose 1500 mg at bedtime. Review of R102's progress note, dated 3/25/26 at 9:45 a.m., by Licensed Practical Nurse (LPN) B, revealed, Resident (102's) Depakote was not transcribed into (Name of EMR) correctly from hospital discharge instructions. (R102) was receiving delayed release Depakote instead of extended-release Depakote. Facility made aware of error after discharge. Management, doctor and family notified of incident. This progress note showed R102 did not receive the correct dosing of their Depakote during the duration of their facility stay. Review of R102's February MAR (Medication Administration Record) showed Divalproex Sodium (Depakote) delayed release was administered 2/01/26 to 2/10/26 at the dose of 1500 mg once a day at night. The MAR continued to show from 2/11/26 to 2/28/26 three Divalproex Sodium 500 mg tablets were administered at night (all together) delayed release for a total dose of 1500 mg noted. This showed R102 continued to have delayed release medications verses extended release, with all their medication being given once a day, at night. Review of R102's January (2026) MAR showed Divalproex Sodium delayed release was given at night at 1500 mg on 1/30/26 and 1/31/26. Review of R102's March (2026) MAR showed they received 1500 mg total of Divalproex Sodium at night daily in the delayed release form, not extended release. Review of R102's Order Summary Report, dated 3/23/26 (Date of facility discharge), revealed Divalproex Sodium (name brand Depakote) Oral tablet delayed release 500 mg was dosed three tablets at bedtime, for a total of 1500 mg a day. This showed the medication was still not the extended-release version upon R102's facility discharge, and three shorter acting pills were given together at night, and not spread throughout the day for extended coverage, despite three pills being prescribed (500 mg) instead of the one pill (1500 mg) dosing. On 5/27/26 at 3:09 p.m., LPN B reported the facility did not discover the medication dosage type error regarding the inaccurate medication transcription of R102's Depakote from the hospital medication list until after R102 was discharged , when they were made aware by R102's family member via email along with the Director of Nursing (DON). LPN B explained they made Physician I aware of the situation after R102's discharge. LPN B reported while R102 had behaviors during their stay, they could not necessarily attribute them to the medication dose type transcription error. LPN B clarified R102 had verbal behaviors at times, such as yelling out however said they had no physical behaviors or resident-to-resident incidents. LPN B was asked to review R102's February MAR with Surveyor during the interview, and the change of dosing on 2/11/26. LPN B acknowledged there would be no difference in 3 - 500 mg pills (totaling 1500 mg) vs (verses) one 1500 mg pill (totaling 1500 mg), when each dose was given at night. LPN B clarified this was the same medication dose type, and amount of Depakote delayed release, and said the MAR showed R102 received the medications at night only, not staggered (like two to three times a day). LPN B reported they understood the transcription error concern and the potential for a mood or behavior outcome. Review of R102's Care Plan, accessed 5/27/26, revealed, (R102) at risk for changes in mood and behavior due to diagnosis of pseudobulbar affect, schizoaffective disorder, depression, bipolar, and anxiety disorder. (R102) admitted on two antipsychotics (medications to treat psychosis symptoms), antidepressant, antianxiety, and mood stabilizer medications. I (R102) have been on these medications for 10 - 20 years. I (R102) have a community psychiatrist. I (R102) have a history of hallucinations and hearing voices. I (R102) can be labile and religiously preoccupied. (R102) may make false accusations about staff mistreating her, has catastrophic responses. Date initiated 2/04/26. The Care Plan also revealed R102 had a history of traumatic experiences. On 5/27/26 at approximately 3:50 p.m., the Director of Nursing (DON) acknowledged being made aware R102 had not received the correct Depakote dose type during their stay and had received delayed release verses extended release. The DON said they had re-educated the nurse involved. The DON understood the concern for a potential outcome however could not ascertain this had occurred, as R102 reportedly had behaviors throughout their stay, and said they generally only saw behaviors when one family member was present. The DON explained there were times when R102 did not want their family member involved in their care, since they were their own responsible party. The DON said they had received complaints from R102's family member, but R102 did not have complaints themselves. On 5/27/26 at 4:01 p.m., and 5:04 p.m., attempts were made to contact R102, who was their own person, with no call returned. Review of the psychiatric practitioner's evaluation, by Nurse Practitioner (NP) H titled, Psychiatry Initial Evaluation, dated 2/04/26, dated 2/04/26, revealed, Chief complaint: Schizoaffective disorder (a mental health disorder with schizophrenia and mood symptoms), bipolar disorder (mood disorder), neurocognitive decline (significant decline in neurological function). History of present illness: (R102) is a [AGE] year-old female admitted [DATE] for skilled nursing and rehabilitation services following hospitalization related to recurrent falls, deconditioning, and functional decline. It was noted R102's medications were documented as reconciled by NP H during the visit, and Divalproex 1500 mg was prescribed to be administered at bedtime. It was noted their reconciliation did not designate extended release or delayed release in their medication review. On 5/27/26 at approximately 4:20 p.m Physician I was asked during a phone interview about the R102's medication concerns with wrong dose type of Depakote administered during their stay. Physician I acknowledged being made aware after R102 was discharged and understood the concern. Physician I referred Surveyor to follow up with the outside behavioral care practitioner if needed, to ascertain if there was a potential outcome. On 5/27/26 at 5:11 p.m., NP H was asked during a phone interview about R102 being administered the wrong dose type of Depakote during their stay and any outcome. NP H said they were not made aware of the medication dosage concern with Depakote during their stay. NP H said there was a difference in the dosing and they would opt for Depakote DR with bipolar disorder and did not have a concern with them receiving the full amount at night. NP H said when they saw R102 on 2/04/26 and at that time R102 had no symptoms of (acute) mania or psychotic symptoms and had a consistent clinical representation per their review. NP H reported their records showed R102 was on Depakote 1500 mg at night per their documentation with no documentation of the dose type (ER vs delayed release). NP H denied an outcome per their awareness. NP H acknowledged while there may have been a difference in the conversion from a Depakote delayed release to Depakote extended release, they did not provide an answer as to whether more or less medication would be needed for a resident with bipolar disorder. Review of the policy, Medication Reconciliation, revised 9/2025, revealed, This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors. Definitions: 'Medication reconciliation' refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay. Policy Explanation and Compliance Guidelines: Medication reconciliation involves collaboration with the resident/representative and multiple disciplines, including admission liaisons, licensed nurses, physicians, and pharmacy staff. Resident identifiers will be verified on all medication labels and documents containing medication information to verify the correct person and that the documents are placed in the correct resident's medical record. Pre-admission Processes: Obtain current medication list from referral source (i.e. hospital, home health, hospice, or primary care provider). Obtain current medication/admission orders. Verify resident identifiers. Forward to nursing unit accepting the resident. admission Processes: Verify resident identifiers on the information received. Compare orders to hospital records, etc. Obtain clarification orders as needed. Transcribe orders in accordance with procedures for admission orders. Order medications from pharmacy in accordance with facility procedures for ordering medications. Verify medications received match the medication orders. Obtain home list of medications from the receiving facility and/or resident/representative. Place in the EHR for physician review and revision of medication regimen, if warranted. Interim medication review completed on upon admission, if warranted. Daily Processes: Address any clinically significant medication irregularities reported by pharmacy consultant. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed. Order medications from pharmacy in accordance with facility procedures for ordering medications. Verify medications received match the medication orders. Monthly Processes: Provide pharmacy consultant access to all medication areas and records for completion of pharmacy services activities. Respond to any medication irregularities reported by pharmacy consultant within relevant time frames. Review of the manufacturer's recommendations for taking Depakote, titled, Taking Depakote(R) Products (divalproex sodium), accessed on 6/04/26, revealed, Depakote Tablets are delayed-release, which means they have a special coating that prevents the drug from dissolving too early in the digestive tract. Available in three strengths, Depakote Tablets must be taken twice a day, as prescribed by your doctor. Talk with your doctor about the most appropriate tablet strength for you. Depakote Extended-Release Tablets: The ER in Depakote ER stands for Extended Release. Available in two strengths, Depakote ER contains the same active ingredient as Depakote Tablets but it is designed to slowly deliver the medication over a 24-hour period. This means that Depakote ER has to be taken only once a day. If you have been prescribed Depakote Tablets, ask your doctor if Depakote ER is right for you. What is DEPAKOTE used for? DEPAKOTE comes in different dosage forms for oral use. DEPAKOTE(R) (divalproex sodium) delayed-release tablets, DEPAKOTE(R) ER (divalproex sodium) extended-release tablets, and DEPAKOTE(R) Sprinkle Capsules (divalproex sodium delayed release capsules) are prescription medicines used:alone or with other medicines to treat:- complex partial seizures in adults and children [AGE] years of age and older- simple and complex absence seizureswith other medications to treat:- patients with multiple seizure types that include absence seizuresDEPAKOTE ER and DEPAKOTE are also used to prevent migraine headaches.DEPAKOTE ER is also used to treat acute manic or mixed episodes associated with bipolar disorder with or without psychotic features.DEPAKOTE is also used to treat manic episodes associated with bipolar disorder. Review of the article titled, Divalproex to Divalproex Extended-Release Conversion, accessed 6/04/26, from Medscape, revealed, Abstract and Introduction: Objective: Divalproex extended release (ER) tablets have lower bioavailability than conventional divalproex tablets. Objectives were to provide dose-increment justification for conversion of a patient from conventional enteric-coated divalproex to a once-daily enteric-coated divalproex to a once-daily divalproex ER regimen and to discuss the pharm kinetic factors affecting these unequal total daily dose conversions.Conclusions: An 8-20% higher divalproex ER daily dose should be used when converting from a total daily dose of divalproex. The lower fluctuations of valproic acid concentrations, consistent time to trough concentration, and lower dosing frequency of divalproex ER should offer benefit to the patient by providing convenient once-daily administration, and to the clinician by facilitating easier and reliable therapeutic drug monitoring and improving patient adherence. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: Each resident prescribed Depakote was identified and had their Depakote orders audited to ensure that the correct type of Depakote matched the physician orders. All were in compliance. Nurses were re-educated on the transcribing of medication. Each new admission who is prescribed Depakote will be audited to ensure that the correct order for Depakote is transcribed to the MAR. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake 2966880.Based on observation, interview and record review, the facility failed to maintain clean, comfortable, homelike environment for multiple residents that reside in the facility, including those on the A, B and D units. Findings include:On 3/30/2026 at 10:17 AM observed bagged soiled linens overflowing from vendor provided storage containers and being stored on the floor and a strong odor of urine present. During this observation when queried, Housekeeping/Maintenance Director (Staff 'W') said the laundry service pick up days are Monday, Wednesday, and Friday around 11:00 AM, so Monday is the heaviest collection day. Staff 'W' indicated that they could check if another collection bin is available. On 3/30/2026 at 10:18 AM interviewed Staff 'W' about the strong odor of urine near the building entrance. Staff 'W' said it is a recurring issue with some residents urinating in this area during the night time and that housekeeping staff provide daily cleaning of those areas of the carpeting once they arrive in the morning. Review of a complaint reported to the State Agency included an allegation of .The entire unit smells like rotting bodies and urine . On 3/30/26 at 8:30 AM, upon entry into the facility, a strong urine odor was immediately identified in the front lobby area. There were two ceiling air units that had vent grids that were heavily soiled with stringy, dust debris. Throughout the survey, urine odors remained prevalent throughout the front lobby, and the hallways on A, B, and D units. On 4/1/26 at 10:05 AM, an interview was conducted by the Housekeeping/Maintenance Director (Staff 'W'). When asked if they completed any monitoring of the ceiling ventilation systems, Staff 'W' reported they didn't do that. They reported the ventilation systems from the front lobby and hallways were split systems. When asked about the soiled ceiling vent grids, Staff 'W' confirmed the same and reported housekeeping should have cleaned them. When asked about the strong urine odors, Staff 'W' reported the same concerns and reported there was a resident that had behaviors with urination, and their room was nearby the front lobby. Throughout the survey, the room occupied by this resident was not observed with any urine odors. Additional observations of the A/B nursing station, and D nursing station revealed heavily soiled ceiling vent air units. Staff 'W' acknowledged the soiled status and reported they would need to be cleaned immediately. When asked if that was part of the housekeeping staff's daily rounds, Staff 'W' reported those should be included, including if they were visibly soiled and reported some were missed. Staff 'W' was asked about the internal washable filters that were heavily soiled with dust debris, and they reported their contracted heating and cooling company must've missed a couple. According to the facility's policy titled, Exhaust Fan Inspection dated 1/11/2021: .All resident and non-resident areas have exhaust vents/fan/s. Each area needs to be verified that the vent covers are dust/dirt free and that the vent can be confirmed to function by holding up a piece of multi-fold paper.All vent covers should be cleaned inside and out.

This citation pertains to intakes 2607613, 2658268, 2666429, 2793060.Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse by a staff, verbal abuse by a resident, physical abuse by a resident, and failed to protect the resident's right to be free from neglect for five (R1, R30, R53, R64 and R76) of six residents reviewed for abuse and neglect. Findings include: According to the facility's policy titled, Abuse, Neglect and Exploitation dated 9/2025: .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse.physical abuse.'Verbal Abuse' means the use or oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and kicking.'Neglect' means 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. R1 Review of a facility reported incident (FRI) submitted to the State Agency on 11/28/25 documented, in part: .On November 27, 2025 at around 5.30pm, (R1) asked (Staff 'A') Dietary Aide for a cup of coffee. (Staff 'A') stated that she could not provide him with a cup of coffee at this time. (R1) stated, F*** You. to (Staff 'A') and (Staff 'A') stated back to (R1), FU and walked away from the resident.Investigation Summary.On November 27, 2025 it was witnessed by (Nurse 'F'), (R1) asked (Staff 'A'), Kitchen Aide, for a cup of coffee. (Staff 'A') replied that I can not give you any coffee. (R1) then called (Staff 'A') a Bitch. (R1) replied F*** You. (Staff 'A') replied F U you back. This incident was documented as inconclusive in regard to abuse, despite the witnessed incident. Review of clinical record revealed R1 was admitted into the facility on 2/2/23 and readmitted on [DATE] with diagnoses that included: bipolar disorder current episode depressed, severe, with psychotic features, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, Parkinson's disease without dyskinesia without mention of fluctuations, mild cognitive impairment of uncertain or unknown etiology, schizoaffective disorder bipolar type, chronic pain syndrome, and Post-Traumatic Stress Disorder. According to the quarterly Minimum Data Set (MDS) assessment 2/17/26, R1 had intact cognition and had feelings of being down, depressed, or hopeless 7-11 days (half or more of the days), feeling tired or having little energy for 12-14 days (nearly every day), feeling bad about self - or that you are a failure or have let self or your family down (12-14 days (nearly every day), trouble concentrating on things, such as reading the newspaper or watching television (12-14 days - nearly every day). On 3/31/26 at 1:12 PM, an interview was conducted with R1. When asked about the incident of verbal abuse with Staff 'A' from 11/27/25, R1 reported they didn't think staff should've said that and hadn't seen them since. R1 further reported they were really upset that another resident called them a [NAME] and said they were acting like a little girl during bingo last week. On 3/31/26 11:15 AM, an interview was conducted with the Administrator who also reported they were the facility's Abuse Coordinator. When asked about the abuse incident on 11/27/25 between R1 and Staff 'A' and why they had documented inconclusive in the portal to the State Agency, the Administrator confirmed they had substantiated verbal abuse occurred and that should've been documented as substantiated. During review of R1's clinical record, an additional abuse incident was identified. Review of the progress notes included an entry on 3/27/26 at 12:57 PM by Social Worker (SW 'G') that documented, in part: (R1) spoke with me today to tell me that he is upset about bingo.He was upset also because he said that another resident had called him a '[NAME]' and he did not like the comment being related to sexual orientation. On 3/30/26 at 3:46 PM, the Administrator was asked about R1's concerns documented by SW 'G'. They reported that had not been reported to the state agency. On 3/30/26 at 3:52 PM, the Administrator was asked to clarify if that resident-to-resident incident should've been reported and they stated it wasn't reported because It was verbal and he started it. Basically, he called someone a name and (R53) called him a [NAME]. (R53) said he didn't call him that and said for him to stop. Review of the facility's documentation of the resident-to-resident incident from 3/27/26 further identified the incident occurred between R1, R30, and R53. Documentation included: (R1) has been living at (facility name) since February 10, 2023. (R1) is 63 year of age and has a BIMS (Brief Interview for Mental Status) Score of 15 (which indicated intact cognition). Diagnoses include Bipolar disorder, Neurocognitive Disorder, Schizoaffective Disorder and Generalized Anxiety Disorder. (R53) has been living at (facility name) since January 9, 2024. (R53) is [AGE] years of age and has a BIMS Score of 15. Diagnoses include Mild Cognitive Impairment, Major Depressive Disorder, Other Psychoactive Substance Abuse and Bipolar disorder. (R30) has been living at (facility name) since January 25, 2025. (R30) is [AGE] years of age and has a BIMS Score of 3 (severe cognitive impairment). Diagnoses include Vascular Dementia, Generalized Anxiety Disorder, Major Depressive Disorder and Diabetes Mellitus. (R1) stated that (R53) called him a [NAME]. (R53) was interviewed by Social work (SW 'G') and he stated that he did not call (R1) a [NAME] but did call him a fat punk as he acts like a little girl. (R53) stated that during bingo (R1) was calling (R30) names, Asshole and bitch and stated that it was because the bingo screen was in front of (R30) and that (R1) was upset as that is why (R30) has all the bingo bucks. (R1) stated that he was upset about what happened at Bingo on Monday. (R1) stated, (Name of Activity Aide/Staff 'B') put the screen that gives the bingo numbers right in front of (R30's) face. (R1) stated, Its not fair as she has a stack of over $100 bingo dollars. (R1) stated, I don't care if she is retarded or not its not fair that I only have 4. (R1) said, Everyone in the room was raising hell at me because they were afraid of not getting bingo bucks. (R53) another resident was worried about his Bingo Bucks and he called me a [NAME] to get even with me. (R1) stated that (R53) said stop acting like a little girl>' <sic> (R1) stated, I want to be treated fairly in Bingo. (Staff 'B') is not honest as he puts the screen in front of (R30). On 3/31/26 at 10:54 AM, further discussion was conducted with the Administrator regarding their documentation of the resident-to-resident incident from 3/27/26. When asked about their documentation above, which included derogatory/disparaging remarks and how that had not been identified as instances of verbal abuse, the Administrator acknowledged they should have. R76 On 4/1/226 at 10:39 AM, a review of a facility reported incident investigation file completed by the facility's Administrator/Abuse Coordinator was reviewed. The investigation file contained a summary that read, .(R76) has a BIMS (Brief Interview for Mental Status) score of 15 (indicating intact cognition). Diagnoses are Malignant Neoplasm of Bilateral Ovaries, Malignant Neoplasm of Abdomen, Bipolar disorder and Depression. On October 23, 2025, on rounds (R76) reported to the Administrator at around 8:30am [sic] that she has [sic] pushed her call light asking for pain medication and the Nurse did not respond timely .(Social Worker 'G') interviewed (R76) and (R76) Stated: [sic] I woke up during the night and I was in pain. I put my call light on for pain medication. The nurse came into my room and I told her that I wanted pain medication. The Nurse turned off my call light and left the room About 90 minutes later the Nurse had not returned with my pain medication so I put my light on again. The Nurse came back in the room and left again without giving pain medication and I had to wait for another hour before the Nurse returned with my pain medication .CONCLUSION 1. The Nurse has been counselled to ensure that when a resident requests pain medication to administer the pain medication as ordered by the Doctor timely . Continued review of the file revealed a Facility Reported Incident (FRI) electronically submitted to the State Agency that alleged Nurse 'U' neglected R76. The file further contained past non-compliance documents, however; the past non-compliance was not accepted as the facility was out of compliance at the time of the survey. On 4/1/26 at 11:06 AM, an interview was conducted with the facility's Administrator/Abuse Coordinator regarding the investigation. The Administrator was asked how they determined to submit a FRI for Nurse 'U' neglecting R76 and said, I felt like it was neglect, further adding R76 needed their narcotic pain medication on a regular basis due their end-of-life Hospice Status and aggressive cancer diagnoses. They were asked if they interviewed Nurse 'U' and said they did. When asked what Nurse 'U' reported to them, the Administrator said they did not remember and added, I don't think she (Nurse 'U') understood why R76 needed her hourly pain medications. The Administrator was then asked if Nurse 'U' was still employed at the facility and reported Nurse 'U' quit without notice after leaving her shift on the morning of 10/23/25. R64 and R30 A review of a FRI reported to the State Agency revealed an allegation that R30 tapped R64 on the bottom and R64 hit R30 on her face. On 3/30/26 at 11:10 AM, R30 was interviewed. When asked about the altercation with R64, R30 did not remember the incident. On 3/30/26 at 11:59 AM, R64 was interviewed. When asked about the altercation with R30, R64 mumbled and said something about being a pimp. R64 did not give a sensical answer. A review of an investigation conducted by the facility revealed the following: A typed summary (undated and unsigned) that noted, .On October 28, 2025, (R30) went up to (R64) and yelled at (R64) and hi [sic] him on his buttocks. (R64) turned around and hit (R30) on her right chin .(R30) stated, 'I was in the game room. It was a bad thing, that guy is good to me from way back in the day. Yesterday he hit me in the face. I can't remember if I did anything .(R64) stated, 'I was throwing something away in the garbage can and I got punch on my [NAME] by a 'Transgender'. The crowd joined in they wanted me to accept the assault. I punched him back . The summary did not include any conclusion to the investigation. A review of the investigation submitted to the State Agency revealed abuse was Unsubstantiated. A handwritten statement (undated) by Activity Staff 'E' noted, On Tuesday October 28th 2025, (R30) came into the dining room while (Staff name) and I were doing our craft activitie [sic]. (R30) stated (R64) had just struck her in the forehead. I immediately went to go speak with (R64) to see his side of the story. (R64) stated (R30) had struck him in the [NAME] end so he turn around and hit her in the forehead .(R64) then came in to the dining room after all has settled down and incident had been reported yelling at (R30) stating very mean and inappropriate things . A typed statement dated 10/29/25 from an unknown person noted, .Met with (R64) today in follow up after an incident yesterday with another resident. I asked him if he could tell me what happened yesterday. He stated that he was throwing something way in the garbage can and 'I got punched on my [NAME] by a transgender'. He went on to say 'the crowd joined in, they wanted me to accept the assault'. I asked him what he did and he stated, 'I punched him' . A review of R64's clinical record revealed R64 was admitted into the facility on 6/14/24 and readmitted on [DATE] with diagnoses that included: schizoaffective disorder, bipolar type, and dementia. A review of a MDS assessment dated [DATE] revealed R64 had intact cognition and no behaviors. A review of an Incident Note for R64, dated 10/28/25 revealed, It was reported to writer that resident had an incident with another resident (R30) in activity room. resident interviewed and stated 'I was standing up throwing some papers away in the garbage can and she came up behind me and punched me right in my [NAME], so I turned around and punched her back.' A review of R30's clinical record revealed R30 was admitted into the facility on 1/25/24 and readmitted on [DATE] with diagnoses that included vascular dementia with behavioral disturbance. A review of a MDS assessment dated [DATE] revealed R30 had severely impaired cognition. A review of a Nursing Progress Note for R30 dated 10/28/25 revealed, (R30) went up to (R64) in the hall. She yelled what are you doing. She hit (R64) in the buttocks. (R64) turned around and hit patient in right chin area with closed fist. She stated she yelled, 'What are you doing sir?' She stated, 'He punched in the face.' On 3/31/26 at 11:33 AM, an interview was conducted with the Administrator, who was the Abuse Coordinator for the facility. When queried about how she determined abuse was not substantiated, the Administrator reported she read the resident's statements. When queried about R64 admitting to punching R30 in the face and whether that would be considered physical abuse, the Administrator reported it was.

Based on interview and record review, the facility failed to report witnessed resident to resident verbal abuse and an injury of unknown origin to the State Agency for four (R1, R30, R53, and R80) of six residents reviewed for abuse and neglect. Findings include: R1, R30, R53 During an investigation of a separate verbal abuse incident between a staff member and R1, the following additional verbal abuse concerns were identified: An entry in R1's clinical record included a progress note dated [DATE] at 12:57 PM by Social Worker (SW 'G') documented, in part: (R1) spoke with me today to tell me that he is upset about bingo.He was upset also because he said that another resident had called him a '[NAME]' and he did not like the comment being related to sexual orientation. On [DATE] at 3:46 PM, the Administrator was asked about R1's concerns documented by SW 'G' and whether that had been reported to the State Agency. The Administrator reported that had not. On [DATE] at 3:52 PM, the Administrator was asked to clarify if that resident-to-resident incident should've been reported and they stated it wasn't reported because It was verbal and he started it. Basically, he called someone a name and (R53) called him a [NAME]. (R53) said he didn't call him that and said for him to stop. Review of the facility's documentation of the resident-to-resident incident from [DATE] further identified the incident occurred between R1, R30, and R53. Documentation included: (R1) has been living at (facility name) since February 10, 2023. (R1) is 63 year of age and has a BIMS (Brief Interview for Mental Status) Score of 15 (which indicated intact cognition). Diagnoses include Bipolar disorder, Neurocognitive Disorder, Schizoaffective Disorder and Generalized Anxiety Disorder. (R53) has been living at (facility name) since [DATE]. (R53) is [AGE] years of age and has a BIMS Score of 15. Diagnoses include Mild Cognitive Impairment, Major Depressive Disorder, Other Psychoactive Substance Abuse and Bipolar disorder. (R30) has been living at (facility name) since [DATE]. (R30) is [AGE] years of age and has a BIMS Score of 3 (severe cognitive impairment). Diagnoses include Vascular Dementia, Generalized Anxiety Disorder, Major Depressive Disorder and Diabetes Mellitus. (R1) stated that (R53) called him a [NAME]. (R53) was interviewed by Social work (SW 'G') and he stated that he did not call (R1) a [NAME] but did call him a fat punk as he acts like a little girl. (R53) stated that during bingo (R1) was calling (R30) names, Asshole and bitch and stated that it was because the bingo screen was in front of (R30) and that (R1) was upset as that is why (R30) has all the bingo bucks. (R1) stated that he was upset about what happened at Bingo on Monday. (R1) stated, (Name of Activity Aide/Staff 'B') put the screen that gives the bingo numbers right in front of (R30's) face. (R1) stated, Its not fair as she has a stack of over $100 bingo dollars. (R1) stated, I don't care if she is retarded or not its not fair that I only have 4. (R1) said, Everyone in the room was raising hell at me because they were afraid of not getting bingo bucks. (R53) another resident was worried about his Bingo Bucks and he called me a [NAME] to get even with me. (R1) stated that (R53) said stop acting like a little girl>' <sic> (R1) stated, I want to be treated fairly in Bingo. (Staff 'B') is not honest as he puts the screen in front of (R30). On [DATE] at 10:21 AM, a phone interview was completed with Staff 'B'. When asked to recall the events from the resident-to-resident altercation with R1, R30 and R53, Staff 'B' reported they were playing bingo and R1 was freaking out because R30 had to be by them and they had the bingo tablet. Staff 'B' reported R1 started going off and another resident (R53) stepped in and said he needed to stop or leave and then R1 went full blown at him. Staff 'B' reported R1 said he couldn't see the table and was being rude to (R30). When asked what they meant by being rude Staff 'B' reported they couldn't recall specific details. When asked if they reported that to anyone, Staff 'B' reported they did report it to a few CNAs (Certified Nursing Assistants) and the nurses and then after the shift, they reported it to their boss and that was it. When asked if they continued the bingo activity, Staff 'B' reported they did and also reported R1 got angry and left and did return but stayed silent. When asked if anyone from Administration had requested they write a statement of the events that occurred, Staff 'B' reported they had been asked on Monday and they verbally told them what happened. When asked who they talked to, Staff 'B' reported their boss (Activity Director/Staff 'V'). On [DATE] at 10:44 AM, an interview was conducted with the Staff 'V'. When asked what they could recall regarding the verbal abuse incident between R1, R30 and R53, Staff 'V' reported Staff 'B' had called them to explain (R1) was upset. They further reported they were not in the facility. Upon review of their cell phone, Staff 'V' reported Staff 'B' had called them on [DATE] at 5:59 PM. When asked what had been reported to them, Staff 'V' reported just that R1 had a verbal issue that he was upset and left. Staff 'V' further reported Staff 'B' never reported any derogatory statements but should've notified the abuse coordinator which was (Name of Administrator). When we had discussion it was investigated and that's when the other things came to light (with R30 and R53). On [DATE] at 10:54 AM, further discussion was conducted with the Administrator regarding their documentation of the resident-to-resident incident from [DATE]. When asked about their documentation which included derogatory/disparaging remarks and why those had not been identified that as instances of verbal abuse, the Administrator acknowledged they should have and was unable to offer any further explanation. When asked when they were first notified of the allegations of verbal abuse, the Administrator reported they were notified on a concern form from a Nurse on Monday ([DATE]). The Administrator reported the concern form was dated [DATE] and acknowledged that date did not make sense and further reported they should've been notified of the actual incidents. When asked why this hadn't been reported as an instance of resident-to-resident verbal abuse once they completed their investigation, the Administrator reported they should have. When asked if Staff 'B' should've notified them of what they witnessed, the Administrator reported they should have been notified immediately. A review of a facility policy titled, Abuse, Neglect and Exploitation revised on 9/2025, revealed, in part, the following, .The facility will implement the following .Reporting of all alleged violations for the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes .Immediately, but not later than 2 hours after the allegation is made, if the vents that cause the allegation involve abuse or result in serious bodily injury . R80 A review of R80's clinical record revealed R80 was admitted into the facility on [DATE], readmitted on [DATE], and expired in the facility on [DATE]. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R80 had moderately impaired cognition, one-sided impairment of the upper and lower extremities, was dependent on staff for toileting hygiene, rolling left and right, transferring, and going from sitting to lying. R80 did not stand or walk and had no history of falls. A review of R80's progress notes revealed the following: On [DATE] at 3:38 AM, Registered Nurse (RN) 'H' documented the following in a Nursing Progress Note, Resident last seen alive between 01:30 (AM) and 01:45 (AM) at which time he was repositioned, changed. At 02:08 (AM) nurse called to the room as resident observed out of bed. Nurse observed resident between bed and window with his shoulders off the floor, head stuck between bed and wardrobe face down. Unable to free resident's head until bed moved. Resident had no pulse, no respirations, No heart sounds on auscultation. Pronounced deceased at 02:13 (AM) by the nurse, RN. 911 called, administrator, DON (Director of Nursing), unit managers notified by phone . On [DATE] at 3:16 AM, Unit Manager, Licensed Practical Nurse (LPN), 'I' documented the same as the above progress note in a Nursing Progress Note. On [DATE] at 11:18 AM, the Administrator and DON were asked to provide any incident reports and investigations for R80 for the month of February 2026. A review of an incident report provided by the facility revealed on [DATE] at 2:08 AM, Resident last seen alive between 01:30 (AM) and 01:45 (AM) at which time he was repositioned, changed. At 02:08 (AM) nurse called to the room as resident observed out of bed. Nurse observed resident between bed and window with his shoulders off the floor, head stuck between bed and wardrobe face down. Unable to free resident's head until bed moved. Resident had no pulse, no respirations, No heart sounds on auscultation. Pronounced deceased at 02:13 (AM) by the nurse, RN . No documented investigation was provided with the incident report. On [DATE] at 3:55 PM, an interview was conducted with the Administrator, who was the Abuse Coordinator for the facility. When queried about whether she was notified about R80's death and how he was found, the Administrator reported the nurse (RN 'H') called her and said R80 was found on the floor with his head stuck between the bed and the dresser and that he was deceased . When queried about how that happened, the Administrator reported she did not know. The Administrator said she did not report the incident to the State Agency and did not offer a reason why. On [DATE] at 8:05 AM, an interview was conducted with RN 'H', who was the nurse assigned to R80 on the night shift of [DATE]-[DATE]. When queried about what happened with R80 on [DATE], RN 'H' reported she was called to the room by two Certified Nursing Assistants (CNAs), one of them being CNA 'J'. They told her R80 was out of bed. When RN 'H' entered the room, R80 was observed with his head face down stuck between the armoire and the bed frame with his feet forcefully wedged underneath the metal base of the over bed table that was beside the bed. RN 'H' explained R80 was unable to be freed from between the bed and the armoire without moving the nightstand on the opposite side of the bed and moving the bed away from the armoire. It was not until she got R80 unstuck that she was able to assess him and determined he was deceased . RN 'H' further explained the way R80 was positioned was unusual and could not have happened from a fall and likely did not happen during care. RN 'H' reported R80 was not a fall risk and was unable to move himself in bed. RN 'H' reported she notified the Administrator/Abuse Coordinator right away.

Based on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of plumbing and the ice machine, resulting in an increased potential for contamination including the water supply affecting all residents. Findings Include:On 3/30/2026 at 9:00 AM during a kitchen tour with dietary manager (DM) 'Z' observed sewer gas odor present near the sub floor grease trap by the 3-compartment sink. Also smelled the same odor at 3 in-floor drains, and near 3 kitchen sink drains. During this observation, when DM 'Z' was asked if he smelled this odor or knew what the issue was, DM 'Z' indicated having a diminished sense of smell and was not aware of the odor or what the issue may be. When asked about the frequency of service for the grease trap, DM 'Z' indicated about every 6 months and that the building was serviced by village of [NAME] sanitary sewer. On 3/30/2026 at 9:20 AM observed two kitchen sink drain lines (provide with sanitary air gaps to waste drain) with dark soil build up at the end of the drain line. On 3/30/2026 at 12:30 PM interviewed DM 'Z' further regarding grease trap maintenance procedures. When asked if there are service records, he said to ask of the maintenance supervisor or administrator. He also indicated that it would probably be a good idea to have it serviced more frequently. On 3/30/2026 at 12:50 PM interview with maintenance director (MD) 'W' indicated no plumbing service records are available, but he called the service company and last service was August 2025. MD 'W' indicated having the grease trap cleaned/serviced annually and the service company would be out to the facility tomorrow to investigate/provide service. MD 'W' said he has smelled the sewer gas odor and indicated that any service needs to be done by the professionals. According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. On 3/30/2026 at 9:50 AM observed the kitchen ice machine drip panel with spots of a pink substance forming. During this observation, when queried, DM 'Z' says the ice machine is deep cleaned quarterly and wiped down as needed. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. On 3/30/2026 at 10:15 AM observed the D Hall janitor sink connected to the chemical supply tower (with shut off valve). This water line is provided with an atmospheric vacuum breaker but is subject to back pressure. There is no wasting/vented T device provided to relieve the pressure in the line. On 3/30/2026 at 12:35 PM observed the garbage disposal sink with a submerged jet inlet located below the sink flood rim. There is also an air gapped over-sink faucet at this location. DM 'Z' showed that the water inlet valve to the garbage disposal is currently off and not used. When the valve was turned on and operated, water came out. There is currently no cross-connection prevention in place for this submerged inlet.According to the 2022 FDA Food Code section 5-203.14 Backflow Prevention Device, When Required.A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by:(A) Providing an air gap as specified under S 5-202.13 P; or(B) Installing an APPROVED backflow prevention device as specified under S 5-202.14.

Based on interview and record review, the facility failed to investigate an injury of unknown origin for one (R80) of six residents reviewed for abuse and neglect. Findings include:A review of R80's clinical record revealed R80 was admitted into the facility on [DATE], readmitted on [DATE], and expired in the facility on [DATE]. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R80 had moderately impaired cognition, one-sided impairment of the upper and lower extremities, was dependent on staff for toileting hygiene, rolling left and right, transferring, and going from sitting to lying. R80 did not stand or walk and had no history of falls. A review of R80's progress notes revealed the following: On [DATE] at 3:38 AM, Registered Nurse (RN) 'H' documented the following in a Nursing Progress Note, Resident last seen alive between 01:30 (AM) and 01:45 (AM) at which time he was repositioned, changed. At 02:08 (AM) nurse called to the room as resident observed out of bed. Nurse observed resident between bed and window with his shoulders off the floor, head stuck between bed and wardrobe face down. Unable to free resident's head until bed moved. Resident had no pulse, no respirations, No heart sounds on auscultation. Pronounced deceased at 02:13 (AM) by the nurse, RN. 911 called, administrator, DON (Director of Nursing), unit managers notified by phone . On [DATE] at 3:16 AM, Unit Manager, Licensed Practical Nurse (LPN), 'I' documented the same as the above progress note in a Nursing Progress Note.On [DATE] at 11:18 AM, the Administrator and DON were asked to provide any incident reports and investigations for R80 for the month of February 2026. A review of an incident report provided by the facility revealed on [DATE] at 2:08 AM, Resident last seen alive between 01:30 (AM) and 01:45 (AM) at which time he was repositioned, changed. At 02:08 (AM) nurse called to the room as resident observed out of bed. Nurse observed resident between bed and window with his shoulders off the floor, head stuck between bed and wardrobe face down. Unable to free resident's head until bed moved. Resident had no pulse, no respirations, No heart sounds on auscultation. Pronounced deceased at 02:13 (AM) by the nurse, RN . No documented investigation was provided with the incident report. On [DATE] at 2:14 PM, the Administrator was asked to confirm via email that there was no investigation associated with the above-mentioned incident report regarding R80's death. The Administrator replied that there was no specific investigation and that the notes were documented in the progress notes. On [DATE] at 3:55 PM, an interview was conducted with the Administrator, who was the Abuse Coordinator for the facility. When queried about whether she was notified about R80's death and how he was found, the Administrator reported the nurse (RN 'H') called her and said R80 was found on the floor with his head stuck between the bed and the dresser and that he was deceased . When queried about how that happened, the Administrator reported she did not know and asked LPN 'H' what she thought happened. According to the Administrator, RN 'H' said maybe R80 had a seizure but was not sure if he had a seizure disorder. The Administrator reported she did not conduct an investigation beyond talking to RN 'H' when she contacted her and stated, The Medical Examiner wasn't concerned so she did not look into it further. The Administrator reported she did not interview the CNA who provided care or who found R80 and did not interview R80's roommate. On [DATE] at 3:41 PM, an interview was conducted with the DON. When queried about R80 being found with his head stuck between the bed frame and armoire and his death and what was done to look into what happened, the DON reported it was not investigated and said it should have been. On [DATE] at 8:05 AM, an interview was conducted with RN 'H', who was the nurse assigned to R80 on the night shift on [DATE]-[DATE]. When queried about what happened with R80 on [DATE], RN 'H' reported she was called to the room by two Certified Nursing Assistants (CNAs), one of them being CNA 'J'. They told her R80 was out of bed. When RN 'H' entered the room, R80 was observed with his head face down stuck between the armoire and the bed frame with his feet forcefully wedged underneath the metal base of the over bed table that was beside the bed. RN 'H' explained R80 was unable to be freed from between the bed and the armoire without moving the nightstand on the opposite side of the bed and moving the bed away from the armoire. It was not until she got R80 unstuck that she was able to assess him and determined he was deceased . RN 'H' further explained the way R80 was positioned was unusual and could not have happened from a fall and likely did not happen during care. RN 'H' reported she had never experienced anything like what she observed with R80. RN 'H' reported R80 was not a fall risk and was unable to move himself in bed. RN 'H' reported she notified the Administrator/Abuse Coordinator right away. On [DATE] at 8:30 AM, an interview was conducted with CNA 'J' who was assigned to R80 on the night shift of [DATE]-[DATE]. CNA 'J' was asked to explain any interaction and/or care provided to R80 on that shift and to describe what happened when he was found deceased . CNA 'J' confirmed she was the CNA assigned to R80 and checked on R80 every two hours throughout the shift. CNA 'J' explained the nurse got her at some point to re-center R80 in bed because he was trying to crawl out of the bed and was on the edge. CNA 'J' repositioned R80 with another CNA at that time. CNA 'J' further reported she had to reposition R80 in the bed twice that shift because he was on the edge. Later in the shift, CNA 'J' responded to R80's roommate whose tube feeding machine was beeping and she noticed R80 on the floor. CNA 'J' got RN 'H' who came to the room immediately. R80's head was wedged face down between the bed frame and the armoire and his body was on the floor with his feet underneath the over-bed table. They were unable to get R80's head out and had to move the nightstand and the bed to pull his head out. When RN 'H' assessed R80, he was not breathing. CNA 'J' explained R80 was not a fall risk and did not have a history of falls but would sometimes try to get out of bed. When queried about whether she was interviewed by Administration after the incident, CNA 'J' said Not until yesterday. A review of a facility policy titled, Abuse, Neglect and Exploitation, revised 9/2025, revealed, in part, the following, .Possible indicators of abuse include, but are not limited to .Physical injury of a resident, of unknown source .An immediate investigation is warranted when suspicion of abuse, neglect of exploitation, or reports of abuse, neglect or exploitation occur .Investigations may include but not limited to .Providing complete and thorough documentation of the investigation .

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to address a resident's ileostomy [surgically created opening to allow waste to exit the body] for one [R35] of one resident reviewed for ostomies. Findings include:On 3/30/26 at 9:11 AM, R35 was observed sitting on the side of the bed. R35 was asked about care at the facility. R35 explained she had an ileostomy and needed assistance emptying and changing the bag. Review of the clinical record revealed R35 was admitted into the facility on 2/25/26 with diagnoses that included: kidney disease, osteoarthritis and ileostomy status. According to the Minimum Data Set [MDS] assessment dated [DATE], R35 had intact cognition and had an ostomy.Review of R35's comprehensive care plan revealed no care plan for an ileostomy.On 3/31/26 at 1:13 PM, the Director of Nursing [DON] was interviewed and asked if a resident should have a care plan for an ileostomy if they had one. The DON explained if a resident had any type of ostomy, it should be in the care plan.Review of a facility policy titled, Care Planning revised 6/2023 read in part, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. Any special needs.

This citation pertains to intake 2801923.Based on observation, interview, and record review, the facility failed to thoroughly assess and document a change in condition for one (R79) of two residents reviewed for changes in condition. Findings include: On 3/30/26 at 10:13 AM, R79 was observed in bed. He was holding himself between his legs with his feet pressed against the foot board. R79 had some twitching movements and appeared disheveled. When spoken to, R79 mumbled and was difficult to understand. On 3/30/26 at approximately 11:00 AM, R79 was observed exiting the facility on a stretcher with EMS (Emergency Medical Services) staff. On 3/30/26 at 1:00 PM and 3:30 PM a review of R79's clinical record revealed R79 was sent to hospital in a Medication Administration Note. There was no documentation of why R79 was sent to the hospital. Further review on 3/31/26 at 9:00 AM and 1:14 PM, revealed no progress notes that documented why R79 went to the hospital on 3/30/26. Progress notes indicated R79 returned to the facility on the same day, 3/30/26. On 3/31/26 at 8:55 AM, R79 was observed lying in bed receiving oxygen via nasal cannula. R79 was able to participate in an interview on that date. R79 confirmed he was sent to the hospital the previous day but said he did not know why he went and that they sent him after he woke up. R79 expressed not feeling well and having difficulty breathing, but it was likely due to anxiety and would receive his anxiety medication soon. A review of a R79's assessments on 3/31/26 at 12:15 PM revealed no transfer form or change of condition assessment was completed for R79 to indicate what was going on with the resident. There was no progress note that documented R79 was readmitted into the facility. A review of R79's physician's orders revealed no order to send R79 to the hospital on 3/30/26. On 3/31/26 at 12:31 PM, an interview was conducted with the Director of Nursing (DON). When queried about what the expectation was for assessment and documentation if a resident had a change in condition and was sent to the hospital, the DON reported there should be a discharge emergent note in the progress notes, a physician's order to send to the hospital, and an E interact transfer form that included the assessment of the resident at the time of the change in condition. When queried about why R79 was sent to the hospital on 3/30/26, the DON said Unit Manager, Licensed Practical Nurse (LPN) 'K' and LPN 'M' sent him to the hospital and would have more information. The DON reviewed R79's clinical record and confirmed there was nothing documented according to the facility's policies and procedures and it should have been. On 3/31/26 at 12:50 PM, an interview was conducted with LPN 'K'. When queried about why R79 was sent to the hospital on 3/30/26, LPN 'K' said the nurse came to get him and said R79 was not verbally responding. LPN 'K' and LPN 'M' assessed R79 together and checked his vital signs which were within normal limits, but he was not responding and R79's son who worked in the facility said something was not right with the resident. R79 was then sent to the hospital. LPN 'K' reported LPN 'M' should have completed a discharge emergent note, obtained a physician's order, and completed a transfer form. LPN 'K' reported R79 had a change in condition a couple days prior but was not sent to the hospital. A review of R79's progress notes revealed a not dated 3/28/26 that noted, Patient told aide that he was having trouble breathing. I went into the room and checked his O2 (oxygen) saturation. Patient was stating at 68 (percent) on 4L (liters). I got patient a non-rebreather on 6L. Patient's O2 is at 96. Patient is back on nasal cannula. Dr. notified. The note was written by LPN 'X'. Further review of R79's clinical record revealed an incomplete change of condition assessment that was left blank and no documentation of what the physician's response was or if they were able to get ahold of them. On 3/31/26 at 1:34 PM, an interview was conducted with LPN 'X'. When queried about R79's change in condition on 3/28/26, LPN 'X' reported she contacted Physician 'Y' via text and made her aware R79's oxygen dropped, required a re-breather, and came back up. LPN 'X' said Physician 'Y' instructed LPN 'X' to monitor R79's oxygen level and gave specific parameters for when to apply oxygen and how much to administer. However, those instructions were not documented in the clinical record. A review of R79's clinical record revealed R79 was admitted into the facility on 3/25/26 with diagnoses that included: lung cancer. A review of a facility policy titled, Change in Condition, revised 6/2023, revealed, in part, the following, .The organization utilizes an interaction platform in the electronic health record to recognize and manage a potential change in condition . There was no additional information about resident assessment or documentation included in the policy.

This citation pertains to Intake 2966880Based on observation interview and record review the facility failed to ensure physician/extender pressure ulcer treatment orders were followed for one [R55] of one resident reviewed for pressure ulcers. Findings include: A complaint was filed with the State Agency [SA] that read in part, .[R55] has bed sores on his bottom with [sic] are not always being taken care of. At times he has no bandages covering the sores and there is no cream or ointment placed on the sores.On 3/30/26 at 9:24 AM, R55 was observed sitting in a wheelchair in his room. R55 was asked if he had any wound or sores on his body. R55 explained he had a wound on his bottom. R55 was asked if the wound was getting better, worse or staying the same. R55 explained he did not know. When asked if the facility was doing treatments on the wound, R55 explained they did sometimes.Review of the clinical record revealed R55 was admitted into the facility on 1/3/26 and readmitted [DATE] with diagnoses that included: acute and chronic respiratory failure, diabetes and heart failure. According to the Minimum Data Set [MDS] assessment dated [DATE], R55 had moderately impaired cognition.Review of an Weekly Skin Sweep for R55 dated 2/17/26 revealed R55 had an open area on the coccyx.Review of a wound consult for R55 dated 2/18/26 read in part, .Wound #1 Coccyx is a Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer. Initial wound encounter measurements are 1.8cm [centimeters] length x 2cm width x 0.1cm depth. Wound bed has 30% granulation, 70% slough [non-viable yellow, tan, gray, green or brown tissue]. Plan: .Cleanse wound with Normal Saline. Apply Medihoney Gel [product that supports wound healing and removes necrotic tissue] QDay/PRN [every day/as needed]. Cover with secondary dressing(s). Plan of Care discussed with Treatment Nurse.Review of wound consults for R55 dated 2/25/26, 3/4/26 and 3/11/26 revealed documentation of Wound #1 as an Unstageable Pressure Injury and the treatment plan continued to be to cleanse wound with Normal Saline and apply Medihoney Gel and cover with a dressing every day and as needed.Review of wound consults for R55 dated 3/18/26 and 3/25/26 revealed documentation of Wound #1 as an Unstageable Pressure Injury and the treatment plan added calcium alginate [product that aids in debridement] along with the continued use of NS and Medihoney with a dressing every day and as needed.Review of R55's February 2026 Treatment Administration Record [TAR] revealed the only treatment for R55's bottom read May apply barrier cream to buttocks BID [two times a day] PRN every shift for skin with a start date of 2/17/26. Review of R55's March 2026 TAR revealed a treatment that read, Cleanse coccyx w/NS [with Normal Saline]. Pat Dry. Apply Medihoney to wound bed. Cover w/ boarder dressing. Every day shift for wound care with a start date of 3/12/26.On 4/1/26 at 9:15 AM, observation of R55's wound with the Consultant Wound Care Physician Assistant [PA] 'L' revealed a wound that appeared almost completely obscured with yellow slough. PA 'L' explained it was an Unstageable Pressure Injury, measured it to be 2 cm x 1.6 cm x 0.1 cm, 90% slough and 10% granulation tissue.On 4/1/26 at 9:20 AM, PA 'L' was interviewed and asked if she had ordered the treatment on R55's wound to be Medihoney from the first time she had seen R55 on 2/18/26. PA 'L' explained she had ordered Medihoney from the beginning. PA 'L' was asked if she put her own orders into the electronic medical record [eMAR]. PA 'L' explained she did not, she would tell the Wound Coordinator who rounded with her and they would put the orders into the eMAR. PA 'L' also explained the Wound Coordinator was usually Unit Manager [UM] 'K', but he had been doing other things for approximately three weeks and someone else had been acting as the Wound Coordinator. PA 'L' was asked if she had been aware the facility had not started using Medihoney until 3/12/26, approximately a month after she had ordered it on 2/18/26. PA 'L' explained she had not known that. PA 'L' was asked if the lack of Medihoney could have delayed the wound from healing. PA 'L' explained it could have delayed the healing; she had been concerned about the wound not healing and staying an Unstageable and had added the calcium alginate because it was not healing.On 4/1/26 at 9:23 AM, UM 'K' was interviewed and asked about R55's wound treatment not including Medihoney for a month after PA 'L' ordered it. UM 'K' explained he would look into the issue.On 4/1/26 at 10:25 AM, the Director of Nursing [DON] was interviewed and asked if treatment orders from the Wound Consultant should be entered into residents' TAR. The DON explained all treatment orders should be entered into the TAR and initiated. When asked why R55's order for Medihoney not being initiated for a month, the DON explained she would look into it.On 4/1/26 at 10:38 AM, UM 'K' explained when R55 was admitted , there was an order to clean the wound with Normal Saline and a place a dry dressing until wound care could be consulted.Review of R55's discontinued physician orders revealed an order dated 2/17/26 that read, Cleanse coccyx with normal saline, pat dry and apply Border gauze or coccyx dressing to ensure wound healing until seen by wound care team. The order was discontinued on 2/17/26 and was never documented as having been done.

Based on observation, interview, and record review, the facility failed to consistently implement fall prevention interventions according to the resident's plan of care for one (R52) of two residents reviewed for falls. Findings include: On 3/30/26 at 9:24 AM, R52 was observed sleeping in bed. A walker and a wheelchair was observed in the room and were placed across the room near the window, not at bedside. When R52's name was called he did not wake up or respond. On 3/30/26 at 2:25 PM, R52 was observed sleeping in bed. R52 was lying horizontally on the bed with his feet and legs partially hanging off the side of the bed. A walker and wheelchair were observed near the window, not at bedside. On 3/30/26 at approximately 11:00 AM, a review of R52's care plans on 3/30/26 revealed the following: A care plan initiated on 5/7/25 and revised on 3/20/26 that noted, I have potential for injury r/t (related to) hx (history) falls, weakness, poor safety awareness, routine psych (psychotropic) med (medication) use, Parkinsonism w/ (with) impaired gait. An intervention initiated on 3/10/25 noted, .ensure that walker is next to bed during all rounding, and during med pass q (every) shift . On 3/31/26 at approximately 8:45 AM, a review of R52's progress notes revealed R52 had a fall on 3/24/26 and was observed on the floor of his room lying on his left side. R52 reported he was getting up to go to the bathroom. A review of a Nursing: Antigravity Team Note dated 3/25/26 revealed R52 had a fall on 3/24/26 and the root cause of the fall was documented as Unassisted ambulation to bathroom. It was documented a prior intervention was ensure that walker is next to bed during all rounding, and during med pass. On 3/31/26 at 9:00 AM, R52 was observed sleeping in bed. R52's walker was observed by the window and not at bedside. On 3/31/26 at 9:15 AM, an interview was conducted with the Director of Nursing (DON) who reviewed R52's clinical record and confirmed R52's walker should have been at bedside as it was a care planned intervention. The DON reported staff should move it to bedside if they notice it is not there. Further review of R52's clinical record revealed R52 was admitted into the facility on 3/26/21 and readmitted on [DATE] with diagnoses that included: dementia and Parkinson's Disease. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R52 had moderately impaired cognition and had a history of falls.

Based on observation, interview and record review, the facility failed to ensure nephrostomy tube [surgically implanted catheter into the kidney to drain urine] drainage bags were positioned correctly for dependent drainage for one [R25] of one resident reviewed for nephrostomy tubes. Findings include:On 3/30/25 at 9:34 AM, R25 was observed lying in bed. A drainage bag was lying on an overbed tray table positioned above the height of the bed on R25's right side. A second drainage bag was lying on a pillow propped against the wall on R25's left side, positioned above the height of R25 lying in bed. Both bags and tubing did not appear to have drainage fluid. R25 was asked what the drainage bags were connected to. R25 explained they were connected to his back. When asked if they were nephrostomy tubes in his kidneys, R25 agreed.On 3/30/26 at 12:35 PM, R25 was observed lying in bed. The nephrostomy tube drainage bags were still positioned above the level of R25's kidneys with no drainage fluid in bags or tubing.Review of the clinical record revealed R25 was admitted into the facility on 2/26/26 with diagnoses that included: acute kidney failure, cancer of the bladder and hydronephrosis [buildup of urine in the kidney]. According to the Minimum Data Set [MDS] assessment dated [DATE], R25 had a Brief Interview for Mental Status [BIMS] exam of 12/15 indicating moderately impaired cognition.Review of R25's physician orders revealed an order with a start date 3/3/26 that read, Keep Nephrostomy tubing taped to skin and connected to a drainage bag placed below the level of kidneys.On 3/31/26 at 12:27 PM, both of R25's nephrostomy tube drainage bags were observed lying on the tray table to R25's right side, above the height of the bed. The bags and tubing appeared empty.On 4/1/26 at 10:22 AM, the Director of Nursing [DON] was interviewed and asked how nephrostomy tube drainage bags should be positioned. The DON explained they should be below the level of the kidneys, due to they relied on dependent drainage the same as a urinary catheter. When informed of the multiple observations of the drainage bags being above the level of the kidneys, the DON explained she wanted to see R25.On 4/1/26 at 10:23 AM, R25 was interviewed with the DON present. The DON asked R25 how his drainage bags got placed on the tray table. R25 explained the staff would put the bag up there when they emptied the bags. Review of a facility policy titled, Nephrostomy Tube Care and Maintenance , undated, read in part, .Drainage Bag Management: Positioning: Always maintain the drainage bag below the level of the kidney to prevent the backflow of urine.

This citation pertains to intake: 2582047. Based on interviews and record reviews the facility failed to identify a substance use disorder (sud) -alcohol, and failed to implement a care plan/interventions for the sud, for one (R302) of one resident reviewed for elopements, resulting in R302 having left the facility without the knowledge of staff. Findings include: A review of the medical record revealed R302 was admitted to the facility on [DATE] with a primary admitting diagnosis of alcohol dependence with withdrawal and was documented to have intact cognition. Further review of the medical record revealed no plan of care or implemented care plan for R302's primary diagnosis of alcohol dependence or withdrawal. A review of the medical record revealed no interventions implemented to ensure the safety of the resident. On 7/25/25 R302 was reported to the State Agency (SA) to have eloped from the facility. On 8/14/25 at 11:55 AM, a telephone interview was conducted with RN D. RN D was asked about being the assigned nurse to R302 when the elopement incident occurred (on 7/25/25) and RN D replied . No, I was not. He (R302) got out sometime between 3:30 to 4 PM. RN D explained that was the time of the dayshift nurse shift and upon receiving report at 6 PM when they came on duty nothing was said about R302 to have been missing. RN D confirmed they had not seen R302 on their shift until they were brought back to the facility by RN C and CNA E.A telephone interview was conducted with Registered Nurse (RN) C on 8/14/25 at 12:47 PM. RN C was asked to recall the elopement incident with R302. RN C stated they received a phone call from a female neighbor of the facility stating a man had been outside of their house since 4 PM. RN C explained how they (along with Certified Nursing Assistant- CNA E) went to the neighbor's house where R302 and a female neighbor were observed yelling at each other. RN C stated initially R302 refused to go back to the facility, however after talking to the resident R302 agreed to go back. RN C stated several neighbors had informed them that R302 was observed outside of the facility since 4 PM. RN C stated the resident also confirmed they had been out of the facility since 4 PM. RN C stated R302 was starving so CNA E went to McDonalds to get them some food, which helped to calm the resident down. RN C stated R302 verbalized that he wanted to get cocktails and still be able to work while admitted to the facility. On 8/14/25 at 1:20 PM, a telephone interview was conducted with CNA E. When asked, CNA E confirmed they arrived to start their shift at 7 PM on 7/25/25. CNA E stated there was no CNA to give them report and the nurse was administering the resident's medications. CNA E explained several incidents that had occurred which caused it to be a busy shift with multiple residents to have required their attention. CNA E stated they did check in R302's room and saw that their dinner tray was untouched. CNA E stated they figured R302 was out on a LOA (leave of absence). CNA E explained it was after 9 PM and they were on their way to the kitchen to make waters and saw a man at the door. CNA E stated the man outside of the facility door informed them that a resident was sitting out in front of their house and had been since 4 PM. CNA E explained at that time RN C had approached the front door of the facility and explained how they received a call from a female neighbor who informed them that R302 was outside of their house. CNA E explained that they along with RN C went to the neighbor's house. CNA E stated R302 was agitated because . him and the neighbor was going back and forth. CNA E stated the neighbors reported that (R302) had asked for beer, an alcoholic drink or a ride. CNA E confirmed that they along with RN C was able to calm the resident down and get R302 back into the facility. On 8/14/25 at 2:42 PM, a telephone interview was conducted with R302. When asked, R302 confirmed they had left the facility by following another person out. R302 also confirmed the dinner tray had not been delivered to them before they left the facility. R302 admitted to having a . rough couple of weeks. and stated . I was not in a good space when I was there.R302 also confirmed that staff came to the neighbor's house and talked them into going back to the facility. On 8/14/25 at 2:05 PM, the Administrator was asked to provide the name of the CNA that was assigned to R302 from 3PM (when the dayshift CNA went off duty) to 7 PM (when CNA E came on duty). The Administrator did not provide a response. It was identified that the staff were unaware of the resident's departure and/or whereabouts from approximately 4 PM until approximately 9:15 PM (the approximate time RN C received the phone call from the reporting neighbor), more than five hours. The facility failed to develop and implement a substance use disorder plan of care and/or care plan for R302's alcohol dependence, resulting in the R302 to have eloped from the facility undetected for several hours in attempts to satisfy their addiction to alcohol. A review of the facility policy titled Behavioral Health Services dated 6/1/23, documented in part . Substance use disorder (SUD) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Facility efforts to help residents with. SUD , such as individual counseling services, access to group counseling or access to a Medication Assisted Treatment program.On 8/13/25 at 3:50 PM, Social Worker (SW) H was interviewed and asked their involvement in the implementation of a plan of care and/or care plan for R302's substance use disorder for alcohol dependence. SW H explained they typically have not created a care plan for substance use disorder. SW H stated they would review the facility policy and talk with the Administrator. SW H stated . I honestly didn't know we had that policy.On 8/14/25 at approximately 8:30 AM, the Administrator was interviewed and asked about the failure to implement a care plan and/or interventions for R302, a resident with a primary admitting diagnosis of alcohol dependence and withdrawal. The Administrator acknowledged the concern. The concern was discussed regarding the lack of a plan of care for the resident substance use disorder (alcohol) that ultimately resulted in the resident to have eloped from the facility undetected for hours to satisfy their addiction. The Administrator stated the facility staff had been re-educated on the elopement policy. The Administration team failed to re-educate the facility staff on the substance use disorder policy. On 8/14/25 at approximately 9:10 AM, the Director of Nursing (DON) was interviewed and asked why a substance use disorder plan or care and/or care plan was not implemented for R302's alcohol addiction. The DON stated usually the social worker completed those types of care plans, however, would look into it. Shortly after the DON confirmed they could not find anything implemented for R302's substance use disorder. The DON stated they would start education with their staff. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: 2583159. Based on interview and record reviews, the facility failed to protect the resident's right to be free from mistreatment by a staff member for one resident (R303) of two residents reviewed for neglect/abuse. Findings include:A review of a Incident Summary submitted by the facility to the State Agency (SA) documented in part . A Nursing Manager reported to this Administrator that an allegation of staff abuse against (R303's name). was brought to his attention at 11:30am on 7/30/2025. The allegation was made by a Certified Nurse's Aide (CNA- CNA J) who informed the nurse manager that another CNA (CNA I) held her hand over the resident's mouth because the resident was yelling. The alleged Perpetrator was suspended immediately pending a facility investigation. (Police department name) was contacted and an officer arrived at the facility to investigate the report.A review of the medical record revealed R303 was admitted to the facility on [DATE] with diagnoses that included: parkinsonism, bipolar disorder with severe psychotic features, and schizoaffective disorder.On 8/13/25 at 2:14 PM, CNA J was interviewed and asked about the incident that occurred with CNA I and R303. CNA J explained that CNA I was helping them change the brief of R303. CNA J stated they rolled (R303) towards CNA I and heard (R303) voice to be muffled. CNA J stated they looked over and observed CNA I 's hand over R303's mouth. CNA J stated they told CNA I not to do that and CNA I responded . she (R303) shouldn't be here she should be in a fu**ing psych ward. CNA J stated that CNA I said they were tired of hearing (R303) screaming. CNA J stated after the incident they went outside to take a few minutes to rethink the situation and returned and reported it to Nurse Manager (NM K). CNA J stated that CNA I was asked to leave the facility and the Administrator followed up with them regarding the incident. (Nurse Manager) NM K was on leave at the time of the survey and was not interviewed. Review of a written statement documented by NM K confirmed CNA J reported to them the incident with CNA I and R303. NM K documented they notified the Administrator after it was reported to them. A review of a written statement conducted with CNA I documented in part . (R303 name) was yelling right in our faces even when we were helping her. (CNA I) reported that she placed one finger over the resident's mouth and shussed <sic> her. R303 denied stating that R303 belonged in a psych ward. A review of the time sheet for CNA I verified their last day on site at the facility was 7/30/25 at 12:17 PM, when they were instructed to leave the facility. A review of a termination letter dated 8/6/25, revealed the alleged perpetrator (CNA I) was terminated due to the incident on 8/6/25. A review of a facility policy titled Abuse, Neglect and Exploitation dated 3/28/22, documented in part . It is the policy of. to follow facility protocol to provide protections for the health, welfare and right of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Mistreatment means inappropriate treatment or exploitation of a resident. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of. efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Reporting of all alleged violations to the Administrator, state agency. law enforcement when applicable.

This citation pertains to intake: 2582047. Based on interviews and record reviews the facility failed to complete a thorough investigation for an elopement and failed to submit accurate details to the State Agency (SA) regarding the elopement incident for one (R302) of one resident reviewed for an elopement. Findings include: Review of an Incident Summary submitted to the SA documented in part . At approximately 9:45pm on Friday 7/25/2025, the Administrator was notified by a facility nurse that a nearby neighbor of the facility contacted her via phone and told her that a resident had approached their house and was asking for a ride. This nurse reported that she and a Certified Nurses Aide went outside the building, found the resident and returned him safely to his room. The resident was in no physical distress.Review of an Investigation Summary documented in part . Time of Occurrence: Approximately 7:35 pm. At 9:15pm, on the day of the incident (Registered Nurse - RN C) was notified by a Certified Nurses Aide (aide) (CNA), that a distressed neighbor was on the phone. (RN C) answered the phone and was informed by the neighbor that one of the facility residents was causing a disturbance outside of the facility. Accompanied by (Aide name), CNA (CNA E), (RN C) immediately went outside to evaluate the situation. Resident (initials) was found standing outside the facility door. It was reported by the neighbors that (R302's initials) had knocked on their door and asked for something to drink. Gatorade was offered but decline by. did trigger for elopement risk as a result of his leaving the premises unsupervised for a period of 2.5 hours. Conclusion: Based on interviews and record reviews. Once elopement was identified as a risk on 7/26/2025, Care Plan was updated. The resident demanded to the leave the facility the following day against medical advice and did so.A review of the medical record revealed R302 was admitted to the facility on [DATE] with a primary admitting diagnosis of alcohol dependence with withdrawal. A review of the admission Elopement Risk Assessment dated 7/17/25 at 1:50 PM, noted . Resident Is Not At Risk for Elopement. The assessment failed to identify the residents substance use disorder (alcohol). Review of a Nursing note created on 7/26/25 and back dated to 7/25/25 at 9:15 PM, documented in part . Notified by CNA to accept phone call from a distressed neighbor of the facility. This nurse informed by neighbor that a resident was causing a disturbance outside of the facility. Accompanied by a CNA, this nurse immediately went outside to evaluate the situation. found standing outside facility door. He explained that he needed to leave to attend to personal matters. Resident escorted into building by CNA. This nurse spoke with neighbors concerning the residents behaviors and disturbance created. This note was documented by RN C. RN C was not the assigned nurse for R302 at the time of the elopement incident. Review of an assignment sheet provided by the facility's Administrator revealed RN D was the assigned nurse for R302 at the time of the elopement incident. On 8/14/25 at 11:55 AM, a telephone interview was conducted with RN D. RN D was asked about being the assigned nurse to R302 when the elopement incident occurred and RN D replied . No, I was not. He (R302) got out sometime between 3:30 to 4 PM. RN D explained that was the time of the dayshift nurse shift and upon receiving report at 6 PM when they came on duty nothing was said about R302 to have been missing. RN D confirmed they had not seen R302 their shift until they were brought back to the facility. RN D read the investigation summary details regarding the resident to have been missing for a little over two hours and RN D replied .What was reported was not correct. RN D explained how the neighbors who informed the staff that R302 was at their house stated that the resident was out there for more than six hours. RN D explained they had no CNA to help with their assignment until 7 PM, when CNA E came on duty. RN D stated it was RN C and CNA E who went to get the resident on the night of 7/25/25 from the neighbor's house. On 8/14/25 at 12:47 PM, a telephone interview was conducted with RN C. When asked, RN C stated R302 was not outside the facility door, the male neighbor was outside the facility's door as they (RN C and CNA E) were leaving the facility to go to the neighbor's house to get R302. RN C explained how they (along with CNA E) went to the neighbor's house where R302 and a female neighbor were observed yelling at each other. RN C stated initially R302 refused to go back to the facility, however after talking to the resident R302 agreed to go back. RN C stated several neighbors had informed them that R302 was observed outside of the facility since 4 PM. RN C stated the resident also confirmed they had been out of the facility since 4 PM. RN C stated R302 was starving so CNA E went to McDonalds to get them some food, which helped to calm the resident down. RN C stated R302 verbalized that he wanted to get cocktails and still be able to work while admitted to the facility. RN C was asked about the discrepancies regarding their documented note and what was submitted to the SA and RN C stated they informed the Administrator that if the SA questioned them about the elopement incident that they were not going to lie. RN C feared retaliation from the Administration for being truthful with the surveyor. RN C was asked if they reported the same details in its entirety to the Administrator during the investigation and RN C confirmed they reported everything to the Administrator.On 8/14/25 at 1:20 PM, a telephone interview was conducted with CNA E. When asked, CNA E confirmed they arrived to start their shift at 7 PM on 7/25/25. CNA E stated there was no CNA to give them report and the nurse was administering the resident's medications. CNA E explained several incidents that had occurred which caused it to be a busy shift with multiple residents to have required their attention. CNA E stated they did check in R302's room and saw that their dinner tray was untouched. CNA E stated they figured R302 was out on a LOA (leave of absence). CNA E explained it was after 9 PM and they were on their way to the kitchen to make waters and saw a man at the door. CNA E stated the man outside of the facility door informed them that a resident was sitting out in front of their house and had been since 4 PM. CNA E explained at that time RN C had approached the front door of the facility and explained how they received a call from a female neighbor who informed them that R302 was outside of their house. CNA E explained that they along with RN C went to the neighbors house. CNA E stated R302 was agitated because . him and the neighbor was going back and forth. CNA E stated the neighbors reported that (R302) had asked for beer, an alcoholic drink or a ride. CNA E confirmed that they along with RN C was able to calm the resident down and get R302 back into the facility. CNA E was asked if they reported the same details to the Administrator during the investigation and CNA E confirmed they reported the same details to the Administrator. On 8/14/25 at 2:42 PM, a telephone interview was conducted with R302. When asked, R302 confirmed they had left the facility by following another person out. R302 also confirmed the dinner tray had not been delivered to them before they left the facility. R302 admitted to having a . rough couple of weeks. and stated . I was not in a good space when I was there.R302 also confirmed that staff came to the neighbor's house and talked them into going back to the facility. On 8/14/25 at 1:55 PM, Licensed Practical Nurse (LPN) G (the dayshift nurse assigned to R302) was interviewed. When asked LPN G could not recall the exact time R302 was last seen by them, but stated the resident was observed several times throughout their shift. When asked if any of the Administration staff and/or anyone had followed up with them regarding the elopement of R302, LPN G stated . No, no one.A review of the employee statements revealed no statement obtained from the dayshift nurse for R302 on 7/25/25. This is the shift the resident allegedly eloped on. Further review revealed statements from RN C and CNA E that reflected the investigation summary submitted to the SA, however, lacked the details provided to the surveyor and the Administrator as verbalized by the staff. The investigation did not contain a statement from R302 who was documented to have been cognitively intact. On 8/14/25 at 2:05 PM, the Administrator was asked to provide the name of the CNA that was assigned to R302 from 3PM (when the dayshift CNA went off duty) to 7 PM (when CNA E came on duty). The Administrator did not provide a response. On 8/14/25 at 2:49 PM, the Administrator was interviewed and confirmed they were the Abuse Coordinator for the facility and had conducted R302's elopement investigation. The Administrator was asked about the discrepancy of the duration of time the resident had eloped from the facility. The Administrator denied to have been informed by the multiple staff members of the neighbors observation to have seen the resident outside of their home since 4 PM. The Administrator was asked if they had interviewed the neighbor during their investigation and the Administrator stated they did not. The multiple discrepancies with their investigation was discussed and compared with what was submitted to the SA. When asked why a statement had not been obtained by the assigned nurse to R302 for the day shift of 7/25/25, the Administrator stated he did not have an answer for that. No further explanation or documentation was provided by the end of the survey.

Based on interviews and record reviews the facility failed to ensure all admission orders were reported and reconciled with the Physician for one (R302) of one resident reviewed for an elopement. Findings include: A review of the medical record revealed R302 was admitted to the facility on [DATE] with a primary admitting diagnosis of alcohol dependence with withdrawal and was documented to have intact cognition. A review of R302's hospital discharge medications revealed the following:Lorazepam tablet sliding scale. If CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) is 0-7: No Benzodiazepine dose indicated. 1 mg (milligram) if CIWA-AR Mild - MOD 8 -15. 2 mg if CIWA - AR Mild - MOD 16-67. Greater than 35, Notify Provider. PO (by mouth), every 2 hours PRN (as needed) for Per CIWA Scale. If CIWA-Ar is 0-7: No Benzodiazepine dose indicated. If CIWA-Ar is 8-15, give 1mg then reassess 2hrs after dose given. If CIWA-Ar >15, give 2mg then reassess 1 hr after dose given (Maximum dose 12mg/day). If score > 35 give dose indicated and notify provider; IV (intravenous) if unable to take PO. A review of the medical record and Physician orders revealed the as needed CIWA protocol was not reconciled or implemented like the rest of the medications documented on the hospital discharge medication report. On 8/14/25 at approximately 9:10 AM, the Director of Nursing (DON) was interviewed and asked why the CIWA alcohol withdrawal protocol was not implemented like the rest of the medications on the hospital discharge document. The DON stated they would look into it and follow back up. At 10:44 AM, the DON returned with Physician F (the assigned Physician to R302). Physician F was asked if they were informed of the as needed CIWA protocol that was on the discharge medication list from the hospital and Physician F stated they were not informed. The DON stated they were also unaware of the hospital discharge medication list that noted the CIWA protocol. The DON and Physician F stated they would start education with their staff. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: 2570372.Based on interview and record reviews the facility failed to accurately identify a pressure wound, accurately documented the worsening and correct staging of a coccyx wound for one (R301) of one resident reviewed for pressure wounds. Findings include:Based on interview and record reviews the facility failed to accurately identify a pressure wound, accurately documented the worsening and correct staging of a coccyx wound for one (R301) of one resident reviewed for pressure wounds. Findings include:A review of a complaint submitted to the State Agency (SA) documented concerns regarding the accurate assessment and description of the resident's pressure wound. A review of the medical record revealed R301 was admitted to the facility on [DATE] with a primary diagnosis of dementia and required staff assistance with all Activities of Daily Living (ADLs). A Nursing note dated 6/25/25 at 3:55 PM, documented in part . This writer was informed by resident's aide that resident had an opening located on the coccyx (L). This writer went to assess resident and see in fact there an <sic> opening on her coccyx. This writer. wound care nurse. Wound care nurse came to assess. DX (diagnosis):MASD (moisture associated skin damage). This writer was cleanse <sic> Coccyx w (with)/N.S. (normal saline) Pat dry. Apply Medihoney to wound bed. Cover with ABD (abdominal) and tape closed. This will be the treatment in place for the MASD. This note was documented by Licensed Practical Nurse (LPN) A.A review of the wound consultation reports completed by the facility's third party wound clinic revealed the following: A wound consult dated 7/2/25, documented in part . Wound #1 Coccyx is an acute Partial Thickness MASD and has received a status of Not Heal. Initial wound encounter measurements are 2.5cm (centimeters) length x 1.3 cm width x 0.1 cm depth, with an area of 3.25 sq (square) cm and a volume of 0.325 cubic cm. Wound bed has 100%, pink, granulation. Irritant contact dermatitis due to friction or contact with body fluids.A wound consult dated 7/9/25, documented in part . This patient seen today for a follow-up visit for the management of the patient's wound. Wound #1 coccyx is an acute Partial thickness MASD and has received a status of Not Healed. Subsequent wound encounter measurements are 2.3cm length x 1.5cm width with no measurable depth, with an area of 3.45 sq. cm. There is scant amount of sero-sanguineous drainage noted. The wound margin is well defined Wound bed has no granulation, 100% slough (non-viable yellow, tan, gray, green or brown tissue. Maybe adherent to the base of the wound or present in clumps throughout the wound bed).A wound consult dated 7/16/25, documented in part . Coccyx is an acute Partial Thickness MASD and has received a status of Not Healed. Subsequent wound encounter measurements are 2.5cm length x 2.3 cm width with no measurable depth, with an area of 5.75 sq cm. There is scant amount of sero-sanguineous drainage noted which has no odor. The wound margin is well defined Wound bed has no, granulation. 100% slough.A stage 2 pressure ulcer is identified as a partial-thickness loss of skin with exposed dermis. A progress note dated 7/17/25 at 9:04 AM, documented . Pt (patient) was taken to hospital by granddaughter on 7/16/25.A review of the hospital documentation (7/16/25) to revealed the following in part . presenting from her living facility. per request of granddaughter who is patient's guardian for change in patient's mentation as well as a suppose it new bedsore that was 'extremely dirty and contaminated.' . Stage 3 pressure ulcer of coccyx (Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough maybe visible but does not obscure the depth of tissue loss). Tissue trauma consult. Present on admission.On 8/13/25 at 1:17 PM, LPN A was interviewed and asked to review their note documented on 6/25/25. LPN A stated they remembered the observation. LPN A was asked to describe the wound. LPN A confirmed the wound to be circular and stated the . hole was not bigger than a nickel. LPN A confirmed the loss of the top layer of the skin for the wound. The facility wound nurse was not present for the duration of the survey and was not interviewed. On 8/13/25 at 1:41 PM, the Director of Nursing (DON) was interviewed and questioned about the accuracy of the wound assessments for R301 on 7/2/25, 7/9/25 and 7/16/25. The review of the hospital diagnosis of the wound on the same day the resident was last assessed in the facility on 7/16/25, was reviewed. The DON stated they would look into it and follow back up. On 8/13/25 at 3:34 PM, the DON returned with the Wound Physician (WP) B on the phone for an interview. The connection of the call was bad and the interview was not conducted at that time. On 8/14/25 at 3:14 PM, a telephone interview was conducted with WP B the concern of the accuracy of the staging of the wound compared to the documented assessment of the wound was discussed. WP B acknowledged the wound initially started as MASD. WP B stated they could have changed the documentation of the staging of the wound as it worsened. WP B stated their assessment noted the exact description of the wound, however acknowledged the wound staging documentation should have been updated. No further information or documentation was provided before the end of the survey.

This citation pertains to intake: 2570372.Based on interview and record reviews the facility staff failed to follow the recommendation of the psych nurse practitioner (NP) and failed to identify a change of condition (urinary tract infection - uti) as the cause of a mental status/behavioral changes for one (R301) of two residents' reviewed for neglect/abuse. Findings include:A review of the medical record revealed R301 was admitted to the facility on [DATE] with a primary diagnosis of dementia and required staff assistance with all Activities of Daily Living (ADLs). A Social Service Progress Note dated 6/26/25 at 8:03 AM, recapped the recommendations from a psych consultation which documented the following . Seen 6/25/25 by (psych clinician name), NP (nurse practitioner) with psych services. Consult states the following. Patient presents with increased anxiety, agitation, and aggression. Emphasis should be placed on ruling out underlying medical or environmental contributors. Patient has a known and established history of significant agitation in the presence of acute etiologies, particularly UTIs. If behavioral changes continue to persist, would advise consideration to repeat urine analysis.A Nursing progress note dated 7/16/25 at 4:31 PM, documented in part . This writer contacted the guardian because the patient was having a behavior with another resident. The resident was heard and seen calling the resident a whore hopper and a Bitch, The granddaughter asked to speak with her. The resident did speak with her. The writer was asked to take the phone and speak with (guardian name). she told me she was having a NP (nurse practitioner) look over the resident medications. And she will be here later to see (R301's name).A Nursing progress note dated 7/16/25 at 5:28 PM, documented in part . the resident has been sitting at the nurse station for the past hour. She has been singing and to <sic> talking with this writer and other staff. The resident mood back at baseline with no memory of the previous behavior.A review of the medical record revealed a repeat urinalysis was not considered, ordered or obtained, as the recommended documentation by the psych NP on 6/26/25. A discharge emergent note dated 7/16/25 at 11:08 PM, documented the family of R301 called emergency medical services to transport R301 to the hospital regarding medical concerns with the resident. A review of the hospital documents revealed the following: . presenting from her living facility. per request of granddaughter who is patient's guardian for change in patient's mentation. Family is concerned that patient has a urinary tract infection due to her change from [NAME] <sic> (alert and oriented) to self and place to [NAME] to self. Patient was combative on July 16, 2025. Mentation was worsening from her baseline. Further review of the hospital documents revealed the identification of . Sepsis due to Enterobacter species (type of bacteria). Enterobacter cloacae complex bacteremia (presence of bacteria in the bloodstream) secondary to a urinary tract infection. On IV (intravenous) cefepime (antibiotic) and plan a 14-day course of therapy. Urinary tract infection. ID (infectious disease) on case. present on admission.The facility staff failed in following the recommendation of the psych nurse practitioner and failed to identify R301's urinary tract infection. On 8/13/25 at 1:41 PM, the Director of Nursing (DON) was asked about the mental and behavioral changes documented for R301 and why follow-up testing to rule out a UTI was not completed as recommended by the psych NP. The DON stated they were unaware of the psych NP recommendation and would look into it and follow back up. On 8/14/25 at 9:05 AM, the DON returned and stated they had missed the repeat urinalysis recommendation. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: 2570372.Based on interview and record reviews the facility failed to identify, follow up and follow the facility policy on weight loss for one (R301) of one resident reviewed for weight loss. Findings include: A review of the medical record revealed R301 was admitted to the facility on [DATE] with a primary diagnosis of dementia and required staff assistance with all Activities of Daily Living (ADLs). A review of the resident Weight Summary documented the following: 7/3/25 at 1:25 PM- 134.4 lbs (pounds)6/5/25 at 3:04 PM- 150.8 lbs This indicates a -10.88 loss in less than a month. There was no recorded re-weight to confirm the weight loss documented. A record review of the Electronic Medical Record (EMR) and Nutrition assessments/notes were all reviewed, and none identified the clarification of the 7/3/25 recorded weight, notification to the dietician/physician, monitoring, interventions or modifications to the resident's nutrition plan of care. A review of the facility policy titled Weight Monitoring revised 01/21 documented in part .Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight to determine if a re-weight is necessary.On 8/13/25 at 1:41 PM, the Director of Nursing (DON) was interviewed and asked about the recorded weight loss on 7/3/25 and the lack of follow up. The DON replied the staff should have notified them, and a re-weight should have been obtained. The DON confirmed they were not notified of the recorded weight loss. The DON stated they would look into it further and follow back up. On 8/14/25 at 9:05 AM, the DON returned and stated the therapy staff obtained both weights in June and July 2025, however failed to inform them of the recorded weight loss. The DON stated education will be conducted with the therapy staff. No further explanation or documentation was provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to implement an effective plan of action to correct identified quality deficiencies related to controlled substances (medications regulated by the government due to having a high risk of abuse and/or addiction), resulting in the continuation of deficient practices related to having an effective process to accurately account for all controlled substances for six (R704, R705, R706, R707, R709, and R710) of seven residents reviewed. This had the potential to affect all residents who resided in the facility who were prescribed controlled substances. Findings include: On 8/12/25, a revisit survey was conducted to determine compliance with deficiencies identified during the facility's recertification survey completed on 7/8/25According to a CMS (Center for Medicare and Medicaid) 2567 form dated 7/8/25, the facility was found to be noncompliant with regulatory requirements related to pharmacy services/controlled substances, specifically the failed to ensure appropriate documentation of administration and accountability of controlled substances. A review of the facility's Plan of Correction (POC) with an alleged compliance date of 8/2/25 revealed the facility would do the following to correct the deficient practice: .An audit was conducted of all current narcotic count sheets, for Norco and/or Morphine, to identify any discrepancies. This audit was completed on 7/8/25 .Training for all nursing staff involved in handling narcotics, focusing on proper documentation practices and the importance of legible handwriting was conducted. A segment on managing and counting liquid narcotics accurately, addressing common pitfalls and best practices was included. A system of accountability was established where repeated errors in narcotic counts or documentation will lead to further training or potential disciplinary actions based on the severity and frequency of the errors and was completed by 8-2-2025 . (Contracted pharmacy) was contacted to request additional tracking-controlled substance records be sent with Morphine orders to improve the reliability of Morphine tracking by providing sufficient documentation space. Requirements were added to document the tracking-controlled substance records using black ink, writing legibly and documenting immediately after administration of the medication .The Director of Nursing (DON) or designee under the direction of the Consulting Pharmacist will complete weekly audits x 6 weeks of narcotic count sheets to ensure compliance with new documentation standards and accuracy in narcotic counts and that all issues identified have been addressed and are appropriate. The findings will be submitted to Quality Assurance and Performance Improvement (QAPI). Any concerns identified will be addressed immediately .On 8/12/25, it was identified that there were concerns with 1. accurately accounting for liquid morphine (not recording the actual amount when received from the pharmacy and documenting conflicting amounts used versus what was remaining in the bottle), 2. conducting an inventory count for the medication carts according to proper procedures (counting done with the incoming and outgoing nurse and both nurse's signing off at the time of the count), and 3. documenting on the controlled substance records when a medication was used from the supply. A review of facility audits implemented and initiated due to the prior identified deficiency with controlled substances revealed the first audit was completed on 8/4/25 (two days after the facility's alleged compliance date according to their POC. The 8/4/25 audit was conducted by Unit Manager, Licensed Practical Nurse (LPN) 'F' and included the resident who was the subject of the deficiency (R704) during the abbreviated survey on 7/8/25. The audit included a section that asked, Is the resident receiving scheduled Norco or Morphine Y (yes)/N (no) and a second section that asked, Did the scheduled doses in the MAR (Medication Administration Record) match the control substance record? Y/N Both sections were marked Y for R704 who was originally cited on 7/8/25, despite identified deficiencies with accurate documentation and counting of R704's Morphine. A second audit was conducted by LPN 'F' on 8/6/25 and included R709, a resident sampled on the 8/12/25 survey who deficiencies were identified related to accurate counting of liquid morphine upon receipt from the pharmacy and after use. The audit indicated there were no issues with R709. On 8/12/25 at 12:05 PM, the DON was asked about the auditing process implemented to correct the deficient practice identified on 7/8/25. The DON reported LPN 'F' was assigned to complete the audits and she did not receive any report of identified issues and did not conduct any audits herself. The DON reported the only audits they had were the ones completed by LPN 'F' on 8/4/25 and 8/6/25. At approximately 12:30 PM, the DON was further interviewed regarding R704 and the deficiencies identified. When queried about whether the items on the audit forms captured all the elements of compliance with controlled substances, the DON reported more was supposed to be audited besides comparing the controlled substance record to the MAR. On 8/12/25 at 3:55 PM, an interview was conducted with the Administrator. The Administrator reported they held a QAPI meeting on 7/30/25 and no concerns were brought up. When queried about whether he was aware that audits were not started until after 8/2/25, their POC date, the Administrator reported he was not aware. When queried about how it was determined the plan of action implemented to correct the identified deficiency related to controlled substances was effective, the Administrator did not offer a response. The Administrator was not aware of ongoing deficiencies related to controlled substances and therefore had not implemented any new action plans to correct them. A policy regarding the facility's QAPI program was requested. However, the policy provided only included information on data collection and not the facility's QAPI program.

This citation pertains to Intake Number(s): MI00138552. Based on observation, interview, and record review, the facility failed to ensure physical abuse did not occur for two (R804 and R805) of five residents reviewed for abuse, resulting in R804 choking R805, and other residents reported feeling scared, unsafe, and/or had nightmares after the abuse occurred (R807, R808, R809). Findings include: Review of a Facility Reported Incident (FRI) was submitted to the State Agency on 7/15/23 revealed the facility reported a physical abuse incident that occurred between R804 and R805. An unannounced, onsite investigation was conducted from 8/1/23 through 8/2/23. Review of R804's clinical record revealed R804 was admitted into the facility on [DATE], was discharged to the hospital on 7/15/23, and readmitted on [DATE] with diagnoses that included: schizoaffective disorder bipolar type, post traumatic stress disorder (PTSD), and dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R804 had intact cognition and verbal behaviors. Review of a care plan initiated on 3/10/22 revealed, (R804) at risk for changes in mood/behav (behavior) r/t (related to) dx (diagnoses) depress (depression)/del d/o (delusional disorder), schizoaffective d/o bipolar type .He can be paranoid/short tempered/easily angered, not tolerant of alternative lifestyles . Review of R804's progress notes revealed the following documentation: 7/12/23 at 7:46 PM, Nursing Progress Note written by Nurse 'K' - Late Entry: .around 730pm, writer sitting at nursing station, could hear resident yelling in room with closed door, after knocking, resident refused entrance but after being unable to hear what writer was saying resident allowed writer in room, multiple items on floor, question what happened, resident yelled I hate this place, I hate my stuff, I hate being here, confirmed that he through <sic> items on floor, pushing walker, punching table, cont (continued) to yell, writer stated, you need to stop, resident through <sic> self into chair, sliding chair back and almost falling out, writer about to calm resident with 5 sensed calming tech, resident started talking about topics that anger resident, politic, religion, gay people, his lawyer, his brother, able to redirect, to find out that his phone was not working properly, writer assisted with phone, needs to be changed. assisted resident with calling brother in meeting room called the fishbowl, he left message, resident calmer with no yelling however clear unlined agitation. 7/13/23 at 12:05 PM Nursing Progress Note written by Nurse 'K' - .around 1030am, resident in hallway coming back from dayroom, resident talking to self with agitation, I'm never going to that room again (dayroom), I hate this place, I hate my life, I hate everything, writer overheard resident, question if resident needed anything, resident yelled, (Nurse 'K') there is no point to this or anything, picking up handles of walker and slamming walker down, resident walked quickly away, able to stop resident with calm words, resident sat with nurse doing breathing exercises, effective, discussed what resident needed, resident mad about other resident being 'babied', discussed how everyone is here for a reason and the staff are using their skilled <sic> to help everyone based on their dx (diagnosis), resident pleased with answer and able to move pass challenging moment, resident wanted to call brother, assisted, effective. 7/14/23 at 9:48 PM Physician's Progress Notes - Patient has an episode of severe agitation and staff is worried for his safety .Response: 1- anxiety and depression worsening- discussed with NP (Nurse Practitioner) and DON (Director of Nursing). Will add Abilify (an antipsychotic medication) 5mg (milligrams) for two weeks and if not enough change increase to 10 (mg). DC (discontinue) seroquel (an antipsychotic medication) as it has not helped . 7/15/23 at 2:36 PM Nursing Progress Note - resident lost control of himself and choked another resident in the dining room Responsible party notified , Physician notified, Administrator notified , DON notified . Immediate intervention implemented: resident transferred to (hospital) for psych (psychiatric) eval (evaluation) . Further review of R804's progress notes revealed the following: On 10/25/22, a Social Services Progress Note documented, .We received his notes today. He told him that he was 'mood swings' and a bad temper, but claimed he was not aggressive . On 12/15/22, an Activity Progress Note documented, Resident has become frequently anxious about other residents' involvement in activities .expressed frustration not being able to sit by certain residents, have other residents' attention, and expresses anxiousness about other residents possibly bumping into others . On 12/15/22, a Nursing Progress Note documented, resident had difficulty in dayroom on 12/14/22, Resident stated, I don't want some of the other resident around, they don't need to be in there, they are nothing but stupid .Resident stated that the other people give him anxiety . On 3/6/23, a Nursing Progress Note documented, .social with staff and other resident, in dayroom, resident complaining about other resident volume and dementia behaviors happening on other side of room . On 3/9/23, a Nursing Progress Note documented, during morning meds resident stated that he was feeling so angry and discussed <sic> with this world, resident was watching TV, resident stated he was watching the news ad <sic> they were talking about people choosing to change to become the opposite sex, resident shaking fist, face turning red . On 3/30/23, a Physician's Progress Notes documented, Pts (patient's) anxiety does not seem to be improving - nursing reports he gets very riled up by a few other residents . On 4/5/23, a Physician's Progress Notes documented, Per nursing pt has been having more increased anxiety .they report small incidents will set him off and he gets worked up easily. On 4/13/23, a Nursing Progress Note documented, at shift change, resident self propelled in w/c (wheelchair) from room to day room multiple time with hurried fashion, stopping to say something to nursing staff .upon last lap, resident stopped for shortly, then continued to room, slammed door and yelled loud being heard at nursing station . On 4/17/23, a Nursing Progress Note documented, during am (AM) med pass, resident shaking head, shaking fist, yelling about how other residents were taking the seat that his friend .normally sits in during activities .BP (blood pressure) elevated, face red . On 4/22/23, a Nursing Progress Note documented, Resident has been anxious and crying intermittently for 2 days. He stated, 'I have very angry thoughts. On 5/1/23, a Nursing Progress Note documented, resident has been having difficulty tolerating certain residents in the dining room during activities and at other times too. resident will get very anxious and upset and taking himself out of the situation . On 5/3/23, a Physician's Progress Notes documented, Pts (patients) anxiety does not seem better controlled even with adjustment and <sic> med (medication) .he discussed with me some things that were making him anxious .he does have anxiety about 2 residents in the facility and he does not like their behaviors . On 6/1/23, a Physician's Progress Notes documented, Pt continues to have anxiety that waxes and wanes. It is more situational and he is more agitated when around certain residents . On 7/3/23, a Nursing Progress note documented, Resident tries to get residents/staff to engage in conversation about religion and politics. When someone refuses or states I don't want to talk about the subject he gets upset . On 7/4/23, a Nursing Progress Note documented, resident having increased behavior, easy to anger, such as when his BP is higher than expected, no extra straw for drink, when someone doesn't say hello back to him. Resident pounds fist on table to chair, slamming his door, quickly ambulating in hallways multiple laps. When talking to resident in general conversation resident turns conversation political or religion. these topics cause him to become agitated . On 7/7/23, a Nursing Progress Note documented, around 730am, resident at desk asking for ice cup, writer on phone call, indicated to resident to wait a minute, resident hit walker with closed fist, stormed off yelling that no one ever does what I need, slamming door . On 8/2/23 at 9:50 AM, an interview as conducted with R805. When queried about what happened in the dining room on 7/15/23, R805 reported he was in the dining room listening to music and R804 came into the room and started yelling at him to turn it off. R805 reported he was trying to turn the music off and R804 lunged toward me and started strangling me. R805 reported it was really scary and he was note sure if I would feel safe if he returned. R805 reported he was told R804's medication was wrong but stated, That's no reason to attack someone!. Review of R805's clinical record revealed R805 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Parkinson's Disease, PTSD, and schizoaffective disorder. Review of R805's MDS assessment dated [DATE] revealed R805 had intact cognition and verbal behaviors that significantly intruded on the privacy or activities of others and significantly disrupted the care or living environment. Further review of R805's clinical record revealed progress notes on 5/26/23, 5/27/23, and 5/29/23 that indicated R805 had verbal altercations with other residents in the dining room during activities. Review of R805's care plans revealed there was no care plan regarding the documented verbal aggression displayed toward other residents. Review of an investigation conducted by the facility and submitted to the State Agency regarding the incident of R804 choking R805, revealed the following: Incident Summary: The Administrator was notified today at 12:09 pm that (R804) approached (R805) in the Dining room, who was playing music from his phone to a speaker, and voiced to (R805) to turn that music off, 'No one wants to hear it'. (R804) then allegedly attempted to choke (R805) .Minor scratch was noted on (R804) and Redness in skin tone was noted on (R805's) Face and neck . .Investigation Summary/Actions Taken: .Resident #1 (R804) .(R804) was most often extremely pleasant toward staff and residents. (R804) frequently struggled with his anxiety and therefore had many medication adjustments (It should be noted that there were multiple documentations in R804's progress notes about their anger and negative feelings toward some of the other residents who were in the dining room dating back to 10/2022) .Resident #2 (R805) .(R805) loves to listen to music and interact with other residents in the facility . .Summary of Incident: The administrator was informed by the Registered Nurse (RN) on duty (Nurse 'J') that, at or about 12:00pm on 7-15-23, (R804) (alleged perpetrator), was in the resident dining room. Other resident in the dining room were: (R805 - alleged victim), (R809) BIMS (Brief Interview of Mental Status - an evaluation to determine cognition) of 15 (A score of 13 to 15 indicates intact cognition), (R808), BIMS of 14, also (two residents who were either non-verbal or had severely impaired cognition). (Nurse 'D') (RN) was passing medication outside the dining room. (R805) (victim) was listening to music on his phone. (Nurse 'D') stated that she saw (R804) quickly move towards (R805) and grabbed him by the throat. (Nurse 'D') quickly intervened, telling (R804) to stop and removed his hands from (R805's) throat. (R805 also grabbed (R804's) hands and tried to assist in removing them from his throat. (R804) was escorted from the dining room. At this time (R804) repeatedly informed (Nurse 'D') that he was sorry and did not know what came over him. It was also noted that (R804) reported that he was worried that other residents would no longer like him and not want him around them. He feared he was going to jail and reported that he couldn't be trusted and that he needed to go somewhere else .(R805) reported he was afraid and did not want (R804) around him anymore .Police were called at 12:23pm and arrived at 12:45pm .(R804) was observed, on 1:1 (one to one), until 3:00 PM when he was sent for psychiatric evaluation at (local hospital) . Interviews: (R804) .Its all my fault. Just put me in jail. I need to go somewhere else . (R805) .I was playing the radio in the dining room. (R804) asked me to turn off my (expletive) music and next thing I knew, he was choking me .Do you feel safe in the facility? .Yes if (R804) isn't here anymore . (R809) .(R804) came into the dining room and verbalized, turn off your (expletive) music. (R805) was trying to turn his music off and (R804) lunged at him and started choking him . (R808) .(R804) started yelling and caught (R805) by the throat. I don't want him to do that to me .Do you feel safe in the facility? .Not with him, (R804) . .In Conclusion: The facility has determined that (R804) made physical contact with (R805) by placing his hands on (R805's) throat and trying to choke him. (R804) was undergoing a medication change, which likely was a contributing factor to the unexplained behavior (It should be noted that R804 had several medication changes throughout their admission due to anxiety, anger, and agitation, as well as documented incidents of issues with other residents in the dining room). The Investigation substantiated the incident occurred as described by all parties however, it does not substantiate willful physical abuse. (R804) was extremely remorseful immediately after the incident and he voiced that he did not know what came over him. (R804) further voiced that he needed to sent somewhere else because he could not trust himself. The investigator finds that (R804) was not acting deliberately when he acted out and therefore finds the allegation of physical abuse to be unsubstantiated. The administrator met with (R805) who voiced that he felt safe in the facility but that he would not feel safe if (R804) was returned to the facility. (R804) was sent to (local hospital) for evaluation and treatment. After consultation with the Interdisciplinary team, the Residents physician as well as the medical director, it was determined that (R804) will not be readmitted to the facility at this time, and until the facility can be assured his plan of care has been altered to ensure the safety of other residents with whom he encounters. The risk to the safety and security of our resident population, along with signed statements attesting to the fear and anxiety that would be caused by (R804's) return has made his, (R804's) readmission unadvisable at this time . Further review of the facility's investigation revealed the following: A signed statement by R809 that documented they feel safe in the facility, although she is worried about him (R804) coming back. A second signed statement by R805 dated 7/15/23 that documented, Yes I feel safe here but that does not meant I want you to bring (R804) back because I don't. He will just go off and do the same thing. I won't feel safe if he is here. A signed statement by a resident who resided in the facility, R807, that documented the following in response to being asked if they felt safe at the facility: With exception of (R804). He should never come back. He flies off the handle. On 8/2/23 at 8:10 AM, R804 was observed in their room laying on the bed with the door closed. CNA 'B' was seated in a chair in the resident's room. R804 got out of bed and into the wheelchair. R804 reported CNA 'B' would know more than he would about why she had to sit in the room with him. Throughout the day, R804 was observed walking around the facility with CNA 'B'. On 8/2/23 8:20 AM, R809, who witnessed the altercation between R804 and R805, was observed lying in bed. Their hands appeared contracted. R809 reported they are dependent on staff for activities of daily living (ADLs). When queried about any witnessed altercations between residents in the facility, R804 reported they witnessed R805 playing music on their phone, R804 came in the dining room and told R805 to turn the music off because it was bothering everyone. R809 explained that nobody else in the dining room was bothered by R805's music and R804 was not in the room when he turned it on. R808 further explained that R805 was trying to turn the music off and R805 came back into the dining room, yelled, and then lunged at R805 and started choking him. R809 stated, It was terrifying. I felt helpless because I could not help (R805). R809 reported R805 appeared to be in shock and was trying to take R804's hands off of his neck. R809 stated, I don't feel safe around him (R804) anymore. He was always up and down. I didn't feel unsafe before and now I do. R809 reported she was told R804 was readmitted into the facility and that she was very unhappy about it. R809 stated, I don't feel safe. (R804) is a ticking time bomb. Review of R809's clinical record revealed R809 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included: multiple sclerosis and quadriplegia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R809 had intact cognition and was totally dependent on staff for ADLs, bed mobility, and transfers. BIMS = 15, total dependence on staff for ADLs, bed mobility and transfers. Review of R809's progress notes revealed a Social Services Progress Note dated 7/20/23 that read, (R809) was witness to an incident between 2 residents on 7/15/23 in which one of the residents but <sic> his hands on the others throat .When I spoke with her today, I asked how she would feel if the resident who had put his hands on the other resident returned to us, She stated, 'It won't be good because he likes to instigate stuff, nobody will be happy'. I asked if she would feel safe here if he returned, She stated, 'No, he's a ticking time bomb, no one knows what to say to him because he can blow up any time, you never know with him. On 8/2/23 at 8:30 AM, R807, who was interviewed as part of the facility's investigation and expressed feeling unsafe around R804, was interviewed. R807 stated, I heard they brought (R804) back last night. I'm really upset about it. We made it clear that we felt unsafe around him and they said he wouldn't be coming back. Review of R807's clinical record revealed R807 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: osteoarthritis and type 2 diabetes. Review of a MDS assessment dated [DATE] revealed R807 had intact cognition and no behaviors. On 8/2/23 at 8:36 AM, R808, who witnessed the altercation between R804 and R805, was observed seated in a wheelchair in her room. When asked about what she witnessed in the dining room on 7/15/23, R808 reported R804 was yelling at R805 and then grabbed his throat and started choking him. R808 stated, It was so scary. Review of R808's clinical record revealed R808 was admitted into the facility on [DATE] with diagnoses that included: Alzheimer's disease. Review of a MDS assessment dated [DATE] revealed R808 had intact cognition. Review of a Social Service Progress Note dated 7/20/23, revealed, (R808) was witness to an incident on 7/15/23 between 2 residents in the dining room where one resident had placed his hands around the others neck .I met with her again today and asked her how she would feel if the resident that had grabbed the other returned to us. She stated 'I don't want him coming after me, he don't like me either. He never liked (R805), I don't know why, (R805) never did nothing to him'. I then asked her if she would feel safe here if he did return, she stated 'I don't know, I would feel on edge like he would grab my throat, I laugh too much, he doesn't like my laughing. On 8/2/23 at 9:03 AM, a phone call was made to Nurse 'D'. Nurse 'D' was interviewed via telephone. When queried about what happened on 7/15/23 between R804 and R805, Nurse 'D' reported R804 tried to strangle R805. Nurse 'D' explained they were walking into the dining room and R804 had a walker and was to the left of them and R805 was on the right, R804 became enraged and went for (R805's) neck and latched on. Nurse 'D' had to assist with getting R804's hands off of R805's neck. Nurse 'D' reported R809 was traumatized and Nurse 'D' no longer feels safe working with R804. On 8/2/23 at 10:05 AM, an interview was conducted with Nurse 'M. When queried about what occurred on 7/15/23 between R804 and R805, Nurse 'M' reported on that day, they were assigned to R805 and R805 reported that R804 tried to choke him because he was upset about R805's music. R805 reported they were trying to assess R805 and he was pretty shook up. When queried about R804 and any known behaviors, Nurse 'M' reported R804 was very anxious and would get upset over nothing. Nurse 'M' reported R804 usually calmed down after you talked to him. Nurse 'M' further reported that R805 and R807 antagonized R804 and said mean stuff to him (R804). On 8/2/23 at 11:55 AM, an interview was conducted with Nurse 'K' who documented about R804 being agitated and angry when leaving the day room on 7/12/23 and 7/13/23. When queried about why R804 was so upset about the day room, Nurse 'K' stated, He was just agitated. Nurse 'K' reported they sat with R804 and worked with R804 through his feelings and discussed ways to deescalate. When queried about any problems R805 had with other residents in the facility, Nurse 'K' reported R804 did not like some of the residents, but never saw him interact with them. On 8/2/23 at 11:30 AM, an interview was conducted with Unit Manager, Nurse 'J'. Nurse 'J' was queried about the other residents involved in the progress notes she documented on 5/29/23 in R804's clinical record that read, This resident approached another resident to attempt to stop negative disrespectful behavior toward others. He was then called names and talked to disrespectfully by resident. He then was told to shut up and mind his own business and some other curse words .activities coordinator was in charge at the time of this event and deescalated the situation to ceasing it. and the note on 5/1/23 that read, resident has been having difficulty tolerating certain resident in the dining room during activities and at other times too. Resident will get very anxious and upset and take himself out of the situation . Nurse 'J' reported on 5/29/23 she documented for Activities Aide 'G' but was not present during the incident. Nurse 'J' could not recall the incidents that triggered the progress notes on 5/29/23 and 5/1/23. When queried about any known issues with R805 and other residents, Nurse 'J' reported R804, R807, and R805 have issues. R807 feeds into it all and takes sides and R804 has a long history of mental issues and has not made friends with anyone .He is bugged by everything and gets upset about a lot of stuff. When queried about how other residents feel about R804, Nurse 'J' reported R809 is very scared and R808 had a nightmare the next night because she was afraid (R804) would choke her too. Nurse 'J' reported R805 and R807 were afraid initially but now they said they are not. On 8/2/23 at 12:02 PM, Activities Aide 'G' was interviewed by telephone. Activities Aide 'G' reported there were a couple of incidents that involved verbal altercations between R804 and other residents. Activities Aide 'G' reported most were fairly unprompted and due to miscommunication. Activities Aide 'G' explained on 5/29/23 she had Nurse 'J' write a note for her because she doesn't have access to charting and she thought R804 was under the impression another resident was being disrespectful which led to verbal altercations including yelling and swearing and saying shut up. Thinks it was between R804 and R805. On 8/2/23 at 1:27 PM, an interview was conducted with the Administrator, who was the facility's Abuse Coordinator. When queried about whether he was aware of any ongoing tension or problems between R804 and other residents, specifically R804 and R805 as documented in their clinical records, the Administrator reported he was not. He was aware that R804 was going through some medication changes due to anxiety, but not aware of any abuse situations. The Administrator reported he was aware that R804 would do things such as slam his walker down. When queried about what was in place to prevent resident to resident incidents between R804 and other residents prior to the day when R804 tried to choke R805, the Administrator reported R804 was followed by behavioral health and they were trying different medications and monitoring him. Review of a facility policy titled, Abuse, Neglect and Exploitation, revised 6/2023, revealed, in part, the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .The facility will identify, correct, and intervene in situations in which abuse .is more likely to occur .The facility will identify by ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict .

Based on observation, interview, and record review the facility failed to ensure appropriate interventions and monitoring to prevent the worsening of a pressure wound were in place for one resident (R34) of two residents reviewed for pressure ulcers, resulting in the development of a stage four pressure ulcer [Full thickness tissue loss with exposed bone, tendon, or muscle.] to the coccyx area of R34. Findings include: On 10/26/21 at approximately 10:44 a.m., R34 was observed in their room, lying in their bed. R34 was observed to by laying on their back. No offloading of pressure to the back was observed with pillows or positioning wedges. Multiple positioning wedges were observed to be in the corner of R34's room. On 10/26/21 at approximately 12:01 p.m., R34 was still observed in their room, lying in their bed. R34 was observed to by laying on their back in the same position. No offloading of pressure to the back was observed with pillows or positioning wedges. Multiple positioning wedges were still observed to be in the corner of R34's room. On 10/26/21 at approximately 1:25 p.m., R34 was still observed in their room, lying in their bed. R34 was observed to by laying on their back in the same position. No offloading of pressure to the back was observed with pillows or positioning wedges. Multiple positioning wedges were still observed to be in the corner of R34's room. On 10/26/21 the medical record for R34 was reviewed and revealed the following: R34 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R34's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/27/21 revealed R34 needed extensive assistance with most of their activities of daily living. R34's BIMS score (brief interview of mental status) was seven indicating severely impaired cognition. A review of R34's care plan revealed the following: Focus-Actual skin impairment related to: fragile skin, heart failure with [CONDITION(S)], Failure to Thrive, poor appetite, decreased mobility, incontinence, and debility. Date Initiated-12/2/2020 .Interventions-pillows/wedges for positioning while in bed Date Initiated: 05/21/2021 .Resident needs to be turned and re-positioned every 2 hours (12 times a day). Date Initiated: 12/02/2020 .Observe skin weekly and PRN. Date Initiated: 12/02/2020 . A skin observation tool (Nursing weekly skin assessment) dated 4/30/21 revealed the following: Full skin assessment: resident .all bony prominence's are clear and free of breakdown . A skin observation tool dated 5/6/21 revealed the following: Site-Coccyx .Type: Other-Specify-Discoloration .Length 2cm (centimeters), Width-2.5 .Stage-Unstageable .2. Notes-Full skin assessment: .all bony prominence's are clear and free of breakdown Discoloration noted on coccyx does not blanch is dark pain wit <sic> slightly purple edges, Chamosyn cream ordered and applied . A Braden scale (A tool used to predict pressure sore risk) dated 5/7/21 revealed a score of 12 indicating R34 was high risk for skin breakdown. A skin observation tool dated 5/14/21 revealed the following: No wounds identified [site fields were blank. No description of R34's coccyx wound was noted in the site fields] .2. Notes-Skin assessed this shift, no new skin issues noted at this time, will continue to monitor. A skin observation tool dated 5/21/21 revealed the following: Site-Coccyx .Type: Other-Specify [Blank] .Length 2cm, Width-2.5 .Stage-Unstageable .Notes-open area noted to coccyx 2.0 cm X 2.5 cm . A skin observation tool dated 5/28/21 revealed the following: No wounds identified [site fields were blank. No description of R34's coccyx wound was noted in the site fields] .2. Notes-Open Wound to Coccyx. No New Skin Issues . A skin observation tool dated 6/3/21 revealed the following: No wounds identified [site fields were blank. No description of R34's coccyx wound was noted in the site fields] .2. Notes-open area noted to coccyx TX (treatment) to coccyx . A review of R34's Pressure Ulcer Healing Records [Weekly documentation of R34's wounds completed by the facility Wound Care Nurse-Unit Manger H (UM H)] for May and June 2021 revealed the following: Wound Type-[Pressure Ulcer] .Date of Onset 5-6-21 .Date 5-6-21 .Stage: [Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough.)] .Size in Centimeters: 2cm (Length) by 2.5cm (Width) .Exudate ( fluid emitted by an organism through pores or a wound): Serosanguineous (composed of serum and blood) .Oder: [None] .Wound Bed: [Granulation-Tissue-100%] .Surrounding skin color: [Normal for skin] .Comments: Cleanse with NS (normal saline), Pat dry. Apply [MEDICATION(S)] (wound treatment) to wound bed. Cover with borderfoam dressing daily and PRN (as needed) . Date 5-14-21 .Stage: [Stage 2] .Size in Centimeters: 2cm by 2.5cm .Exudate: Serosanguineous . Oder: [None] .Wound Bed: [Granulation-Tissue-100%] .Surrounding skin color: [Normal for skin]Comments: Cont (continue) current TX . Date 5-21-21 .Stage: [Stage 2] .Size in Centimeters: 2cm by 2.5cm .Exudate: Serosanguineous . Oder: [None] .Wound Bed: [Granulation-Tissue-75%. Slough (dead white blood cells, [MEDICATION(S)], cellular debris and liquefied devitalized tissue.)-25%] .Surrounding skin color: [Normal for skin] .Comments: Cont current tx . Date 5-28-21 .Stage: [Stage 4] .Size in Centimeters: 2.5cm by 3.0cm by 0.2cm (depth) .Exudate: Serosanguineous. Exudate Amount: [Moderate] .Oder: [None] .Wound Bed: [Slough-100%] .Surrounding skin color: [Pink] .Response to treatment: [Deteriorated] .Comments: Cont current tx Date 6-2-21 .Stage: [Stage 4] .Size in Centimeters: 3.5cm by 3.5cm by 0.5cm .Exudate: Serosanguineous. Exudate Amount: [Moderate] .Oder: [slight] .Wound Bed: [Slough-100%] .Surrounding skin color: [Pink] .Response to treatment: [Deteriorated] .Comments: Cleanse with NS. Pat dry. Lightly pack with [MEDICATION(S)] gauze and cover with abd (abdominal) pad daily and PRN A review of R34's CNA (Certified Nursing Assistant) documentation for being turned and repositioned every two hours per their care plan for May and October 2021 was reviewed and revealed the following days in which R34 was not documented as to having been turned/repositioned to offload pressure: 5/1, 5/2, 5/3, 5/4, 5/5, 5/6, 5/10, 5/11, 5/12, 5/14, 5/15, 5/16, 5/17, 5/19, 5/22, 5/24, 5/26, 5/27, 5/28, 5/29, 5/30 and on 10/26 which revealed no documentation of turning/repositioning from 4:35 AM until 3:25 PM. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R34's Treatment Administration Record (TAR) for May 2021 for their Coccyx wound revealed no documentation that R34's wound treatment was completed on 5/25. (The week the coccyx wound was identified as having developed into a stage 4) A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .S. Pat dry. Lightly pack wound with [MEDICATION(S)] AG including undermining. Cover with ABD pad. every day shift for Stage 4 pressure wound. A review of R34's TAR for October 2021 for their Coccyx wound revealed no documentation that R34's wound treatment was completed on 10/8 and 10/9. On 10/28/21 at approximately 10:17 a.m., during an interview with UM H regarding the development of R34's stage four pressure ulcer, UM H was queried what interventions they had in place to prevent skin breakdown. UM H indicated that R34 had to be turned and repositioned every 2 hours to offload pressure on their coccyx. At that time, R34's turning and repositioning documentation was reviewed with UM H which showed multiple missed opportunities for turning and repositioning for multiple days in May and October 2021. UM H indicated that they had identified the issue with staff not turning residents and were trying to do audits to ensure the care was completed. UM H indicated they had given multiple discipline actions to staff in attempt to get them to provide the care. UM H was queried regarding the skin observation tools competed in May 2021 which did not accurately reflect R34's wound status. UM H indicated that they had to provide inservice to the nursing staff on completing accurate documentation of wounds. UM H indicated that they needed to be made aware of any changes to the wound and that it had not been done with regards to R34's coccyx wound because R34 was not being followed by the wound Doctor. UM H was shown R34's missed wound treatment for 5/25 and the missed treatments for 10/8 and 10/9 and indicated that they should have been completed and documented. On 10/28/21 at approximately 11:58 a.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the noncompliance they had identified with regards to R34's coccyx wound developing into a stage 4. The DON indicated they had identified that turning and repositioning had not been completed as it should have, and the skin assessments being done by the floor nurses were inaccurate and not completed. The DON further indicated that UM H was documenting deterioration of the wound and was not communicating with the Physician to change the treatments. The DON reported when a wound gets worse you should not continue the same treatment. The DON indicated that they had to provide inservice to their staff to try to correct the noncompliance. On 10/28/21 a facility document titled Wound Treatment and Documentation was reviewed and revealed the following: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of' practice and physician orders. The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment .Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Guidelines for dressing selection may be utilized in obtaining physician orders. a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. The facility will follow specific physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatments will be documented on the Treatment Administration Record. 7. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound. c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 8. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. Wound treatments are documented at the time of each treatment. 9. The following elements are documented as part of a complete wound assessment: a. Type of wound (pressure injury, surgical, etc.) and anatomical location b. Stage of the wound, if pressure injury (stage l, 2, 3, 4, deep tissue) c. Measurements: height, width, depth, undermining, tunneling d. Description of wound characteristics: i. Color of the wound bed ii. Type of tissue in the wound bed (i.e., granulation, slough, eschar, epithelium) iii. Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated) iv. Presence, amount, and characteristics of wound drainage/exudate v. Presence or absence of odor vi. Presence or absence of pain.

This citation pertains to Intake Numbers: MI 234, MI 403 Based on observation, interview and record review the facility failed to accurately perform skin assessments per physician orders, document weekly skin assessments and implement interventions to prevent the development of pressure ulcers for three (R#902, R#903 and R#906) of three residents reviewed for pressure ulcers resulting in R#903 acquiring a Stage III Pressure Ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible) and the potential for delayed identification and development of pressure ulcers. Findings include: R#903 A complaint was filed with the State Agency on 8/26/20 that alleged in part, .facility staff failed to provide adequate and appropriate care to prevent and/or treat pressure sores . Review of the closed record revealed R#903 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated [DATE], R#903 scored 15/15 on the Brief Interview for Mental Status (BIMS) exam, indicating intact cognition. The MDS assessment also indicated R#903 was totally dependent on the extensive assistance of staff for all Activities of Daily Living (ADL's), and had no pressure ulcer/injury upon admission, but was at risk of developing pressure ulcers/injuries. Further review of R#903's closed record revealed: A Nursing Admission Screening/History assessment dated [DATE] with a lock date of 6/13/20 signed by Licensed Practical Nurse (LPN) V documented R#903's coccyx (tailbone) was reddened. A Braden Scale for Predicting Pressure Ulcer Risk dated 6/18/20 with a lock date of 6/23/20 documented R#903 in category At Risk with a score of 15 (15-18 is At Risk). The Clinical Suggestions was left blank. Physician orders [REDACTED]. Skin, Pressure Ulcer & Wound Treatment Protocol - May follow facility protocol dated 6/11/20. Weekly Skin Assessment every night shift every Thu (Thursday) . nights from 7p-7a dated 6/11/20. Monitor skin (specify) bruises, abrasions, skin tears for healing two times a day Notify MD of adverse changes dated 6/11/20. May apply barrier cream to buttocks BID (two times a day) PRN (as needed) every shift dated 6/11/20. A Potential skin impairment care plan for R#903, initiated 6/11/20 revealed interventions that read in part: May use barrier cream after incontinence to coccyx and sacral areas . May use pull sheet or 2 person when repositioning to reduce risk of friction/shearing . Notify licensed nurse of skin conditions observed with care . Observe skin weekly and PRN . Offer/assist to reposition resident routinely . Review of progress notes for R#903 revealed a nursing note by LPN H dated 7/18/20 at 6:34 PM that read, resident complaints (sic) of pain in coccyx. assessed, stage 3 5.0 x 5.0 x 0.2- 80% sloth and 20% granulated wound bed, some clear drainage, peri area intact, no redness, swelling or warm to touch, orders noted for prostat BID return (sic) and reposition, wound tx (treatment), lab orders, resident notified, will cont (continue) to monitor. It should be noted that the weekly skin assessment was documented as completed on 7/16/20, two days before the Stage III Pressure Ulcer was discovered, and the barrier cream to R#903's buttocks was documented as applied consistently two times a day every day. A Braden Scale for Predicting Pressure Ulcer Risk dated 7/18/20 with a lock date of 12/3/20 documented R#903 in category Very High Risk with a score of 9 (9 or below is very high risk). The Clinical Suggestions marked: Utilize draw sheet, Utilize incontinent products after each incontinence episode, Use pillows to position and off load pressure areas, Turn and reposition at least q.2 (every two) hours while in bed . Review of physician wound care notes dated 7/24/20 read in part, Coccyx is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5.5cm (centimeter) length x 2.5 cm width x 0.3 cm depth, with an area of 13.75 sq cm and a volume of 4.125 cubic cm. there is a moderate amount of sero-sanguineous drainage noted. Wound bed has Pale Pink Base [MEDICATION NAME], Minimal Yellow Sough slough . Plan: .LOW AIR LOSS MATTRESS . FREQUENTLY REPOSITION . On 12/15/20 at 2:20 PM, LPN R, who served as Unit Manager and Wound Care Nurse was interviewed and asked about documentation of R#903's skin before the development of a Stage III Pressure Ulcer on 7/18/20. LPN R explained he could find no documentation between the reddened coccyx on 6/11/20 and mention of a Stage III Pressure Ulcer on 7/18/20. LPN R was asked about how R#903's pressure ulcer could be discovered as a Stage III two days after a skin assessment was documented on 7/16/20 and at the complaint of pain by R#903. LPN R had no answer. LPN R was asked about Certified Nursing Assistants (CNA's) providing incontinence care as R#903 was a quadriplegic. LPN R explained the CNA's were trained to go to the nurses with any skin issues they noticed, then the nurse would assess the skin and report any issues to him. LPN R further explained he first learned of R#903's pressure ulcer on 7/18/20 at which time he measured the wound and consulted a wound care physician. On 12/15/20 at approximately 2:30 PM, the Director of Nursing (DON) was interviewed and asked about R#903's pressure ulcer. The DON was asked about the documentation of the weekly skin assessment on the Treatment Administration Record (TAR). The DON explained the nurse marked the TAR when they completed the assessment, but they also should have written a progress note that described the assessment, whether there was an issue or not. On 12/16/20 at 8:17 AM, a phone interview with Registered Nurse (RN) V was conducted. RN V was asked about R#903's skin assessment on 7/16/20. RN V explained she had done the admission assessment on 6/11/20 and remembered R#903 had a reddened area on their bottom but didn't remember any open area. RN V further explained she didn't remember the skin assessment on 7/16/20, and stated, We (nurses) do rely on the CNA's to tell us of skin issues. RN V was asked about documentation of the skin assessment. RN V explained the nurses were supposed to do a completed skin evaluation, the TAR is only marked if there was no issue with the skin, if there was a problem there was a paper skin assessment form. On 12/16/20 at 12:06 PM, LPN H was interviewed and asked about discovering R#903's Stage III Pressure Ulcer on 7/18/20. LPN H explained she didn't remember the pressure ulcer, but upon reading the progress note dated 7/18/20 explained she had not gotten a report at shift change of any skin issues, but after finding the pressure ulcer she informed LPN R and did a Braden Evaluation and got orders for treatment. LPN H was asked if she had taken care of R#903 before 7/18/20. LPN R explained she floated around the facility and did not remember if she had been R#903 nurse before. R#902 Review of the clinical record revealed R#902 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent MDS assessment dated [DATE], R#902 scored 11/15 on the BIMS exam, indicating moderately impaired cognition. The MDS assessment also indicated R#902 required the extensive assistance of staff for ADL's, had no pressure ulcer/injury, was at risk for developing pressure ulcers/injuries but had no formal assessment instrument/tool for documenting risk of pressure ulcers/injuries. On 12/15/20 at 2:32 PM, R#902 was observed lying in bed, dressed, and lying on their back with their knees bent. R#902 was asked about care at the facility. R#902 explained they were happy at the facility. Review of the clinical record for R#902 revealed physician orders [REDACTED]. Review of R#902's TAR's did not reveal documentation of skin assessments or a place to document skin assessments. On 12/16/20 at 9:24 AM, RN S was interviewed and asked how nurses know when to do a weekly skin assessment on a resident. RN S explained on the TAR the order would come up on the day it was ordered for, and the nurse would do it. RN S was asked if there was another place for the weekly skin assessment schedule. RN S explained there was no back-up schedule that she knew of. On 12/16/20 at 9:28 AM, the DON and LPN R were interviewed and asked about documentation of R#902's weekly skin assessments. LPN R confirmed there was an order for [REDACTED]. The DON was asked for any documentation of a skin assessment done on R#902, none was provided by the end of the survey. R#906 R#906's clinical record was reviewed and revealed R#906 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#906 had severely impaired cognition and required extensive assistance with bed mobility, was totally dependent on at least two staff members for transfers, and had one stage III pressure ulcer present upon readmission into the facility. A care plan initiated on 7/7/20 documented R#906 had actual or potential skin impairment related to .fragile skin, decreased mobility, debility. Interventions included: Offer/assist to reposition resident routinely initiated on 7/7/20. There were no care plans as of 12/15/20 that documented R#906 refused to be repositioned. On 12/14/20 at 10:15 AM, R#906 was observed lying on their back in bed. A low air loss mattress was observed. Observations were made of R#906 positioned on their back at 11:34 AM, 12:11 PM, and 12:35 PM. At 1:54 PM, R#906 remained positioned on their back. On 12/15/20, observations of R#906 lying on their back were made at approximately 12:45 PM, 2:08 PM, 3:25 PM, and 3:40 PM. At 3:25 PM, R#906 stated, Can you help me? Can you get me out of bed? Certified Nursing Assistant (CNA) N addressed R#906 and R#906 yelled out and stated, My back hurts. I just want to get up in the chair. CNA N and CNA M assisted R#906 into a wheelchair using a mechanical lift and R#906 appeared comfortable. On 12/16/20 at 8:15 AM, 8:30 AM, 9:00 AM, 10:20 AM, and 11:50 AM, R#906 was observed lying on their back in bed without being repositioned. On 12/16/20 at 11:50 AM, CNA O who was identified as R#906's assigned CNA, was interviewed. When queried about how often R#906 needed to be repositioned, CNA O reported every two hours. When queried about the last time R#906 was repositioned, CNA O stated, It's been more than that. CNA O reported R#906 got up before her morning meal today, but they put her back down. CNA O did not offer a response when questioned about R#906 being in bed at 8:15 AM. CNA O reported R#906 refused to be repositioned. POC Response History (Electronic record of CNA care provided) for R#906 was reviewed for 12/16/20. It was documented by CNA Q that bed mobility and transferring occurred for R#906 three or more times as of 11:23 AM. On 12/16/20 at 12:30 PM, the DON was interviewed. When queried about turning and repositioning of residents who are at risk of pressure ulcers, the DON reported they should be turned and repositioned at least every two hours and it would be documented in the CNA electronic record. The DON reported if a resident refused, it would be documented in the clinical record. The observations of R#906 remaining on her back for extended periods of time beyond two hours and the documentation by CNA Q that noted R#906 was moved and/or transferred three or more times before 11:23 AM were discussed and reviewed with the DON. The DON reported documentation should be done at the point of care. The DON reviewed R#906's clinical record and confirmed there was no documentation of R#906 refusing to be repositioned. Review of a facility policy titled, Skin Management Facility Guidelines revised January 2020 read in part, .Residents admitted without pressure ulcers will have measures implemented to reduce the prevalence of acquired pressure ulcers . Residents at risk for pressure ulcers will be identified and will receive interventions to reduce the risk of pressure ulcer development . All residents will be assessed from head to toe weekly by a licensed nurse to identify any new pressure ulcers or other types of skin alterations. Results of weekly assessment will be documented by the licensed nurse on the weekly head to toe skin check form .

This citation has two deficient practices. Deficient Practice #1 This citation pertains to Intake #MI 596 Based on observation, interview and record review the facility failed to ensure a resident with a history of falls was consistently provided with appropriate supervision for one (#703) of three residents reviewed for falls, resulting in an additional fracture to the left femur. Findings include: On 5/2/19 at 9:30 AM, R#703 was observed lying in bed. R#703 was asked questions and would respond with yes or no answers. R#703 indicated they had fallen several times and had broken the left femur twice within a couple of months. Review of R#703's clinical record revealed R#703 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], R#703 scored 4/15 on the Brief Interview of Mental Status (BIMS) exam indicating severe cognitive impairment. The MDS assessment also indicated R#703 required the extensive assistance of staff for all Activities of Daily Living (ADL's) and required two people and a mechanical lift for transfers. A further review of R#703's clinical record revealed R#703 fell on [DATE] with no injury. On 10/11/18, R#703 fell out of bed and fractured the medial condyle of the left femur (inside end of the femur at the knee). R#703 was sent to the hospital and a brace was applied to the left femur. On 1/15/19, R#703 fell attempting to get into bed and sustained an additional segmental left distal femur fracture (section of bone not connected at either end). R#703 was sent to the hospital and pins were surgically implanted to realign the bone. On 4/16/19, R#703's left leg was amputated above the knee. Review of a facility Incident and Accident (I&A) report read in part, On (MONTH) 15, 2019 around 3:00pm resident was observed by CNA (Certified Nursing Assistant) laying on the floor in front of her high back w/c (wheelchair). CNA had just been in room a few minutes prior telling (R#703) who was siting in her w/c, she would be back in a few minutes to put her into bed as she was on her way to answer a call light. When CNA returned to the room, she noted (R#703) on the floor . Resident had her leg brace on and the leg was noted to be in malalignment . On 5/2/19 at 10:33 AM, an interview with CNA 'D' was conducted. During that interview, CNA 'D' was queried about what happened on 1/15/19 when R#703 fell . CNA 'D' stated, That day, she kept rolling herself to her room. We would try to keep her by the nurses station to keep an eye on her, but that day I would take her to the nurses station and she would roll herself to her room. It happened several times that day. I saw her in her room and I told her I would put her to bed after I got a call light. When I got back she was on the floor. I asked 'What are you doing?' she said she wanted to go to bed and tried to do it by herself. CNA 'D' was asked if R#703 was supposed to be alone in her room. CNA 'D' stated, No, not while she was out of bed. That's why we kept her by the nurse's station. Review of R#703's fall care plan revealed interventions for Frequent rounding hourly to anticipate needs, Offer to lay resident down after lunch and When out of bed, keep within close visual proximity of staff. These interventions were put into place after the fall on 1/15/19. On 5/2/19 at approximately 11:00 AM, an interview with the Director of Nursing (DON) was conducted and the DON was asked about R#703's falls. The DON stated, She has fallen several times, we moved her room closer to the Nursing Administration office. Review of a facility policy titled, Fall Management Guidelines revised (MONTH) 2013 read in part, Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls . Deficient Practice #2 This citation pertains to Intake # MI 530 Based on observation, interview and record review the facility failed to ensure an effective elopement system was in place for a resident who exited the facility through the main doors for one (#701) of three residents reviewed for elopement, resulting in the resident exiting the facility unattended without knowledge of the staff. Findings include: On 5/1/19, a review of a Facility Reported Incident (FRI) reported to the State Agency include an allegation that R#701 exited the facility through the main doors. According to the FRI, on 11/7/18 at approximately 4:16 PM, R#701 was observed in the lobby. At approximately 4:18 PM R#701 was observed outside unattended wearing his coat. Certified Nursing Assistant (CNA) assisted resident back into the facility. On 5/1/19 at 12:11 PM, R#701 was observed dressed and lying on the bed. R#701 was asked if they had ever gone outside unattended. R#701 indicated they didn't remember going outside. Review of R#701 clinical record revealed R#701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], R#701 scored 8/15 on the Brief Interview for Mental Status (BIMS) exam indicating moderately impaired cognition. The MDS assessment also indicated R#701 was independent for Activities of Daily Living (ADL's). On 5/1/19 at 2:48 PM, Environmental Services Director 'A' was interviewed and asked if the front door had a camera monitoring system. Environmental Services Director 'A' stated, There was no camera/video recording in November. We have one now, it was put up after (R#701) got outside. On 5/2/19 at 8:19 AM, an interview with CNA 'B' was conducted. During the interview, CNA 'B' was queried about finding R#701 outside. CNA 'B' stated, I was walking from one unit to another, it was around 4:15 PM, I saw (R#701) outside so I went to his nurse to see if he was supposed to be outside. When she said no, I ran outside and brought him back in. He had turned around and seemed to be coming back toward the door. He didn't remember how he got outside. He said he was waiting for his son to pick him up. He came back easily, he didn't resist. CNA 'B' was asked how far from the door R#701 was. CNA 'B' stated, He was at the second handicap parking space (approximately 50 feet). CNA 'B' was asked what R#701 was wearing. CNA 'B' stated, He had on pants and shoes and a heavy coat. Review of R#701's Elopement Risk assessment dated [DATE] at 4:40 PM, indicated R#701 was an elopement risk. There was no assessment completed before R#701 eloped from the facility. Review of R#701's Behavioral Symptoms care plan dated 11/7/19 included interventions that included, Follow regular routines as much as possible, If resident looks for family/significant other, reassure that others know where to find him/her and Maintain a calm environment and approach to the resident. On 5/2/19 at approximately 11:30 PM, an interview with the Administrator was conducted and the Administrator was asked about R#701's elopement. The Administrator stated, We have changed a lot of things since that happened. Review of a facility policy titled, Elopement Policy and Procedure dated (MONTH) (YEAR) read in part, An elopement assessment will be implemented with each new admission or quarterly evaluation and as needed .