Every finding on record at Monticello Nursing & Rehab Center

Based on record review, staff interview and policy interview the facility administered a antipsychotic medication without a physician's order for 1 out of 1 residents reviewed with agitation and behaviors (Resident #1). The facility reported a census of 43 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS Assessment showed Resident #1 exhibited behavioral symptoms including rejection of care on 1 to 3 days during the observation period, which worsened compared to prior assessments. The MDS Assessment indicated Resident #1 maintained independence with toilet transfer, sit to stand transfer, and ambulation (walking). The MDS Assessment listed diagnoses of hypertension (high blood pressure), arthritis (joint inflammation), and chronic obstructive pulmonary disease (COPD; chronic lung disease). The MDS Assessment indicated Resident #1 hadn't received antipsychotic (hallucination treatment) medication since admission/entry. Resident #1's May 2026 Electronic Medication Administration Record (EMAR) revealed a physician order for Haloperidol (antipsychotic medication) in Pentravan Cream (cream used to help absorb medication) 5 milligram (mg)/milliliter (ml) (2mg/0.4ml) to apply to the skin topically four times a day for agitation to give 2mg = 0.4ml, 4 times daily. Staff signed out the medication as administered on 5/29/26 at 7:00 AM, 11:00 AM, 3:00 PM, and 8:00 PM. The EMAR lacked an as-needed order for the medication. Staff didn't sign out the medication as administered again until 5/30/26 at 7:00 AM. Review of the Nurse Progress Note dated 5/26/26 at 10:02 AM revealed the nurse spoke with the hospice (end-of-life care) nurse and received an order to discontinue the as-needed haloperidol cream and schedule it. The new order directed staff to apply Haloperidol in Pentravan Cream 5mg/ml (2mg/0.4ml) to the skin topically four times a day for agitation to give 2mg = 0.4ml, 4 times daily. Review of the Physician Order Summary Report revealed an order for Haloperidol in Pentravan Cream 5mg/ml (2mg/0.4ml) to apply to the skin topically four times a day for agitation to give 2mg = 0.4ml, 4 times daily that became active on 5/26/26. Review of the Care Plan dated 5/30/26 failed to address the use of antipsychotic medications. Review of the facility Self-Report dated 6/3/26 regarding an incident on 5/29/26 revealed that during an incident with Resident #1, Staff B, Certified Nursing Assistant (CNA), requested permission from Staff A, Licensed Practical Nurse (LPN), to hug Resident #1 while Staff A applied topical cream to Resident #1's back. Review of the written statement from Staff A dated 6/2/26 at 10:45 AM revealed Resident #1 awoke and walked down the hallway. Resident #1 exhibited a negative mood, walked down the 500 hallway, turned lights on, and screamed for help. Resident #1 pulled the fire alarm, walked down the 100 hallway, and pulled the fire alarm there. Staff C, CNA, reported that Resident #1 grabbed a fire extinguisher. Staff A walked down the hallway and found the fire extinguisher already away from Resident #1. Staff A denied placing hands on Resident #1 and noted only applying cream to Resident #1's back. On 6/23/26 at 2:17 PM Staff E, LPN, revealed the order for Haldol (antipsychotic medication) for Resident #1 shifted from an as-needed basis to a scheduled basis. Staff E expressed uncertainty regarding subsequent events after Resident #1 changed rooms and hallways. Staff E explained that a nurse should never administer a medication without a physician order and noted checking the computer to find orders because the EMAR contains the physician orders. On 6/23/26 at 3:35 PM the Director of Nursing (DON) confirmed the facility lacked an as-needed order for the topical Haldol that Staff A administered to Resident #1 on 5/29/26. The Director of Nursing confirmed Staff A administered Haldol during behavioral episodes on 5/29/26 to Resident #1. The Director of Nursing confirmed this administration constituted a chemical restraint (medication control) because the nurse administered the medication without an order. The Director of Nursing stated an expectation that staff obtain an order prior to administering any medication. The Director of Nursing also noted this action provided grounds for termination because management refuses to retain a nurse who administers medication without an order. On 6/24/26 at 9:41 AM Staff G, Registered Nurse (RN), revealed every medication administration requires an order, noting that even Tylenol requires approval from a medical doctor. Staff G stated that administering an antipsychotic medication remains unacceptable even during behavioral episodes. Staff G reported checking the EMAR or the orders tab on the Electronic Health Record (EHR) and explained that if an order lacks documentation, administration can't occur. Staff G stated a nurse must call the provider to obtain a physician order under those circumstances. On 6/24/26 at 9:55 AM the Director of Nursing revealed that giving medication without a physician order remains entirely inappropriate. The Director of Nursing stated that Staff A should've requested a medication order when calling the provider, informed the Resident #1 Representative about the order, and requested consent. In the case of Resident #1, the Resident #1 Representative would've consented because they desired whatever measures maintained the safety of Resident #1 at the facility. The Director of Nursing stated an expectation that staff refrain from giving medication before obtaining an order, even when pulling items from the pharmacy emergency kit. The Use of Psychotropic Medication(s) policy dated undated instructed that chemical restraints refer to any drug utilized for discipline or staff convenience that lacks medical necessity to treat symptoms. The policy directed that although a psychotropic (mind-altering) medication may have approval to treat certain symptoms, staff must attempt nonpharmacological (non-drug) interventions unless clinical contraindications exist because they present fewer dangers to a resident's health and safety. The policy explanation and compliance guidelines directed that staff use psychotropic medications only when a practitioner determines the medication is appropriate to treat a specific, diagnosed, and documented condition and demonstrates a benefit through monitoring and documentation of the resident's response.

Based on observation, record review, resident, and staff interviews the facility failed to keep a resident free from physical restraints during a period of behaviors. A staff member used her body to force a resident to ambulate to her room for 1 out of 1 residents reviewed with behaviors (Resident #1). The facility reported a census of 43 residents. Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS showed Resident #1 rejected care on one to three days during the observation period, and these behaviors worsened compared to previous evaluations. Resident #1 didn't require assistance with toilet transfers, sit-to-stand transfers, and walking. Active diagnoses for Resident #1 included hypertension (high blood pressure), arthritis (joint inflammation), and chronic obstructive pulmonary disorder (COPD; long-term lung disease). Review of Resident #1's care plan initiated 5/21/26 revealed Resident #1 didn't maintain a calm status and experienced behavioral episodes including paranoia (unfounded suspicion), negative statements, medication and care refusals, attempts to leave the building, calling the police, hallucinations (false sensory perceptions), and delusions (false beliefs). Care plan interventions directed staff to reassure Resident #1 if Resident #1 resisted everyday tasks, then leave and try again five to ten minutes later. Another intervention instructed staff to protect the rights and safety of other residents by speaking calmly, diverting attention, or removing Resident #1 to an alternate location. A nurse's progress notes from 5/30/26 at 1:01 AM revealed Resident #1 walked over to the fire alarm and pulled it. Resident #1 then walked down the hallway, entered multiple resident rooms, and screamed for help. Resident #1 didn't stop there; Resident #1 walked down a different hallway screaming for help, ripped a telephone off the wall, and destroyed it. Resident #1 pulled the fire alarm a second time, grabbed a fire extinguisher, and aimed it at other residents and staff. Resident #1 then sat on the floor and refused all assistance to get up. Staff notified Resident #1's Power of Attorney Representative and hospice (end-of-life care) of these behaviors. Review of the hospice notes from 5/30/26 at 12:27 AM revealed Staff A, Licensed Practical Nurse (LPN), notified hospice of Resident #1's aggression and agitation. This review failed to reveal any orders for staff to physically restrain Resident #1, and the records didn't contain such authorizations. A written statement dated 6/2/26 at 10:54 AM from Staff B, Certified Nursing Assistant (CNA), revealed that staff members performed every possible action that night. Resident #1 exited the room, grabbed the walkie-talkie belonging to Staff A, and placed it against Staff B's neck. Resident #1 acted as if the device served as a taser, and this incident occurred in the circle area. Staff didn't make eye contact, hoping Resident #1 wouldn't react. Resident #1 claimed Staff B laced Resident #1's coffee. Resident #1 then walked over, pulled the fire alarm near the front door, proceeded down the 500 hallway, and screamed for everyone to wake up and see the facility's activities. Resident #1 entered resident rooms and turned on lights before moving down the 100 hallway. Resident #1 ripped a telephone and a thermostat off the wall and whipped them around. Staff B and Staff C, CNA, tried to assist, and Staff B attempted to guide Resident #1 to Resident #1's room while Staff A and Staff C positioned themselves in the circle area to contact family members. Resident #1 placed full body weight on Staff B during this guidance and tried to drop to the ground. Staff B wrapped an arm around Resident #1's backside, held Resident #1's wrist, and secured Resident #1's waist with the other hand. This hold kept Resident #1 steady to prevent a fall through a gentle wrist grasp. Staff B finally escorted Resident #1 into the room and onto the bed, but Resident #1 didn't stay in bed and returned to the hallway. Staff B asked Staff A about available as-needed medication, and Staff B obtained permission from Staff A to hug Resident #1 to help calm Resident #1. This interaction occurred on the 100 hallway after Resident #1 dismantled the fixtures and threw the fire extinguisher. Staff didn't have other options remaining at that point. The hug didn't succeed as a distraction because Resident #1 dropped to the floor during the encounter while Staff A simultaneously applied topical medication to Resident #1's back. A written statement from Staff C on 6/2/26 at 11:39 AM regarding the incident with Resident #1 on 5/30/26 revealed Staff B held an arm around Resident #1's back with a hand on the other side and instructed Resident #1 to return to the room. Staff C didn't view this action as a problem. Resident #1 resisted and fought during the encounter, but Staff B executed a necessary action because Resident #1 entered other residents' rooms. Staff C didn't believe Staff B acted aggressively. Staff B maintained this hold from the 500 hallway to the 100 hallway and into the room. Resident #1 attempted to hit and kick Staff A and Staff B during the escort back to the room. Review of the facility investigation revealed that on 5/29/26 at approximately 11:45 PM, Resident #1 exited the room and approached the common area where Staff A, Staff C, and agency Staff B gathered. According to video evidence, Resident #1 took Staff A's walkie-talkie from the table and poked both Staff B and Staff C in the back of the neck. Staff reported that they avoided eye contact to de-escalate the situation and minimize further agitation. Resident #1 then moved toward the front entrance, triggered a wander guard alarm, and pulled the fire alarm near the front door. Following this, Resident #1 proceeded down the 500 hallway and verbally called out for help. Staff A and Staff B attempted to calm Resident #1 while Staff C reset the fire alarm panel. Staff B and Staff C both reported that Resident #1 struck Staff C during the de-escalation attempt, though Staff C didn't include this detail in a separate statement. Resident #1 continued to the 100 hallway and activated a second fire alarm. Resident #2, Resident #3, Resident #4, and Resident #5 stood at their doorways during this time. In an attempt to redirect Resident #1, Staff B approached from behind, placed one arm around Resident #1's back to hold Resident #1's wrist, and held Resident #1's waist with the other hand. Staff B then escorted Resident #1 back to the room and assisted Resident #1 into bed. Resident #1 immediately got up, returned to the 100 hallway, and removed the telephone and a thermostat cover from the wall. At this point, Resident #2 and Resident #3 remained in the hallway. Resident #1 then retrieved a fire extinguisher from the wall mount. Video evidence confirmed that Resident #1 handled the extinguisher and attempted an underhanded throw, but it fell directly in front of Resident #1's feet. The canister didn't strike any staff or residents. Staff B then requested permission from Staff A to hug Resident #1 while Staff A applied topical cream to Resident #1's back. Video evidence confirmed that during this interaction, Staff B held Resident #1 by the wrist and waist and didn't release Resident #1. Resident #1 didn't consent to this physical contact and couldn't disengage. During this interaction, Resident #1 lowered herself to the floor and refused to stand. Resident #1 remained on the floor until Resident #1's son arrived on site. Staff contacted hospice during this time. At 11:57 PM, the facility's alarm monitoring company contacted the Administrator and provided notification of the fire alarm activation. The Administrator immediately contacted the facility, and Staff A answered and reported that staff actively managed the situation. At 5:54 AM, the Administrator received a call from the on-call nurse, Staff G, Registered Nurse (RN), who reported that during the overnight incident, Resident #1 entered resident rooms and pointed the fire extinguisher at Resident #2 and Resident #3. Upon receiving this information, the Administrator immediately filed a self-report and initiated a formal investigation. On 6/22/26 at 11:28 AM Resident #1 sat in a recliner chair in the room. Resident #1 maintained an alert and pleasant status and responded to questions appropriately. Resident #1 stated that memory remained regarding pulling the fire alarm because staff members chased Resident #1. Resident #1 recalled three people present before the alarm activation but didn't remember the reason for pulling it. Resident #1 felt angry at that time, which occurred shortly after arrival when no one provided advance notice of the institutional transfer. Resident #1 revealed a dislike for losing independence. Resident #1 believed facility staff caused confusion. Resident #1 acknowledged probably threatening to strike others but didn't remember executing any hits. Resident #1 didn't recall if anyone struck Resident #1 but knew that staff grabbed for Resident #1. Resident #1 admitted feeling scared during the encounter when staff arrived and grabbed Resident #1. Resident #1 didn't think staff caused injury, noting that pain would've increased the anger. Resident #1 concluded that the staff grabbed Resident #1 but didn't act roughly or cause harm. On 6/23/26 at 8:50 AM Staff B confirmed working the night of the 5/30/26 incident with Resident #1. Staff A revealed that staff only supervised until Resident #1's son arrived. Resident #1 actively tried to go down on the ground, and Staff B tried to guide Resident #1 down. Staff B didn't touch Resident #1 otherwise and didn't hold Resident #1 at all. Resident #1 displayed a large amount of aggression at that time. Staff B didn't utilize a full restraint on Resident #1. Every action aimed to prevent a fall because Staff B didn't want Resident #1 to suffer an injury. Staff A and Staff B walked with Resident #1 a few times and tried to speak with Resident #1, but Resident #1 didn't demonstrate any reasoning capacity at all. On 6/23/26 at 1:32 PM Staff C revealed that regarding Resident #1's behaviors on 5/30/26, staff members tried talking to Resident #1 and asking about the problem. Staff C didn't exactly remember Resident #1's statements. Staff C confirmed that Staff B walked Resident #1 back to the room while holding onto Resident #1, and Staff C witnessed this guidance back to the room. Staff C revealed that facility rules didn't allow staff to use physical restraints at any time. Staff C didn't want involvement in the situation because staff members felt helpless in that moment. Resident #1 displayed behavioral symptoms, and Staff C believed that staff reactions increased Resident #1's agitation; therefore, Staff C wanted to leave Resident #1 alone so Resident #1 might calm down before staff reapproached. On 6/23/26 at 1:24 PM Staff D, CNA, revealed that when a resident displayed behaviors, Staff D attempted to remain calm and speak politely and respectfully. Successful approaches depended on the specific behavior. For example, if a resident exhibited extreme agitation by screaming, throwing items, or pulling a fire alarm, maintaining distance and using a calm voice worked best. Staff D used relaxing body language and tried to speak in a respectful manner. Staff D allowed residents space as long as they didn't cause harm to themselves or others. Staff D indicated that physical restraints didn't represent an appropriate response at any time, and staff should always pursue a hands-off approach. If residents calmed down, staff might touch a shoulder or hand, ask questions about personal topics like family or work history, and introduce alternate subjects. On 6/23/26 at 2:17 PM Staff E, LPN, confirmed that Resident #1 displayed paranoid behaviors. Staff E stated that whenever a resident exhibited such actions, Staff E attempted redirection. Staff E explained that talking about family or personal relationships helped redirect Resident #1. Staff E reassured Resident #1 and allowed space so Resident #1 didn't maintain the agitation. Staff E noted that staff shouldn't physically restrain a resident at any time unless that individual physically harmed someone, and then staff would only separate the individuals rather than apply a physical restraint. On 6/24/26 at 9:24 AM Staff F, CNA, revealed that handling agitated behaviors required stopping, assessing the situation, ensuring safety, and de-escalating the crisis. Staff F attempted to identify the resident's underlying problem and hoped that coworkers didn't delay in assisting. Staff F explained that separating the resident from the agitation source worked best. Staff F indicated that immediate danger to oneself or others represented the only time physical force became necessary, and staff shouldn't use force without immediate harm threats. Leaving the resident alone, providing space, and removing other residents didn't fail as the best options. On 6/24/26 at 9:41 AM Staff G, RN, expressed disagreement with the handled intervention. Regarding a fire alarm activation, Staff G responded immediately by standing with Resident #1, talking to Resident #1, and attempting to block the fire alarm to calm Resident #1 without physical touch while maintaining safety. Staff G explained that initiating a conversation to understand the behavior's cause prevents escalation. Staff G utilized a calm, reassuring voice without raising the tone. Staff G stated that physical force or touch didn't represent acceptable actions with a resident. If situations escalated, staff notified the healthcare provider and transferred the resident to the hospital. Staff G indicated that staff shouldn't hold or hug a resident to administer medication. Staff G expressed belief in resident rights, noting that the facility didn't exist to force interventions on individuals. On 6/24/26 at 9:55 AM the Director of Nursing (DON) confirmed the 5/30/26 incident regarding Resident #1's behaviors. The DON revealed initially thinking Resident #1 posed a risk to others, but that didn't reflect reality. Although staff members claimed they felt fearful, they didn't separate Resident #1 from other residents. The DON noted that staff didn't use available distraction and verbal redirection techniques. Staff could've contacted family members who expressed a willingness to come, and the family ultimately arrived once Resident #1 sat on the floor and refused to get up. Resident #1 typically cooperated with staff and responded well to family reassurance. The DON would've distracted Resident #1 with familiar topics like family and sewing. The DON believed staff ignored Resident #1 initially, which didn't represent appropriate care. The DON questioned if an early acknowledgement might've changed the outcome, or if Resident #1 sought coffee or alternate items that staff didn't offer to prevent escalation. Once the situation escalated, the DON disagreed with the physical holding executed by the staff, emphasizing that the facility didn't utilize hands-on restraints. The DON felt that staff physically restrained Resident #1 while walking Resident #1 up the hallway. The DON stated that if she worked at that time, she would've intervened, instructed staff to remove their hands, and notified a supervisor. The DON emphasized the duty to protect residents and expressed anger over the staff's actions, noting that staff didn't serve as the residents' voice. The DON stated that other staff should've intervened to separate the residents from harm, and she wouldn't tolerate such behavior because she wanted staff who protect residents. The DON concluded that physical restraints didn't represent an acceptable practice under any circumstances. The Restraint Free Environment policy dated [Undated] directed that a physical restraint refers to any manual method, physical or mechanical device, material, or equipment attached or adjacent to a resident's body that the individual cannot remove easily, restricting freedom of movement or normal access to one's body. The policy instructed that physical restraints include holding down a resident in response to a behavioral symptom or during care provision if the resident resists or refuses care. Compliance guidelines specified that residents maintain the right to respect and dignity, including freedom from any physical or chemical restraint imposed for discipline or staff convenience rather than medical necessity. The policy allowed brief physical restraints in emergency care situations to permit ordered, medically necessary treatments, unless the resident previously refused the treatment. Finally, the policy directed that falls didn't constitute self-injurious behavior or medical symptoms that warrant physical restraints.

Based on observation, clinical record review, and staff and resident interviews, the facility failed to ensure adequate supervision was provided for a resident with a history of falls for one of three residents reviewed (Resident #2). The facility reported a census of 51 residents.The facility corrected the deficient practice per past noncompliance through the following actions: -Staff education initiated on 3/10/2026 regarding importance of proper rounding and resident monitoring. Education continued on 3/11/2026, and ongoing until all Certified Nursing Assistants (CNAs) and nurses have completed and signed the education form. -Alert and oriented residents were interviewed regarding their safety and well-being. -Incident was added to the Quality Assurance and Performance Improvement (QAPI) agenda. Findings include:The MDS (Minimum Data Set) an assessment tool dated 3/5/2026 revealed Resident #2 had diagnoses including Alzheimer's Disease, Hypertension, Traumatic Brain Injury and Seizure Disorder. The resident transferred from one surface to another and ambulated without assistance, and had physical behaviors. The resident had two or more falls with injury, not major, since the prior assessment. The resident's Care Plan revealed the resident ambulated independently with or without a cane (date initiated 3/9/2026), and had a fall risk related to poor safety awareness and impaired balance (date initiated 3/9/2026). Interventions dated 3/9/2026 revealed, in part, to ensure he had the call light within reach, wore appropriate foot wear, and to leave the bathroom door ajar with the light on. On 3/10/2026, the Care Plan directed staff to remove the bedside table and provide an extra table without wheels. The Care Plan focus area dated 3/9/2026 reported the resident received anti-platelet medication putting him at risk for bleeding. On 3/9/2026, the Care Plan instructed staff to encourage the resident to keep the door open at night as resident allows to allow for more frequent staff checks. The Care Plan, with revision date 3/9/2026, also indicated the resident had behaviors directed towards others. The Care Plan focus area dated 3/23/2026 revealed the resident was at risk for making false accusations. In a Progress Note dated 3/10/2026 at 1:43 p.m., Staff D, RN (Registered Nurse) documented staff notified her that Resident #2 had blood on his lips. Staff D found the resident with a swollen bottom right lip with redness that measured 2x2 cm (centimeters), and an opening on the inside of the lip. The resident also had abrasions on the anterior right arm that measured 2x14 cm., and right shin that measured 2x0.7 cm. with scant blood. Staff D cleansed the areas and left them open to air. The resident complained of pain in the lip and arm, and Staff D administered Tylenol as scheduled and a cool cloth. The resident denied difficulty drinking. Staff D assessed the resident and found his range of motion and neurological examination within normal limits. The resident denied falling and indicated someone came into his room and picked a fight with him. Staff D notified Staff B, DON (Director of Nursing) and the Physician Assistant.In a Progress Note dated 3/10/2026 at 11:39 a.m., Staff B noted the Physician Assistant saw the resident during rounds. Staff requested a psychiatry referral due to the resident's continued behaviors and increased paranoia. An Incident Report at 6:25 a.m. reported the same information documented in the progress note.An Incident Report dated 1/13/2026 revealed the resident fell outside of his room in the hall. He walked out with his cane and cursed at staff complaining he had no underwear. He threw his cane back into his room, lost his balance and fell. He sustained a 1.4 x 3.5 cm abrasion to his right knee. The resident stood up unassisted, and staff showed the resident where he had his underwear in his room.An Incident Report dated 2/8/2026 at 2:40 a.m. revealed staff heard a loud bang and found the resident seated on the floor in his room near the bathroom door. The resident reported no injury, had no idea how it happened and he used his cane.The facility self report included: On 3/10/2026 at approximately 6:15 a.m., Staff C entered Resident #2's room during rounds and discovered the resident had a bloody lip and marks on his arms. The resident reported a female employee came into the room and assaulted him. Staff C notified Staff D, charge nurse immediately. Staff D assessed the resident and notified Staff A, Administrator and Staff B, DON. Staff E, ADON (Assistant Director of Nursing) observed the resident and also found blood on the night stand and the floor. The resident told Staff E that a male employee came into his room during the night and assaulted him. Staff A, interviewed the resident, and resident reported a male employee came into his room and assaulted him. The resident reported he did get out of bed during the night but could not recall if he fell. Staff A noted blood on the night stand and floor, and immediately filed a self-report and initiated the investigation. Staff A reviewed camera footage from the camera located in the resident's hallway. The footage showed Staff N, C.N.A. entered the resident's room at approximately 9:36 p.m. and the time Staff C entered the room. Camera footage confirmed that no one entered or exited the resident's room between 9:36 p.m. on March 9, and the time Staff C entered the room the following morning. Additionally, Staff A confirmed through staffing records that there were no male C.N.A.'s working the night of the incident, further contradicting the resident's account.Observation on 3/23/2026 at approximately 8:10 a.m. revealed the resident's bedroom door shut with sign with instructions to knock before entering. Staff F, RN reported the resident keeps his door shut at all times and eats in his room. Observation on 3/23/2026 at 9:20 a.m. revealed the resident in bed. Staff E encouraged the resident to sit up and eat breakfast. Staff E reported staff encouraged him to come out for activities and meals, however he typically only came out of the room for baths. The cane and call light were within reach, and he wore gripper socks. The resident reported nobody had ever mistreated him, he felt safe, and staff treated him okay. At 11:30 a.m. the resident continued to lay in bed, alert and verbal, though difficult to understand stating he had cotton mouth. The resident requested ice for his water. When asked what happened to his closet door, he indicated he got into a fight with the maintenance man. Staff G entered the room and the resident made inappropriate comments directed towards her. Staff G reported the resident refuses to sit in the recliner for meals, and prefers to sit at the edge of the bed. On 3/25/2026 at approximately 10 o'clock a.m. the resident shouted in his room for someone to shut his door. Staff interviews revealed the following: On 3/25/2026 at 9:45 a.m., Staff A, Administrator reported on March 10, the aide found Resident #2 with blood on his lip and some abrasions on his arms. The facility had cameras in the hall. When he reviewed the footage, it showed on 3/9/2026 at 9:36 p.m., Staff N entered the resident's room. Nobody entered the room until the next morning, 3/10/2026 at 6:15 a.m. They provided education on the importance of rounding, and the lack of rounding was unacceptable. The cameras failed to capture the resident's call light in the hall. The agency aide working during the night did not round on him. Staff B spoke to her and she did not have anything to say. She went to the door and listened but did not go in. That was a big thing with the training. The resident hates it when people opened up his door during the night but it had to happen. The resident had no recall of falling, but there was blood at the base of the night stand and on the floor next to it. He did not have to go to the emergency room. The physician was in the building that day and he saw him. Staff B, DON had shown up twice on third shift to check on things, and she said it had gotten better. On March 10, the resident said a female employee came in and beat him up. Staff A, Administrator explained he spoke to him (resident) immediately when Staff A got to work and he (resident) told me it was a male employee who beat him up. Staff A further explained he filed the report and started the investigation. On March 18, Staff H, Maintenance was in his room, and looked into fixing the closet door which has been off since August. The resident told Staff H the reason he did not have a door was because someone beat him up, he fell into the door , that is why it broke, and that person took the door. After he reported that, Staff H notified Staff A. Staff A went immediately into his room and he told him that Staff H beat him up and took the door. Staff A reminded him that he fell into the door in August and that is why they had to take it. Staff H did not work at the facility at that time. Because he thought that, Staff A filed a self- report (reported the incident to the State Agency). Staff H was told not to go into his room, and they moved the maintenance office to the [redacted] hall next to the dietary supervisor and housekeeping supervisor. The facility has investigated four abuse allegations from the resident, and all were unverifiable. They updated his care plan, and take everything he said and investigate it. At every QAPI, Quality Assurance and Performance Improvement, they address every self-report from the previous month. On 3/23/2026 at 12:20 p.m., Staff E, ADON, explained Resident #2 stayed in his room most of the time, and explained he had inappropriate behaviors. That morning Staff D, charge nurse told Staff E that the resident had a bloody lip and some marks on his arm, and said someone came into his room during the night and beat him up. Staff E went into his room and saw he did have a bloody lip and marks on his arms. He said it was a woman and then changed it to a man. He said he did not know if it was someone who worked at the facility, and that it happened in the middle of the night. Staff E explained had cameras on every hall. Staff A, Administrator clarified with the cameras that nobody went into his room during the night. He does make false allegations and yells at the aides. He has his meal tray on his night stand. There was blood on the leg of the tray table so it was removed after the fall on 3/10/2026. With the blood on the tray table and on the night stand, Staff E explained knew he had a fall and he got himself up. He never had his call light on that night. He was able to use his call light and did. Staff was supposed to check on each resident at least every two hours. Staff E explained followed up with staff education. Staff B spoke to the night shift staff. One of the aides said she did not go into his room because he yelled at them when they did. They were educated and told that they just needed to lay eyes on the residents. On 3/23/2026 at 1:40 p.m., Staff B, DON, explained Resident #2 was on the list to be seen by telehealth psychiatry when they got family consent. He had a history of false allegations with hallucinations. The primary physician felt it was appropriate for him to see psychiatry. After the two recent incidents occurred, staff called the DON and the Administrator. Staff E went in to assess the resident after he stated someone came in and beat him up. We reviewed the camera footage and saw staff went in the night before around 9:30 p.m. and then at 6:15 the following morning. Staff B reviewed with staff the importance of rounding and educated staff. The aide who worked the night before said he would get mad at them if they went in, and that they answered his call light when he needed something. Staff B told staff they had to lay eyes on him to be sure he was safe. He got angry if someone opened the door, however we still need to. The resident used his call light or comes to out to the hall and yells. When they have tried to make him an assist of one he was noncompliant and refused to cooperate with therapy. He said someone beat him up but Staff B explained analysis revealed he fell, due to the blood on the tray night stand and no camera footage of anyone entering his room. The Physician Assistant was at the facility, he checked the resident, and he felt it resulted most likely from a fall. The resident has made other false allegations in the past and he is care planned for it. He does not leave his room unless he is looking for something, and comes out and yells for someone to come help. If he gets angry he gets shaky if staff try to help him. If staff try to put a gait belt on him, he gets upset. He is inappropriate and then he will say I am not a liar, I would not say that. On 3/25 at approximately 2 p.m., Staff B revealed the night shift received an employee education acknowledgement that they had to sign, and it is in the employee file. She also posted the education in the communication book and in the employee break room for all staff to view when they arrive to work.On 3/24/2026 at 8:22 a.m., Staff F, RN explained the resident was known to make false allegations and he preferred females. He was more likely to make an allegation about a male. Staff were educated after his fall. Per Staff F, were to do one hour rounding. Eyes need to be laid on him, especially at night. Staff F explained he did not come out of his room unless he wanted something. He would go to his doorway and yell for staff. He did use his call light.On 3/24/2026 at 1:30 p.m., Staff D, RN explained Staff C, CNA let Staff D know that she went into Resident #2's room in the morning and he had blood on his lip, and a swollen upper lip. The resident said someone came in and picked a fight with him, and that it was a male. Staff D checked him out, he had a couple of other abrasion type marks on his arm and shin. Staff D did neurological checks over the course of the day. The resident did not really say anything more. He did not recall that he slipped and fell. He had gripper socks on but Staff D replaced them with a new pair. In the past he has that someone attacked him. Staff were educated and instructed to make sure they check on residents even if they did not need to be changed. Just to be sure they were all okay. The resident did use his call light if he wanted something or he yelled. He insisted his door stayed closed and there was a sign on his door that told people to knock first. On 3/24/2026 at 1:45 p.m., Staff C, CNA explained on March 10, around 6:10 a.m. Staff C entered Resident #2's room to assist him with morning cares, like she did every morning. He did not have his call light on. Staff C asked him if he was ready to get up and get washed up. He was laying down in bed and she saw he had smeared blood on his chin. She reported it to Staff D. The resident said she came and beat me up. He had a tendency of making false allegations. Per Staff C, he broke his fan and now he was saying someone stole it, but we are trying to get him a new one. She was not told anything in report. His cane was by his chair and he had gripper socks on. His tray table was next to his bed. Staff C heard there was blood on the floor by the tray table, and they removed it. The resident now had a night stand in its place. After that incident with the resident, they received education regarding the need to check the residents on hourly rounds. They recently had abuse re-education as well. On 3/25/2026 at 8:10 a.m. Staff N, CNA explained the following via phone: Staff N worked from 6 p.m. - 10 p.m. as the medication aide on March 9, 2026. Staff N went into the resident's room around 9:30 p.m. to administer his bedtime medication. He was at the sink brushing his teeth, and then he got into bed and showed her what he was watching on TV. He can and does put his call light on. He would come to the bedroom door and yells when he wanted something. He was able to make his needs known. They were educated about doing hourly rounds and pamphlets were placed in the break room. Staff N explained had to do a walk through and check on the residents. On 3/25/2026 at 8:20 a.m., Staff I, RN explained the following via phone: Staff I worked from 10 p.m. on March 9 until 6:00 a.m. on March 10. The facility staffed one nurse and two aides on the night shift. Staff I reported she did not go into Resident #2's room during the shift. The resident typically put his call light on if he wanted something. She thought an aide went into his room, but the cameras showed otherwise. They received education about the need to check every resident every hour, open the doors, and lay eyes on them. On 3/25/2026 at 9:00 a.m., Staff J, CNA explained the following via phone: Staff J currently worked on the night shift from 10 p.m. - 6 a.m. That evening, March 9th on the night shift, she worked as well as an agency aide. The agency aide was assigned to the [redacted] and [redacted] hall. The resident normally put his call light on. The agency aide had worked at the facility in the past and normally did a pretty good job. Staff received education regarding the need to do hourly rounds.

Based on clinical record review, staff and resident interviews, and facility policy review the facility failed to ensure a resident remained free from verbal mistreatment by staff for one of three residents reviewed (Resident #1). The facility reported a census of 51 residents. The facility corrected the deficient practice per past noncompliance through the following actions: -An all-staff meeting was held on 3/1/2026. Abuse training completed and abuse policy signed by all attendees.-Two additional all-staff meetings were held on 3/2/2026. All attendees completed abuse training and signed the abuse policy. -All alert and oriented residents were interviewed regarding their safety. -Incident review by Quality Assurance Performance Improvement (QAPI) meeting on 3/10/2026.Findings include:Resident #1 admitted to the facility on [DATE] and passed away on 3/10/2026 with hospice services in place. The MDS (Minimum Data Set) dated 1/8/2026 revealed the resident had severe cognitive impairment, had physical, verbal and other behaviors directed towards others, relied on staff assistance to transfer from one surface to another and used a wheel chair for mobility. The resident's diagnoses included Alzheimer's Disease and cancer. He sustained a fall since the prior assessment that resulted in injury, not major. Resident #1's Care Plan, initiated 10/25/2025, revealed the resident had physical behaviors and mood problems related to his Alzheimer's Disease. It directed staff to redirect his behaviors and if resistive, leave alone and try again after a few minutes. Reward verbally all positive behavior and administer medication as ordered. The resident's progress notes included:The General Progress Note dated 3/01/2026 at 12:49 p.m., written by Staff F, Registered Nurse (RN), revealed Staff F was notified by a CNA (Certified Nursing Assistant) that another CNA yelled at Resident #1. This happened when resident was getting dressed for lunch and resident rolled towards CNA, and went to punch him and jabbed him in the eye. CNA at this time turned away from resident and turned back towards resident and grabbed him by the shoulders and telling him to shut the f**k up He also stated If you weren't a resident I would beat the s**t out of you. Both CNA's exited the room together. CNA immediately reported the incident. Staff F immediately called on call and reported the incident. At this time, CNA was sent home. Incident was also reported to the administrator and also to the Staff B. When Staff F entered the room the resident started smiling and talking and denied any pain or discomfort.A full body skin assessment done and no evidence of any injury at this time. Vitals- Blood Pressure 126/70, Oxygen Saturation 95%, Respirations 18, Pulse 72, Temp 97.2 degrees. Resident was then transferred Ax3 (assist of three) with Hoyer (mechanical lift) into his wheelchair for lunch.The Incident Note dated 3/01/2026 at 8:17 p.m., written by Staff M, LPN (Licensed Practical Nurse), revealed, Resident up in wheelchair for supper without complaint. Visited with this resident in his room. Asked how his day was today. His response was good you say . Asked if he had the convertible out today and he laughed. Resident shows no signs of distraught or concern. No injury noted.The facility investigation included the following: An allegation of abuse was reported, with abuse type documented as staff to resident. The incident occurred approximately on 3/1/2026 at 11:45 a.m. in Room [Number Redacted] Law Enforcement was notified. The Incident Summary section revealed while Staff K, CNA assisted Resident #1, the resident punched Staff K in the face. Staff L, CNA, also present at the time reported Staff K stepped back from the resident and then proceeded to grab the resident by the shoulders and told him to shut the F up. The resident laughed and Staff K grabbed the resident's shoulders again and told him to shut the F**k up again. Staff K was sent home. The facility terminated Staff K as of 3/5/2026. Staff K admitted to yelling and cussing at the resident. Staff K denied grabbing the resident but admitted to the verbal altercation. Staff K reported that Resident #1 jabbed him in the eye first, causing him to react. The Facility Actions section revealed Staff K was immediately sent home by Staff F, RN and suspended by Staff A, Administrator on 3/1/2026. A self-report submitted and law enforcement notified on 3/1/2026. Staff F completed a body assessment with no visible signs of injury or trauma. An all staff meeting was held on 3/1/2026 with abuse training completed at 2:00 p.m., signed by all attendees. On 3/2/206, two additional all-staff meetings were held at 2:00 p.m. and 4:00 p.m. with all attendees completing abuse training and signing the abuse policy. The Conclusion section revealed, in part, This investigation concludes that abuse has been verified. Verbal abuse was confirmed based on Staff L's eyewitness account and corroborated by a resident who heard loud yelling from Staff K. Physical abuse in the form of aggressively grabbing the resident by the shoulders was reported by Staff L. though Staff K denied it. Staff interviews and Resident #5's interview revealed the following: On 3/23/2026 at 12:25 p.m., interview with Staff E, Assistant Director of Nursing (ADON) revealed the following: Staff F, RN called Staff E and reported Staff L, CNA reported that she and Staff K were in Resident #1's room assisting the resident. Staff K got upset because the resident punched or scratched him in the eye. Staff K backed away and when he turned to assist him again, the resident was laughing. Staff K grabbed the resident by the shoulders, shook him and said shut the f . up. They left the room and Staff L reported the incident to Staff F. Staff A, Administrator and Staff B, DON (Director of Nursing) handled the investigation. At the time, the resident had hospice services and non-sensical verbal communication. He required two staff to assist with cares and three to use the Hoyer mechanical lift. He needed assistance for eating and had bowel and bladder incontinence. He passed away within the last month. No other residents or staff voiced a concern about Staff K. He had recently started on week-end package and worked here for at least a year. Staff L has also worked here about a year and works weekends. Staff E had no concerns regarding Staff K or Staff L and the way they treated residents. On 3/23/2026 at 2:00 p.m., Staff B, Director of Nursing (DON) explained on Sunday, 3/1/2026 she received a call from Staff F who was working at the time. Staff L, CNA came out of the room and reported what she witnessed. Staff F sent Staff K home, assessed Resident #1 immediately, and took witness statements from staff working. Staff A came in and did education with staff. The resident had no injuries. On March 3rd the resident saw the Medical Director during rounds, and he had no concerns. The resident received hospice services at the time, and admitted from a memory care unit on hospice on 10/7/2025. Family reported his dementia had progressed significantly in the last year. The resident passed away on 3/10/2026. Staff A completed the investigation and interviewed staff and residents. The roommate, Resident #5, was in the room and they got his interview right away. He has Schizophrenia and ALS (Amyotrophic Lateral Sclerosis-disease of the nervous system), and has a BIMS of 11 (moderate cognitive impairment). When Staff F called, she reported Staff K assisted Resident #1 and Staff L assisted Resident #5. Staff L went to assist Staff K. When they rolled Resident #1, he hit Staff K in the face. The resident had inappropriate laughter, and Staff K took it that the resident laughed at him. Staff K took the resident by the shoulders and said shut the f up. Staff L never left him alone in the room and she immediately reported it. Staff F immediately assessed the resident and saw him smiling with no signs of injury. Staff A notified the police. Staff A interviewed Staff K over the phone. Staff K worked at the facility over a year. No other staff or residents ever voiced a concern about Staff K. Staff K seemed to care and enjoy his job. The abuse policy was reviewed with all staff that day and the following day.On 3/24/26 at 8:09 a.m, Staff F, RN explained the following: Right before lunch, during medication administration, she observed Staff K and Staff L exit Resident #1's room. Staff L came and reported an incident occurred with Staff K and Resident #1. The resident was being feisty per his normal behavior. Staff F has instructed staff to step away and re-approach. The resident started swinging and got Staff K in the eye. Staff K turned away for a minute and held his eye. He took the resident by the shoulders and the resident started laughing. Staff K yelled at him again and said shut the F up. Staff F immediately called the on call nurse, Staff E. Staff F sent Staff K home. Staff K did not say anything and left the building. Staff F had no prior concerns about Staff K, it was a shock. Staff F assessed the resident and found no signs or symptoms of injury. The resident had severe dementia, and did not remember the incident. He was smiling and he said he was good when she asked him how he was doing. Staff F assisted Staff L in getting him ready. Staff L was shocked when it happened. She is a very good aide. No other residents or staff complained about Staff K. Staff F spoke to his roommate and he was very hesitant to say anything about Staff K because he did not want to get him in trouble. Staff A called Staff F right after the incident occurred and then he came in. Staff F notified the family. On 3/24/2026 at 8:40 a.m., Staff K, CNA was interviewed via telephone. Staff K reported working two years full time days at the facility, and had a couple of write ups during that time. One was not having a second person present during a two person resident transfer. The second one was about 6 months ago when he took a resident outside to smoke. A resident communicated to staff that they were allowed to go out to the parking lot to smoke, which was not the case. He received a write up for it. Regarding Resident #1, just prior to lunch time he went into his room with Staff L. The resident required two staff with cares at all times because of his combative behaviors. Staff L started providing cares for the roommate and then came to help him with Resident #1. The curtain was closed and he stood on the curtain side. He assisted the resident to roll onto his side so Staff L could provide incontinence cares. Staff K attempted to keep the residents swinging arms free from Staff L. The resident jabbed him in the eye. Staff K admitted he yelled a couple of profanities, not directed towards the resident. The resident started laughing and Staff L said 'it is not funny', and he said 'it is funny'. Staff K explained [Staff K] said no, it is not f funny. Staff K denied grabbing the resident's shoulders. He denied yelling at the resident, but said it was not f ing funny. After Staff K got himself sorted and made sure he did not have damage to his eyes, they continued cares. Staff L asked him if he was okay or if he needed to step out. He said they needed to get done so they could get the resident to lunch. They finished cares, put his pants on and a sling under him. Staff L made a report to Staff F, and he was sent home. He had gone into another resident's room to provide cares and when he came out he was sent home without writing a statement. Staff A called me that day while driving and he returned the call the following day. Staff K heard it had been reported that he grabbed Resident #1 by the shoulders and yelled at him. Staff K told Staff A that was not what happened. Staff A informed him there had been an allegation of abuse and the police may contact him. The police never contacted him. A few days later Staff A informed Staff K of his termination. He had no prior allegations or concerns of mistreatment. On 3/24/2026 at 1:05 p.m., interview with Staff L, CNA revealed the following: When the incident occurred with Resident #1, Staff L and Staff K were in the resident's room, room [Number Redacted]. They entered at the same time before lunch. Staff L assisted Resident #5 while in bed. Staff K assisted Resident #1, also in bed. The curtain was closed between the two beds. Staff L heard Resident #1 began cussing. He could get combative, kick and hit at times. She went to help Staff K. She stood on the wall side of the bed and Staff K stood on the curtain side. She rolled the resident towards Staff K and the resident jabbed him in the eye. Staff K turned away for a second and she asked him if he was okay. Staff K said that he hit him in the eye and he muttered, If you weren't a resident, I would beat the s**t out of you. The resident started laughing, Staff K grabbed his shoulders and said shut the f**k up. He screamed it two times. She told Staff K they needed to go. Staff K exited the room and she followed. She told him she had eye drops in her purse that he could use. Staff L reported it to Staff F, the charge nurse. The resident laughed and said that is awesome when Staff K said he got hit in the eye. Staff L reported working with Staff K prior to that, quite a few times. They both worked the weekend package for [length of time redacted], and she worked with him before that. She never witnessed him mistreat a resident prior to that. No resident ever voiced a concern about him. It was out of character for him; it came out of nowhere. Staff F sent Staff K home and she wrote a statement. They had a meeting that day and reviewed abuse policies. Staff L explained she followed the policy and reported it immediately. On 3/24/2026 at 1:40 p.m., Staff D, RN reported working with Staff K in the past as a charge nurse and never had a concern with the way he treated residents. No residents or staff ever voiced a concern about the way he cared for the residents. He stayed busy, did his job. There were a few times where he had to be encouraged, but no issues with not taking care of the residents. In fact a lot of the residents really liked him. We were educated regarding abuse policies. It was a Sunday and we were called in if we were available for the mandatory education. On 3/25/2026 at 8:20 a.m., Staff I, RN explained staff were re- educated after the incident with Resident #1 about the abuse policy. No resident ever voiced a concern and staff ever complained about Staff K. Resident #1 had very poor cognition.On 3/25/2026 at 9:00 a.m., Staff J,CNA explained the following via phone: Staff J worked at the facility for three years, currently on night shift. Staff all knew that Resident #1 would grab and curse. Staff J worked with Staff K, she trained him. Staff J had no issues with Staff K, he seemed to be a pretty good aide. Staff received training on the abuse policy, they had to sign it and complete abuse training. On 3/25/2026 at 10:10 a.m., Staff A, Administrator explained the following: Resident #1 was in room [Number Redacted], at the end of the hall until he passed on 3/10/2026. He received a call on Sunday, March 1, around 11:30 am. An incident occurred between Resident #1 and Staff K. Staff L had been working with Resident #5. Staff K had been focused on Resident #1. The resident had a history of being aggressive. According to Staff L, the resident hit Staff K very hard in the eye, and Staff K aggressively shook the resident's shoulders and said shut the f . up, and if you weren't a resident I would f .ing kill you. The resident laughed and Staff K repeated shut the f . up. Staff L stated they both exited the room at the same time, the residents were safe when they exited and she went to Staff F, the charge nurse. Staff F called him and Staff B. Staff K was asked to leave at that point. That was the last he had been in the building. Staff A came in, filed a self report, started interviews and did staff education. He proceeded to do more staff education the next day at 2 and 4 p.m. The education included the facility abuse policy. Staff F did evaluate the resident and found no signs of injury. Resident #5, his roommate also confirmed that Staff K yelled profanity at the resident. The curtain in the room was open. Staff K denied putting his hands on the resident, but did admit to yelling at him. He apologized and said he should not have done it. Staff and residents were interviewed. Staff A concluded it was verifiable that Staff K did verbally and physically abuse the resident and he was terminated. Staff B sat in on the call. Staff K worked at the facility for over a year and there had not been any concerns regarding the way he treated residents. Staff A notified the police right after he did the self report, and they did not come to the facility. Resident #1 had severe dementia and had no recall. We did discuss it in depth in QAPI (Quality Assurance Performance Improvement). Staff A felt staff responded appropriately, Staff L made it a point to leave the room after Staff K. She did not leave him alone in the room. They discussed what happened, the steps we took, the intervention regarding the training we did and how we cannot have that occur among our staff. Interview with Resident #5 (roommate) on 3/23/2026 at approximately 2 p.m. revealed the following: Resident reclined in bed, alert, pleasant and verbal. Resident #5 queried if recalled an incident with your roommate and a staff? He poked a staff in the eye and the staff got mad. Do you recall the staff's name? [Name Redacted], [First Name Matching Staff K Redacted], something like that. Was the curtain open? I can't remember, but I could hear, he called him f .er and that is all. He did not hit him or hurt him. I can't really blame him, it probably hurt him The resident reported no concerns with staff treatment, he was doing the best he could with his diagnosis of ALS. He appreciated the help from staff. The facility policy updated 3/18/2026 titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy revealed, All Residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in personal degradation* including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The policy further revealed, It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of Residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation.

Based on observation, record review and staff and resident interviews the facility failed to provide adequate supervision to prevent resident to resident behaviors (Resident # 2, Resident #4, Resident #6, Resident #8, Resident #9). The facility identified a census of 48 residents. Findings include:1.) The Minimum Data Set(MDS) assessment tool, dated 8/21/25, listed diagnoses for Resident #2 which included anemia, hypertension (high blood pressure), arthritis and Non-Alzheimer's Dementia, anxiety and post traumatic stress disorder. The MDS stated the resident was independent for transferring and listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, which indicated severe cognitive impairment. An incident report from 10/27/25 at 7:00 PM revealed Resident #4 found lying in the hall outside her room and Resident #2 walking away yelling profanities at her. Resident #4 stated this lady attacked me and started yelling at me and I yelled back. Review of Resident #4's Progress Note 10/27/25 at 7:00 PM revealed Resident #2 struck Resident #4 left lower jaw. No injuries noted. The care plan with a revision date 7/3/25 revealed Resident #2 has physical behavioral symptoms toward others (for example: hitting, kicking, pushing and scratching) the following interventions were implemented on the dates indicated:-7/3/25 when a resident becomes physically abusive, move to a quiet, calm environment.- 9/23/25 the intervention when a resident becomes physically abusive, keep distance between the resident and others (e.g. staff, other residents, visitors).- 10/2/25 directed 15 minute checks.On 11/12/25 at 12:26 PM the Director of Nursing stated on 10/27/25 the incident with Resident #4 happened and Resident #2 was walking the hallway. Resident #4 came out of her room to put her food tray in the hallway. Resident #4 does not like people around her room or people next to her room. Resident #4 shoved Resident #2 and she called her a name and then slapped her across the face. Resident #4 denied any injury, she slapped me just once. The facility then placed Resident #2 immediately on 1:1 supervision by staff and placed Resident #4 on 15 minute checks. The facility provided a policy titled Management of Inappropriate Resident Behavior: Resident to Resident Aggression dated 2/6/17. The policy directed if aggressive behavior is witnessed or reported, intervene immediately and separate the residents involved. The policy failed to direct further interventions to prevent further incidents. 2.)The MDS assessment dated [DATE] for Resident #8 revealed the resident was independent with transfers and ambulation. The MDS listed the resident's BIMS score was 9 out of 15, which indicated moderate cognitive impairment. Review of Resident #8's Care Plan revealed the resident had impaired cognition related to cerebrovascular accident (CVA). The intervention initiated 11/3/25 and revision on 11/7/25 directed staff there is to be no sexual contact with Resident #9. The care plan did not have interventions to prevent further sexual contact with other residents. a. The incident report dated 11/2/25 at 4:15 PM revealed Resident #8 sitting with a female resident watching television and holding hands. Nurse observed Resident #8 groping female resident's breast. Resident #8 then was observed by other staff and residents, again touching the female's breast and putting her hand in his groin. Residents were separated at this time and manager on call notified. Review of an incident report for the same date and time identified the female resident as Resident #9. b. An incident report on 11/7/25 at 5:00 PM revealed Resident #6 was sitting in the dining room with Resident #8 a male resident had his hand between her legs and was rubbing her legs. Resident #6 stated she attempted to push his hand away but he was not moving it. Resident #6 stated that he did not hurt her but he is just a very persistent guy. She stated that she did not like this behavior. Review of the MDS for Resident #6 dated 10/13/25 indicated a BIMS score of 14 out of 15, which indicated intact cognition. Observation on 11/10/25 at 11:30 AM revealed Resident #8 lying on the bed in his room and watched television. Staff E, CNA sat in a recliner in room, he states Resident #8 was a 1:1 (one to one supervision) and they had been providing supervision. Resident stated he has been here for a while, and they were keeping an eye on his diabetes was the reason staff was with him. Staff E, CNA stated if the resident did get up and wanted to walk around the facility, he would go with him.On 11/12/25 at 10:00 AM Resident #6 stated the following regarding the incident from 11/7/25 with Resident #8: She did recall him putting his hand on her left knee and he was rubbing her knee and moving his hand up further on her thigh and she pushed him away and said stop it and he did. Staff did come and separate them. She did not like it and told him that. She did feel safe in the facility and staff removed him immediately. On 11/12/25 at 10:28 AM Staff D, Registered Nurse (RN) stated they was the nurse on duty on 11/7/25 for the incident with Resident #6 and Resident #8. [Staff D] was at the nurses station doing something and Resident #10 reported she had seen Resident #8 with his hand down Resident #6 pants. [Staff D] went out there immediately to separate them and he was not touching her. [Staff D] clarified it with Resident #10 and she verified his hand was on top of her pants and on her thigh. Then [Staff D] talked to Resident #8 and he got defensive and said he didn't do anything. [Staff D] then spoke to Resident #6 and asked her where his hands were. She said it was on top of pants and she said she brushed his hand away and he would not move his hand he started to move his hand up and I told him no and he would not listen. Resident #8 had been on 1:1 supervision since the incident happened. On 11/12/25 11:48 AM Resident #10 stated she did witness Resident #8 touch Resident #6 he had his hand on her thigh and was rubbing it. It was on top of her pants. It just did not seem appropriate. [Resident #10] went to the nurse and let her know and then she immediately went to the residents and staff assisted both of them back to their room. [Resident #10] had been a resident here for a while and had never seen anything like that. [Resident #10] felt safe in the facility. On 11/12/25 at 2:49 PM Staff H, CNA explained worked on the night of 11/7/25 on the [redacted] hall and that was where Resident #8's room was located. Staff H explained at the beginning of the shift we let people know where residents are and [Staff H] did not hear anything about him having any particular incidents prior. He would occasionally walk down the hall and hold hands but not that he had an incident of touching any residents inappropriately. [Staff H] was on break at the time of the incident about 4:10 PM, got back at 4:40 PM, and they told [Staff H] had to do 1:1 with Resident #8 until 9:00 PM when another CNA took over. On 11/12/25 at 3:45 PM the Director of Nursing stated after the incident with Resident #9 and Resident #8 did not do 15 minute checks, they completed the sexual relationship tool, did that for any sort of relationship, would do it for both residents. Resident #8 answered appropriately and was able to give consent but Resident #9 was not. Then, notified the family and then kept those two residents separated. To prevent it from happening with other female residents facility educated the staff of what had happened and how to intervene, and discussed what they should be doing. On 11/12/25 at 3:59 PM the Administrator stated after the first incident with Resident #8 the residents were separated, staff did intervene, and educated staff to separate immediately. Facility had a policy for Sexual Relationship for cognitively impaired residents and staff should follow the policy.The facility provided a policy titled Sexual Relationships for Residents with Cognitive Impairment revised 10/24/22. It revealed the purpose to protect individuals with cognitive impairment who are unable to provide consent to an unwanted sexual relationship. The policy clarified the definition of cognitive impairment for purposes of this policy would consider residents with a BIMS score of 12 or below as cognitively impaired.

Based on observation, record review, resident and staff interviews the facility failed to prevent a resident to resident altercation, involving Resident #1 and Resident #2, for 1 out of 2 incidents reviewed. The facility identified a census of 48 residents. Findings include: The Minimum Data Set(MDS) assessment tool, dated 8/21/25, listed diagnoses for Resident # 2 which included anemia, hypertension (high blood pressure), arthritis and Non-Alzheimer's Dementia, anxiety and post traumatic stress disorder. The MDS stated the resident was independent for transferring and listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, indicating severe cognitive impairment. The Minimum Data Set(MDS) assessment tool, dated 8/8/25, listed diagnoses for Resident #1 which included hypertension, renal insuffieciency and diabetes. The MDS revealed the resident's Brief Interview for Mental Status(BIMS) score was15 out of 15, which indicated no cognitive impairment. An incident report dated 6/27/25 at 5:15 PM revealed Resident #2 elbowed another resident in the stomach. No injuries reported and the residents immediately separated.An incident report dated 9/22/25 at 8:40 AM revealed Resident #2 shoved another resident in her room. No injuries reported from the incident and the residents were immediately separated. Review of Resident #1's Progress Note dated 10/2/25 at 11:55 AM, date of incident not included, revealed Resident #1 had been slapped by Resident #2, Resident #1 had swung their left arm back at Resident #2, and Resident #1 didn't know where she had hit Resident #2. An incident report dated 10/2/25 at 11:50 AM revealed Resident #2 slapped Resident #1 in Resident #1's room. Resident #2 was standing slightly behind the other resident's right wheelchair handle. The nurse separated the residents immediately. No injury observed on either resident. Resident #1 stated she trespassed and pointing to Resident #2 stated she slapped me and pointed to her right cheek, she admitted she slapped her back. Resident #2 denied she slapped Resident #1.The Care Plan initiated on 6/27/25 and revised on 7/3/25 revealed Resident #2 has physical behavioral symptoms towards others (for example: hitting, kicking, pushing and scratching) The interventions directed 15 minute checks initiated on 10/2/25. Another intervention initiated on 9/23/25 directed staff when resident becomes physically abusive, keep distance between the resident and others (for example: staff, other residents and visitors). On 10/23/25 at 1:10 PM Resident #1 stated Resident #2 came into their room and [Resident #1] was in their wheelchair, and [Resident #2] ordered me out of my room. [Resident #1] said this was their room and [Resident #2] said no it wasn't it, was hers, and [Resident #2] slapped [Resident #1] on the right side of [Resident #1's] face. [Resident #2] was agitated because she thought it was her and [Resident #2] knew I (Resident #1] couldn't fight back. Resident #1 explained Resident #2 had come into Resident #1's room before but had never hit them.On 10/27/25 at 10:45 AM Resident #2 observed lying in her bed partially asleep. No one was in the room with her. On 10/27/25 at 2:00 pm Staff E, Certified Nursing Assistant (CNA) stated Resident #2 has declined and she doesn't usually know where she is mentally or physically. She needs to be redirected or an argument might break out. If an argument breaks out we separate them and chart the behaviors. Resident #2 doesn't have 1 on 1 supervision. We just try to keep track of her, the best we can do is redirect her. We lay her down and not a minute later she will be right back up. Sometimes activities will help but she doesn't sit still for them or anything else. On 10/30/25 at 9:15 AM Staff A, Licensed Practical Nurse (LPN) stated they were the nurse for the incident with Resident #1 and Resident #2 on 10/2/25. [Staff A] heard loud voices, walked in the room, and the residents were arguing. Resident #1 stated Resident #2 slapped her. Staff A explained Resident #2 was very confused, was declining, and was more agitated. She got irritated much faster.On 11/12/25 at 12:26 PM the Director of Nursing (DON) stated they did have Resident #2 on 15 minute checks after each of the resident to resident incidents but they were discontinued after moving Resident #2 to a different hall. The DON explained felt that had separated the residents and did not need the 15 minute checks any longer, resident interviews were done, and no one had concerns with safety issues for other residents. On 11/12/25 at 4:08 PM the Administrator stated had moved Resident #2 to the opposite side of the building after this incident with Resident #1. The plan was for the residents involved to be separated. Resident #2 had not had any slapping incidents prior to the one with Resident #1, that was one of the reasons we are attempting to find alternate placement was her behaviors were progressing. Per the Administrator, did not think at that time Resident #2 needed one on one since it was the first slapping incident, we felt moving her room location would be sufficient. This was the first physical alteration and she had not had any issues prior to that. The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated July 2024. The policy directed in the section of Prevention of Abuse: The facility will identify, through ongoing assessment, high-risk situations where abuse, neglect or misappropriation of resident property may occur and provide appropriate intervention in such occasions. Situations that may indicate a higher risk for abuse to occur include, but are not limited to, verbally/physically/sexually aggressive behavior, wandering into other resident's rooms or rummaging through their property, the presence of history of aggressive/violent/self-injurious behaviors, communication deficits, or those residents most dependent upon staff for their care.

Based on clinical record review, resident, and staff interviews the facility failed to account for the resident's location when a resident chose to smoke per Care Plan for one of two residents reviewed (Resident #29). The facility reported a census of 50 residents. Findings include: Resident #29's Minimum Data set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS documented diagnoses of cancer, hypertension, and hyperlipidemia. The Care Plan initiated on 9/26/2023 identified Resident #29 currently using tobacco. An intervention recorded on the Care Plan indicated Resident #29 was to sign out on the Leave of Absence form when leaving the facility to smoke and sign back in upon return. The Release of Responsibility for Leave of Absence form was located on a ledge by the facility main entrance. The Release of Responsibility for Leave of Absence form revealed the name of the resident and facility were to be completed on the top of the form but were left blank. Under the signing out section of the form, numerous resident names were listed along with the date and time. Resident #29 documented on 10/23 at 11:45 exiting the building to smoke. There was no documented time noted for signing in for Resident #29. During an interview on 10/28/2024 at 10:48 AM Resident #29 revealed she is a current smoker. Resident #29 informed this surveyor she leaves the premises and smokes at the edge of the parking lot twice per day. On 10/30/2024 at 12:53 PM observed Staff B, Licensed Practical Nurse (LPN) provide Resident #29 with two cigarettes. Resident #29 propelled herself in her wheelchair to the exit door and exited the facility without signing out. Observed Resident #29 re-enter the facility at 1:17 PM without signing in. During an interview on 10/30/2024 Staff B, LPN reported the designated smoking area is off the premises of the facility grounds. Staff B, LPN verbalized she was unaware if Resident #29 was to sign out of the facility when smoking. Staff B confirmed Resident #29 left the building 2-3 times per day to smoke. On 10/31/2024 at 11:24 AM the Director of Nursing (DON) acknowledged any resident who chose to smoke, must do so off facility property. The DON acknowledged the Care Plan identified the intervention for Resident #29 was to sign out and in when leaving/returning to/from smoking. On 10/31/2024 at 11:58 AM the DON and Administrator confirmed Resident #29 signed out 1 time in the past month to smoke. The facility Smoking Policy revised on 10/24/2022 failed to identify responsibility for accounting for resident location when smoking.

Based on clinical record review, resident and staff interviews, and facility policy review the facility failed to maintain consistent records of Hemodialysis communication for 2 out of 2 months for 1 out of 1 resident reviewed (Resident#10). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], for Resident #10 listed diagnoses of chronic kidney disease (CKD), congestive heart failure. The MDS reflected her Brief Interview for mental status score of 15 out of 15 (intact cognition). The Care Plan for Resident#10 dated 9/29/21, identified she needed dialysis related to CKD, and will have no signs or symptoms of complications from dialysis. The Care Plan directed: encourage Resident#10 to go for the scheduled dialysis appointments Monday, Wednesday, and Fridays. Resident#10's clinical record failed to include Hemodialysis communication forms for September and October 2024. The Dialysis Book for Resident#10 on 10/30/24, failed to hold any Hemodialysis communication forms. On 10/31/24 at 11:28 AM, Staff A, RN reported she failed to know they had a Dialysis book, she thought the pre/post assessment Hemodialysis communication forms went in Resident # 10's chart. On 10/30/24 at 4:18 PM, the Director of Nursing (DON) reported the Hemodialysis assessments are in a binder not in the resident chart. On 10/31/24 at 12:08 PM, the DON reported she expected the Hemodialysis forms to be in the dialysis book. The DON reported she found one sheet for the past 2 months. The facility provided a policy titled Dialysis Care dated 2/2/2017, the policy directed nursing shall assess and document vital signs, including blood pressure in the arm where the access site is not located, weights if ordered, and communicate the information including the resident's status with dialysis facility prior to and post dialysis.

Based on clinical record review, resident, family, and staff interviews the facility failed to complete the facility Smoking Assessment to assess for resident's capabilities and deficits to safely smoke for 2 of 2 residents reviewed (Residents #1 and #29). The facility reported a census of 50 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating moderate cognitive impairment. The MDS documented diagnoses of non-traumatic brain dysfunction, coronary artery disease, hypertension, diabetes mellitus, and cerebrovascular accident. The Admission Nursing Assessment completed on 3/07/2024 at 4:34 PM by Staff A, Registered Nurse (RN) documented Resident #1 as a current smoker. A Care Plan focus area initiated on 06/10/24 identified Resident #1 as currently using tobacco. Facility interventions include assessing Resident #1's capabilities and deficits quarterly to determine if supervision was required. A review of the clinical record revealed the facility completed no Smoking Assessment to assess Resident #1 capabilities and deficits to safely smoke. The facility failed to assess Resident #1 upon admission and quarterly to safely smoke. During an interview on 10/28/2024 at 3:49 PM Resident #1 verbalized he was a current smoker. On 10/30/2024 at 4:09 PM, Resident #1's daughter confirmed he was a current smoker. On 10/31/2024 at 11:19 AM, Staff A, RN acknowledged completing the Admission Nursing Assessment for Resident #1 identifying Resident #1 as a current smoker. Staff A, RN confirmed she did not initiate or complete a Smoking Assessment for Resident #1. 2. Resident #29's MDS assessment dated [DATE] identified a BIMS score of 14 out of 15, indicating intact cognition. The MDS documented diagnoses of cancer, hypertension, and hyperlipidemia. The Care Plan initiated on 9/26/2023 identified Resident #29 currently using tobacco. Facility interventions include assessing Resident #29 capabilities and deficits quarterly to determine if supervision was required. During an interview on 10/28/2024 at 10:48 AM, Resident #29 verified she was a current smoker. Resident #29 verbalized she exited the building twice per day and smoked 2 cigarettes without supervision each time. A record review identified the facility completed Smoking Assessments on 9/24/2023, 1/04/2024, and 10/31/2024. The facility failed to assess Resident #29 quarterly to safely smoke. On 10/31/2024 at 11:24 AM the Director of Nursing (DON) verbalized the Smoking Assessment is completed upon admission and quarterly for current identified smokers. The MDS Coordinator or Care Coordinator are responsible for completing assessments timely. The DON acknowledged missed Smoking Assessments for Resident #29 occurred on 03/28/24, 04/21/2024 and 07/18/2024. Furthermore, the DON acknowledged that no Smoking Assessments were completed for Resident #1. The DON verbalized Smoking Assessments for Resident #1 should have been completed on 03/14/24, 06/06/2024, 07/04/24, 08/08/2024 and 09/26/2024. The facility failed to complete 8 assessments on current residents. The facility Smoking Policy revised on 10/24/2022 failed to identify assessing resident's capabilities and deficits to safely smoke.

Based on staff interview, clinical record review, and review of Centers for Medicare/Medicaid Services document, Form CMS-20052, the facility failed to provide proper notification to residents and/or resident representatives of the right to appeal decision for discharge from Medicare Part A for 3 of 3 residents reviewed for discharge from Medicare Part A with benefit days remaining (Residents #18, #303, and #304). The facility reported a census of 50 residents. Findings include: 1. Review of facility completed document titled, Beneficiary Notice- Residents discharged Within the Last Six Months, revealed Resident #18 had discharged from Medicare Part A and stayed in facility, on 8/23/24 with remaining Medicare benefit days and again discharged from a second Medicare Part A covered stay on 9/30/24 to home or lesser care, with remaining Medicare benefit days. On 8/21/24 at 3:32 PM, a Nursing Progress Note, informed that a Care Conference was held with Resident #18 and resident's spouse, in which both were notified that Resident #18 would be discharged from therapy on 8/23/24. Review of Electronic Health Records (EHR) for Resident #18, lacked documentation of notification prior to discharge from Medicare Part A benefits on 9/30/24. Review of Form CMS-20052, completed by facility, revealed Medicare Part A Skilled services began 7/15/24 with the last covered day of Part A service dated 8/23/24, in which the facility initiated discharge when service days were not exhausted. Facility failed to complete form as no selection had been made, when asked if Form CMS-10055 had been provided to the Resident. No selection made when asked if Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, had been provided to the Resident. Facility unable to provide either completed form upon request. 2. Review of facility completed document titled, Beneficiary Notice- Residents discharged Within the Last Six Months, revealed Resident #303 had discharged from Medicare Part A and stayed in facility, on 10/23/24 with remaining Medicare benefit days. Review of Electronic Health Records (EHR) for Resident #303, lacked documentation of notification prior to discharge from Medicare Part A benefits on 10/23/24. The facility provided a document titled, Discharge Notice from Therapies, dated 10/18/24, which indicated Resident #303 would have last treatment date for Physical, Occupational, and Speech Therapies on 10/22/24, signed by staff nurse notifying family on 10/21/24. Review of Form CMS-20052, completed by facility, revealed Medicare Part A Skilled services began 8/20/24 with the last covered day of Part A service dated 10/22/24, in which the facility initiated discharge when service days were not exhausted. Facility failed to complete form as no selection had been made, when asked if Form CMS-10055 had been provided to the Resident. No selection made when asked if Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, had been provided to the Resident. Facility unable to provide either completed form upon request. 3. Review of facility completed document titled, Beneficiary Notice- Residents discharged Within the Last Six Months, revealed Resident #304 had discharged from Medicare Part A and stayed in facility, on 8/24/24 with remaining Medicare benefit days. Review of Electronic Health Records (EHR) for Resident #304, lacked documentation of notification prior to discharge from Medicare Part A benefits on 8/24/24. Review of Form CMS-20052, completed by facility, revealed Medicare Part A Skilled services began 8/10/24 with the last covered day of Part A service dated 8/23/24, in which the facility initiated discharge when service days were not exhausted. Facility failed to complete form as no selection had been made, when asked if Form CMS-10055 had been provided to the Resident. No selection made when asked if Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, had been provided to the Resident. Facility unable to provide either completed form upon request. On 10/31/24 at 1:20 PM, Facility Administrator informed that the facility had been unable to locate a completed Form CMS-10123 (NOMNC) for Resident #18, Resident #303, or Resident #304. The facility provided document, titled Beneficiary Notice Scenarios for Surveyors, dated 10/2022, instructed that facility complete both Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and NOMNC forms for residents discharged from Medicare Part A with skilled days remaining and will continue living in the facility.

Based on observation, record review, and staff interview, the facility failed to protect a resident's dignity by failing to ensure the indwelling urinary drainage bag was kept in a dignity bag for one of three residents reviewed with an indwelling catheter (Resident #11). The facility reported a census of 50 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] identified Resident #11 as severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15 and had the following diagnoses: Cerebral Infarction and Compression of the Brain. The MDS identified Resident #11 was dependent on staff for toileting, showers, lower body dressing, and putting on/taking off footwear and had an indwelling urinary catheter. Observations of the resident revealed the Foley catheter bag hanging off the bed frame without a dignity bag and visible to anyone walking by or into the room at the following times: a. On 10/29/24 at 10:11 AM, while the resident was lying in bed b. On 10/29/24 at 01:56 PM Observed patient in room lying in bed. The catheter bag had been emptied since last observation but there was still no dignity bag. c. On 10/29/24 at 3:30 PM Resident #11 asleep in bed with the indwelling urinary drainage bag which was not placed in a dignity bag. d. On 10/30/24 at 10:22 AM An observation of catheter care with Resident #11 was completed by facility staff. Staff C, Certified Nursing Assistant (CNA) completed the catheter care. The facility nurse consultant was also present. No dignity bag was observed on the catheter bag when entering the resident's room. Upon completion of the catheter care a dignity bag was not placed over the catheter bag. d. On 10/30/24 at 12:40 PM the resident was observed sleeping in bed and there was no dignity bag in place. e. On 10/30/24 at 3:47 PM stopped by to speak with Resident #11 and he had a visitor. The resident introduced me to his friend and I then left the room. There was not a dignity bag or any type of cover on the catheter bag. A review of the Care Plan dated 8/26/2024 documented resident requires indwelling urinary catheter. Goal: Resident will have catheter care managed appropriately as evidenced by: not exhibiting signs of infection or urethral trauma. Interventions: a. Assess for continued need for catheter at least quarterly. b. Keep catheter system a closed system as much as possible. c. Obtain labs as ordered. d. Provide catheter care BID and PRN e. Report UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, n/v, chills, fever, foul odor, concentrated urine, blood in urine). f. Use a catheter strap. Assure enough slack is left in the catheter between the meatus and the strap. In an interview on 10/30/2024 at 12:45 PM Staff C, Certified Nursing Assistant (CNA) reported the following: a. When a resident has a catheter, staff would need to take the following precautions to respect the resident's privacy, the staff should place the collection bag in a dignity bag. b. Both nurses and nurse aides are responsible to ensure the catheter bag is in a dignity bag. c. Staff C advised she was probably nervous when doing catheter care this morning and forgot to put the catheter bag in a dignity bag. She typically does this. In an interview on 10/30/24 at 1:20 PM Staff B, Licensed Practical Nurse (LPN) reported the following a. When a resident has a catheter, staff would need to take the following precautions to protect a resident's privacy, the staff should place the bag in a dignity bag. b. Both nurses and nurse aides are responsible to ensure the catheter bag is in a dignity bag. c. She could not verify if the resident had a dignity bag on today. In an interview on 10/31/24 at 10:53 AM the Director of Nursing (DON) advised the resident should have had a dignity bag on over this catheter bag. Whenever a resident is in public or if the catheter bag is in sight of others or if he has visitors there should be a dignity bag on the catheter bag. Dignity bags are available to staff in the front linen room. The DON advised the facility is working with volunteers making more dignity bags but there is always some sort of cover staff should use. The CNA's all have onboarding when they first start at the facility and the importance of dignity bags is gone over with them. Staff also complete yearly training that covers catheter care and dignity bags. The Facility Assessment Tool dated 10/1/2024 documented the following: Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity.

Based on observations, resident and staff interviews, the facility failed to respond to resident's needs within the required fifteen minute time frame when residents activated their call lights. Observations of call lights revealed 4 of 14 call lights were over the fifteen minute time frame when responded to (Resident #3, #13, #42, and #205). The facility reported a census of 50 residents. Findings Include: 1. Resident #13 admitted to the facility 2/7/21. The Quarterly MDS dated [DATE] identified Resident #13 had a BIMS score of 10 out of 15, indicating moderate cognitive impairment. The resident had diagnoses including non-Alzheimer's dementia, seizure disorder, traumatic brain injury, and ataxia. The MDS revealed the resident was independent with bed mobility, transfers, and toileting and required supervision of 1 staff person for personal hygiene. In an observation on 11/28/23 of Resident #13's call light, located above the resident's door in the hallway, the call light was noted to already be activated at 3:30 PM and not responded to by staff until 3:47 PM. The call light was not addressed for a minimum of 17 minutes. In an observation on 11/29/23 of Resident #13's call light, the call light was noted to be activated at 8:41 AM and was not responded to by staff until 9:11 AM. The call light was not addressed for 30 minutes. Several staff were noted to walk by the room with the call light lit up above the resident's door and failed to address it. 2. Resident #42 admitted to the facility 7/1/22. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The resident had diagnoses including diabetes mellitus, cerebrovascular accident, hemiplegia, and asthma. The MDS revealed the resident required extensive assistance of 2 staff for bed mobility, transfers and toileting and was always incontinent of urine and always continent of bowel. In an interview on 11/27/23 at 2:31 PM, Resident #42 reported she did not feel the facility had enough staff to care for the residents. The resident stated the staff did not answer call lights timely and at times it took up to 2 hours for staff to respond to her call light. The resident stated it took 2 staff to transfer her to bed or on and off the toilet. The staff have stopped in the room and said they needed to get a second staff person, turn off the light and never come back on several occasions. 48452 3. The MDS for Resident #3 dated 8/31/23 revealed the resident scored 9 out of 15 on a BIMS exam, which indicated moderately impaired cognition. Diagnoses included Alzheimer's disease, dysphagia (difficulty swallowing), and malnutrition. A Care Plan Focus Area initiated 9/26/22 documented a risk for skin breakdown. A focus area revised on 10/11/22 documented a risk for falls. A focus area revised 9/27/23 documented the resident had complaints of pain. On 11/27/23 at 10:55 AM Resident #3 stated her only concern was that it sometimes took 30 - 45 minutes to get anyone to listen to you. She said evenings were the worst for staffing. 4. The Admission MDS for Resident #205 dated 11/23/23 was in progress and indicated submission was 3 days overdue. Section C, completed and signed 11/26/23, revealed the resident scored 15 out of 15 on a BIMS exam, which indicated moderately impaired cognition. The Care Plan included diagnoses of Stage 4 chronic kidney disease, prosthetic heart valve, and paroxysmal atrial fibrillation (intermittent erratic heart rate). A focus area dated 11/26/23 indicated the resident needed 24 hour care due to disease process. During an observation on 11/28/23 at 2:11 PM Resident #205's call light went unanswered for 19 minutes. At 2:30 PM Staff B, Certified Nursing Assistant (CNA) entered the resident's room after the resident called out into the hallway for assistance. On 11/29/23 at 10:51 AM, the Administrator stated she did not know what the protocol was for call lights. She acknowledged that second shift was the most difficult to staff and used the most agency support. On 11/29/23 at 10:52 AM the Nurse Consultant Director, Staff C, stated call lights should be answered in 15 minutes. She further stated she did not believe there was a call light policy and staff were expected to follow the regulations.

Based on observation, interview, clinical record review, and facility policy review, the facility failed to administer medications within the facility scheduled time frame for 4 of 7 residents (Resident #2, #34, #44, #50) observed during medication administration and further failed to administer the correct dosage of the medication Torsemide, to Resident #2, according to physician's order. The facility reported a census of 50 residents. Findings Include: 1. On 11/29/23, the following observations were made while watching Staff H, Licensed Practical Nurse (LPN) complete a Medication Pass to residents as they sat in the dining room: a. At 9:15 AM, Staff H, Licensed Practical Nurse (LPN), prepared and administered medications to Resident #2. b. At 8:36 AM, Staff H, prepared and administered medications to Resident #34. c. At 8:45 AM, Staff H, prepared and administered medications to Resident #44. d. At 9:00 AM, Staff H, prepared and administered medications to Resident #50. At the time of the observations it was noted the Medication Administration Record (MAR) for the residents (#2, #34, #44 and #50) revealed all had medications scheduled for 7:00 a.m. and medication cart computer screen displayed all residents (#2, #34, #44 and #50) medications highlighted red in color. A review of the Residents' Progress Notes in the Electronic Health Records (EHR) revealed the following entries: a. A Progress Note, dated 11/30/23, informed that Resident #2 had received bedtime (HS) medications late; Provider and family to be informed. No documentation of late morning medication administration for date 11/29/23. b. A Progress Note, dated 11/30/23, informed that Resident #34 had received bedtime (HS) medications late; Provider and family to be informed. No documentation of late morning medication administration for the date 11/29/23. c. A Progress Notes for Resident #44 lacked documentation of medications administered late on 11/29/23 morning med pass. d. A Progress Notes in Resident #50's EHR lacked documentation of medications administered late on 11/29/23 morning med pass. On 11/29/23 at 9:20 AM, Staff H informed that the red color highlighted on Resident #2, #34, #44, and #50 MAR's during medication administration meant that the medications were due, but not yet done. LPN explained she had gotten busy which resulted in medications given be past due the scheduled time frame. On 11/29/23 at 9:36 AM, Staff H stated the protocol for medications given late, included notification to the resident's doctor and the family/representative. Staff H stated an extra nurse or herself would notify the resident's doctor and family/representative. On 11/29/23 at 10:00 AM, the Assistant Director of Nursing (ADON) reported the facility medication passing times were 7:00 AM, 11:00 AM, 5:00 PM, and 8:00 PM. The ADON stated medications could be given one hour before and one hour after these times to be considered on time, and confirmed that medications given after 8:00 AM would be considered late. Review of facility policy titled, Medication Administration, revision dated 4/01/23, revealed that medication may be administered one hour prior and one hour after the scheduled administration times, if administration occurs outside of these time frames, physician notification is required. 2. The Minimum Data Set (MDS) Assessment, dated 11/15/23, revealed diagnoses include Chronic diastolic heart failure and atrial fibrillation. The Care Plan focus area, initiated 8/12/2019, for diuretic medication indicated a goal that Resident #2 will receive a diuretic (water pill) as ordered and be free from medication side effects. Order Summary, dated 11/29/23, revealed an order for Torsemide tablet 20 milligrams (mg), give 0.5 (half) tablet, 10 mg, by mouth in the morning related to heart failure. Order initiated 4/19/23. On 11/29/23 at 9:15 AM, Staff H, removed Resident #2's bottle of Torsemide (diuretic) from the medication cart, 1 whole tablet dispensed from bottle and placed in medication cup along with other scheduled morning medications. Medications were administered to Resident #2 in the dining room. On 11/29/23 at 11:40 AM, Resident #2's bottle of Torsemide reviewed following medication reconciliation of Physician order for Torsemide 20 mg half tablet daily. Label on bottle indicated Torsemide 20 mg 1 tablet daily. The majority of remaining tablets in bottle were whole, noted approximately 5 tablets that had been cut in half. On 11/29/23 at 2:20 PM, Staff H denied giving any medications that had been cut in half or cutting any medications in half prior to administration. On 11/29/23 at 2:36 PM, ADON confirmed administration of a whole 20 mg tablet of Torsemide would be a medication error and informed that the protocol is to notify the Provider and family of the error. ADON indicated that documentation of error would be included in Resident #2 Progress Note. Facility policy titled, Physician Notification, effective 10/10/19, instructed to notify physician promptly of any accident or unusual incident. Facility policy titled, Medication Administration, revision dated 4/01/23, revealed that medications shall be administered per physician order.

Based on clinical record review, resident and family interviews, and facility policy review, the facility failed to provide the opportunity for the resident and/or resident representative to participate in the development, review and revision of his/her Care Plan on a quarterly basis for 4 of 4 residents reviewed (Residents #16, #18, #44 and #46). The facility reported a census of 50 residents. Findings Include: 1. The Significant Change Minimum Data Set (MDS) dated [DATE] documented Resident #46 had an admitted [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS indicated the resident had diagnoses that included quadriplegia, dysphagia, neurogenic bladder, anxiety disorder, depression, diabetes mellitus and asthma. Resident was totally dependent on 2 staff for bed mobility, transfers and toileting and totally dependent on 1 staff for eating. Clinical record review revealed the resident had Care Plan Conferences conducted on 12/5/22, 2/23/23, 5/18/23, 7/20/23 (significant change) and 9/21/23 (significant change). Clinical record review revealed a copy of a Care Plan Conference Letter sent to the resident's representative on 2/21/28 and also indicated the resident's representative was present for the meeting held on 3/8/23. No other documentation of Care Plan Conferences being held noted in the Electronic Health Record (EHR) or the paper chart. In an interview on 11/27/23 at 2:06 PM, Resident #46 stated she had never participated in a Care Plan Conference nor had her husband during her time here at the facility. In an interview on 11/30/23 at 9:12 AM, Staff A, Registered Nurse (RN)/MDS Specialist, stated the MDS Coordinator generated a list of upcoming Care Plan Conferences to be held and then a staff person was to send notice to the family or representative of the upcoming Care Plan Conference. She stated she was unsure if the residents were notified of the Care Plan Conferences or not. In an interview on 11/30/23 at 11:03 AM, the Assistant Director of Nursing (ADON) stated it was currently the expectation that the Director of Nursing (DON) send letters to the resident's family/representative of upcoming Care Plan Conferences. She stated the family/representatives would sometimes bring the letter back signed and other times they would mail it back signed. This assignment will transfer from the DON to the MDS Coordinator when they start. Depending on the resident's cognition, the MDS Coordinator or DON was to invite the resident to the Care Plan Conference. 48452 2. The MDS for Resident #16 dated 9/21/23, included diagnoses of other neurologic disorder, seizure disorder and diabetes mellitus. Resident #16's chart reflected one Care Conferences letter dated 10/4/23. The Chart lacked the other three Care Conferences invitations. 3. The MDS for Resident #18 dated 10/10/22, identified a BIMS score of 12 out of 15, indicating mild cognitive impairments. The Care Plan dated 8/21/23 directed Resident # 1 required assist of 1 staff a gait belt and a walker to transfer. Resident # 18's record held a copy of invitation to Care Conferences dated 4/12/23, 7/15/23, 9/21/23, and failed to have the invite for [DATE]. 4. The MDS assessment dated [DATE] for Resident #44 revealed the resident scored 3 out of 15 on the BIMS exam, which indicated severely impaired cognition. The MDS included diagnoses of non-Alzheimer's dementia and amnesia. The Comprehensive Care Plan (CCP) with an admitted [DATE] documented a focus area dated 11/23/22 that the resident needed 24 hour care due to dementia. An intervention with the same date indicated staff should arrange for Care Conferences quarterly and as needed. A document headed Facility Name, with a letter sent date of 5/27/22, listed a Care Conference date of 6/18/22. A note at the top indicated the conference was going to be in person and the responsible party needed to call to make other arrangements. The lower section of the document indicated the following members of the interdisciplinary team participated in the the development of the Comprehensive Care Plan, and was signed by one staff member in nursing. A second document with the same heading, sent to the responsible party on 2/21/23 listed a Care Conference date of 3/21/23 at 10:00 and indicated the conference was held via phone with a person the document was not sent to. The participation section was signed by one staff member in nursing and one staff member in Hospice. The facility failed to document Quarterly Care Conferences in September 2022, December 2022, June 2023, and September 2023. On 11/27/23 at 2:48 PM, the resident's responsible party stated he didn't recall attending a Care Conference. He stated they have been set up but they never follow through. The resident's care and planning were important to him because he didn't see the resident very often, but wanted to know she was okay and if she needed something. He stated the facility was not good at keeping him in the loop unless something was wrong. An interview on 11/29/23 at 10:52 AM with Staff C, Nurse Consultant Director, revealed Care Conferences are documented on forms placed in the resident's paper chart and she expected they would be completed at least quarterly. Review of facility policy titled Comprehensive Assessment and Reassessment dated [DATE] revealed the sources of information for the MDS include: a. Review of resident's record. b. Communication with the resident. c. Observation of the resident. d. Communication with direct care staff. e. Communication with licensed professionals from all disciplines. f. Communication with the resident's physician. g. Communication with the resident's family members. A policy titled Interdisciplinary Plan of Care dated 5/10/17 documented each resident shall be involved in the development and review of their plan of care along with their family member.

Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to conduct comprehensive assessments of residents in accordance with the timeframes specified for 2 of 2 residents reviewed (Residents #12 and #205). The facility reported a census of 50. Findings Include: 1. The Minimum Data Set (MDS) for Resident #12 dated 8/31/23 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Diagnoses included chronic congestive heart failure, end stage renal disease, and anemia. MDS section O failed to include documentation of the resident's need for Dialysis. The Care Plan included a diagnosis of dependence on renal dialysis. A Focus Area dated 9/29/21 indicated the resident needed Dialysis (hemo) related to chronic kidney disease. On 11/27/23 at 12:53 PM Staff D, Registered Nurse (RN) stated that the resident was at Dialysis and was not new treatment for this resident. During an interview with Resident #12 on 11/28/23 at 8:14 AM, she stated she went to Dialysis 3 times per week because her kidneys were failing. 2. The MDS for Resident #205 dated 11/23/23 was in progress of completion and the Electronic Health Record (EHR) indicated the submission was 3 days overdue. At the time of review on 11/29/23 sections A, B, E, GG, H, I, J, L, M, N, O, and P remained incomplete. On 11/29/23 at 10:30 AM Staff A RN, MDS Specialist (Nurse Consultant) confirmed that all sections of the MDS should be completed accurately prior to submission and indicated the facility would have to submit a correction if Dialysis was missing. She stated she was filling in for this position and was unable to confirm the policy regarding timely submission timeframes. A policy entitled Comprehensive Assessment and Reassessment effective 5/10/17 documented an assessment of the care or treatment required to meet the needs of the resident shall be ongoing throughout the resident's stay and individualized to meet the needs of the resident. The RN Assessment Coordinator would ensure the MDS Assessment was completed within 14 days of admission or significant change in status. Assessments and reassessments included special treatments and procedures and a review of the resident's record.

Based on clinical record review, observations, staff interviews and facility policy review the facility failed to put interventions in place as directed by the Care Plan to aid in prevention of the reoccurrence of pressure sore areas for 1 out of 4 residents reviewed (Resident #11). The facility reported a census of 50 residents. Findings Include: The MDS (Minimum Data Set) Assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. The Minimum Data Set (MDS) Assessment for Resident #11 dated 9/21/23, documented an admitted on 9/13/23. The MDS reflected diagnoses of heart failure, diabetes mellitus and cerebrovascular accident (stroke). The MDS identified a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS showed Resident #11 required limited physical assist of 1 staff with bed mobility, dressing, toileting, walking and personal hygiene. The MDS showed Resident #11 lacked pressure ulcers, but identified moisture associated skin damage (MASD), and indicated Resident #11 at risk for pressure ulcers and placed a cushion in the chair for pressure reducing device. The Care Plan for Resident #11 dated 9/25/23, identified a risk for skin breakdown related to immobility and weakness. The Care Plan directed Nursing Staff to assist with repositioning, keep clean and dry as possible, use pressure reduction cushion to chair. The Facility Matrix provided on 11/27/23, identified Resident #11 acquired a Stage II pressure ulcer. The Non-Pressure Skin Condition Report dated 9/15/23, identified MASD to left buttock 5 centimeters (cm) by 1.5 cm red, excoriated with multiple pin point open areas. The Non-Pressure Skin Condition Report dated 9/15/23, identified MASD to right buttock 8 cm by 3 cm and less then 0.1 cm red, excoriated with multiple pin point open areas. The Non-Pressure Skin Condition Report dated 11/11/23, reflected the left buttock healed. The Non-Pressure Skin Condition Report dated 11/11/23, reflected the right buttock healed. The Wound/Skin Healing Record dated 11/23/23, revealed a Stage II wound to the left buttock/coccyx that measured 6 cm by 4.5 cm and less then 0.1 cm deep. The Wound/Skin Healing Record dated 11/23/23, indicated a Stage II wound to the right buttock/coccyx that measured 6 cm by 4.5 cm and less then 0.1 cm deep. The Wound/Skin Healing Record dated 11/30/23, indicated a stage II wound to the left buttock/coccyx that measured 6 cm by 3 cm and less then 0.1 cm deep. The Wound/Skin Healing Record dated 11/30/23, indicated a Stage II wound to the right buttock/coccyx that measured 8 cm by 2 cm and less then 0.1 cm deep. The following observations of Resident #11 revealed the resident lacked a pressure reducing cushion in her recliner: a. On 11/27/23 at 9:50 AM, Resident # 11 sat asleep in her recliner chair. b. On 11/27/23 at 2:00 PM, after lunch Resident # 11 sat in the recline chair, feet up, and asleep. c. On 11/28/23 at 930 AM, Resident # 11 sat in her recliner chair. d. On 11/28/23 at 3:36 PM, Resident # 11 in her recliner with her feet up. e. On 11/29/23 at 8:48 AM, Resident #11 sat in her recliner chair. On 11/29/23 at 8:50 AM. Staff B, Certified Nurses Aid (CNA) confirmed Resident #11 failed to sit on a cushion in her recliner. On 11/29/23 at 8:50 AM, Staff I, Licensed Practical Nurse (LPN) reported Resident #11 came into the facility with small areas on her bottom. She stated they healed and came back. On 11/30/23 at 11:20 AM, the Restorative Registered Nurse (RN) reported she expected a resident with a pressure area on their bottom to sit on a cushion in the recliner and she expected a cushion in place if on the Care Plan. On 11/30/23 at 12:18 PM, the Staff I, RN Consultant, reported she failed to see the wounds to Resident #11's bottom but she thought they were pressure related, due to the fact she sat in the chair a lot between meals. The facility provided a policy titled Skin Checks dated 7/12/23, and the policy failed to address the placement of interventions related skin.

Based on observations, staff interviews, and facility document review, the facility failed to provide clean and sanitary wheelchairs or electric scooter for 3 of 3 residents whom required wheelchair/scooter transportation (Residents #5, #9, and #47). The facility reported a census of 50 residents. Findings Include: On 11/28/23 at 8:49 AM, wheelchairs that belonged to Resident #5 and #47 sat empty in a carpeted area of dining room during breakfast. The residents sat in dining room chairs for the meal. Resident #5's wheelchair held a folded bed pad on the seat of wheelchair with yellow colored rings stained across the pad. Noted wheelchair for Resident #47 with crumbs and white smeared stains across the top of the seat. Both Resident #5 and #47 were transported back into wheelchairs following the meal. An electric scooter, driven by Resident #9, left the dining room, the back and sides of electric scooter covered in dirt and grime and a brown stain noted to back, bottom area of the seat. On 11/28/23 at 12:00 PM, wheelchairs kept in the carpeted area during lunch meal. Resident #9's electric scooter continued to have dirt and grime as well as brown stain across the back and bottom of the seat. Resident #47's wheelchair continued to have white stains across the seat. On 11/29/23 at 9:48 AM, Staff F, Certified Nursing Assistant (CNA), unable to recall a cleaning schedule for resident wheelchairs and reported being unsure of who is responsible for cleaning the wheelchairs. On 11/29/23 at 2:10 PM, Assistant Director of Nursing (ADON) reported an overnight shift CNA made up a schedule of wheelchairs to be cleaned but was unsure of documentation for this. On 11/30/23 at 10:20 AM, Staff G, CNA, worked various shifts as needed since hire, May 2022, and confirmed she worked overnight shift the night before. Staff G unable to recall an assignment or task sheet that indicated wheelchair cleaning but thought all wheelchairs were cleaned a couple days per week. Staff G unaware of a location to find information on or to document completion of wheelchair cleaning. On 11/30/23 at 1:00 PM, the ADON stated everyone had been responsible for checking the cleanliness of wheelchairs, walkers, and scooters. Facility provided a typed, undated document, that indicated all wheelchairs are to be cleaned for one hallway per day, Monday through Friday, by overnight CNA staff. The document lacked any indication of acknowledgement or completion by staff. The facility failed to have a wheelchair cleaning policy.

Based on clinical record review, observations, staff interviews, and facility policy review, the facility failed to notify the physician, assess a resident, or document an incident following a medication error for 1 of 1 residents (Resident #2) reviewed for medication dosage error. The Facility reported a census of 50 residents. Findings Include: The Minimum Data Set (MDS) Assessment, dated 11/15/23, revealed diagnoses include Chronic diastolic heart failure and atrial fibrillation. Resident #2 had Brief Interview for Mental Status (BIMS) score of 5 out of 10, indicative of severe cognitive impairment. The Care Plan Focus Area, initiated 8/12/2019, for diuretic (water pill) medications indicated a goal that Resident #2 will receive diuretic as ordered and be free from medication side effects. Order Summary, dated 11/29/23, revealed an order for Torsemide tablet 20 milligrams (mg), give 0.5 (half) tablet, which equals 10 mg, by mouth in the morning related to heart failure. Order initiated on 4/19/23. Progress Notes lacked documentation of physician notification, resident monitoring, or resident assessment for greater than 24 hours following a medication dosage error. On 11/29/23 at 9:15 AM, Staff H, Licensed Practical Nurse (LPN), removed Resident #2's bottle of Torsemide from the medication cart, 1 whole tablet dispensed from bottle and placed in medication cup along with other scheduled morning medications. Medications were administered to Resident #2 in the dining room. On 11/29/23 at 11:40 AM, Resident #2's bottle of Torsemide reviewed following medication reconciliation of Physician order for Torsemide 20 mg half tablet daily. Label on bottle indicated Torsemide 20 mg 1 tablet daily. A majority of tablets which remained in the bottle were whole, noted approximately 5 tablets that had been cut in half mixed within the whole tablets. On 11/29/23 at 2:20 PM, Staff H, LPN, denied giving any medications that had been cut in half or cutting any medications in half prior to administration. On 11/29/23 at 2:36 PM, Assistant Director of Nursing (ADON) confirmed administration of a whole 20 mg tablet of Torsemide would be a medication error and informed that the protocol is to notify the Provider and family of the error. The ADON indicated that documentation of error would be found in Resident #2's Progress Notes. On 11/30/23 at 9:30 AM, Resident #2 medication bottle of Torsemide had been removed from the medication cart, pill bottle found empty in the Director of Nursing's office. Staff C, Nurse Consultant, reported tablets had been destroyed due to the incorrect dosage and the correct medication dosage had been ordered from Pharmacy. On 11/30/23 at 10:30 AM, ADON confirmed a lack of Provider notification related to Resident #2 dosage error and reported she would send a Secure Conversation to Provider at this time, via the Electronic Health Record (EHR) online chat message system. The ADON unable to locate an Incident Report following the medication error for Resident #2. On 11/30/23 at 1:30 PM, Staff C, Nurse Consultant, explained Secure Conversation, used to send a message to Providers, is not part of Resident #2's Medical Record; Nursing staff would be required to initiate a Progress Note to document communication that occurred within the secure conversation messaging. Facility policy titled, Physician Notification, effective 10/10/19, instructed to notify physician promptly of any accident or unusual incident. Facility policy titled, Medication Administration, revision dated 4/01/23, revealed that medications shall be administered per physician order.

Based on clinical record review, observations, staff interviews, and facility policy review, the facility failed to develop and implement a person centered Care Plan that included measurable objectives regarding safety and risk reduction for 1 of 1 residents reviewed (Resident #30). The facility reported a census of 50 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #30 revealed the resident scored 00 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. The staff assessment section for cognition was not completed and indicated the resident was able to complete the BIMS. The facility failed to complete the resident's Preadmission Screening and Resident Review (PASRR), dated 11/11/22, prior to admission. The legal history section listed convictions on 11/09/2001 for failure to register as a sex offender and on 7/15/16 for assault. The PASRR further indicated any nursing facility, mental health professionals, healthcare professionals, or others who engaged in the treatment of the resident were encouraged to perform a check of registries. The assessment would determine risk and help with the development of a crisis intervention and safety plan. The rehabilitative services section documented the need to identify triggers and symptoms, methods for management of challenges, action steps to be taken by all parties to reduce hospitalization , stressors for behaviors, and how to reduce risk. Specific examples included a single room in line with the nurses station, close supervision during facility events, and restricting access to areas of the facility where vulnerable individuals were present. A document titled Patient Safety Template failed to list warning signs and listed redirection as the way to make the environment safe. It failed to include input from a mental health provider, the physician, or the resident's family. The Comprehensive Care Plan (CCP) with an admitted [DATE] documented a focus area dated 11/9/22 which indicated the resident had impaired cognition. Interventions included cuing, supervision, consistent routine and caregivers dated 11/9/22 and 15 minute checks initiated 1/3/23. The CCP failed to address a specific safety plan that addressed the resident's criminal history to ensure the safety of residents, visitors, and staff or a crisis intervention plan that noted known triggers or stressors for behaviors and how to reduce increased risk. The activities section failed to include resident safety interventions. On 11/27/23 at 10:36 AM, the resident's room was noted to be located in the middle of the hallway, surrounded by other resident rooms. On 11/28/23 at 8:06 AM, Resident #30 was observed sitting at the breakfast table with 2 other residents. At 8:08 AM, he was noted to be standing without staff and reaching toward the left side of the table where another resident was seated. He was not easily redirected back into his chair. A Certified Nursing Assistant (CNA) was called over to sit with him. On 11/28/23 at 8:49 AM, Staff E, Registered Nurse (RN) stated that the resident refused cares, transfers took coaxing, he will stand at the table, and was sometimes difficult to redirect. On 11/28/23 at 9:16 AM, Staff F, CNA stated that the resident can be stubborn and was sometimes hard to redirect. On 11/29/23 at 10:51 AM, the Administrator stated that staff aware of the resident's history. She did not know what type of training staff were provided regarding his care and specific needs. She stated the facility was working on learning more about his history right now. On 11/29/23 at 10:52 AM, Staff C, Nurse Consultant Director, stated that the facility has known about the PASRR results since the date of the PASRR (11/11/22). She stated the intention of the 15 minute checks initiated 1/3/23 under the cognition focus of the Care Plan were related to the PASRR results. She confirmed there was not documentation that this was the intention of the 15 minute checks. A policy entitled Comprehensive Assessment and Reassessment effective 5/10/17 documented that the assessment of the care or treatment required to meet the needs of the resident shall be ongoing throughout the resident's stay and individualized to meet the needs of the resident. The assessment shall be structured to identify factors such as social barriers. Information would be obtained from family, care providers, and paper or electronic documents.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to complete a Baseline Care Plan within the timeframes specified for 2 of 2 residents reviewed (Resident #11 and #205). The facility reported a census of 50. Findings Include: 1. The Minimum Data Set (MDS) for Resident #205 dated 11/23/23 was in progress and the electronic health record indicated the submission was 3 days overdue. At the time of review on 11/29/23 sections A, B, E, GG, H, I, J, L, M, N, O, and P remained incomplete. On 11/30/23 at 10:15 AM, the resident's chart lacked a Baseline Care Plan. On 11/30/23 at 2:20 PM, the Administrator confirmed that the facility was unable to locate the resident's Baseline Care Plan. She believed the Director of Nursing (DON) was completing these and she was out of the building. 34821 2. The MDS for Resident #11 dated 9/21/23, documented an admitted on 9/13/23. The MDS reflected diagnoses of heart failure, diabetes mellitus and cerebrovascular accident (stroke). The MDS identified a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS showed Resident #11 required limited physical assist of 1 staff with bed mobility, dressing, toileting, walking and personal hygiene. Resident #11's clinical record failed to contain a Baseline Care Plan. A policy entitled Comprehensive Assessment and Reassessment effective 5/10/17 documented that the Interim Nursing Plan of Care would be implemented on admission to ensure the resident received necessary and immediate care such as activities of daily living, medications, nutrition, etc.

Based on clinical record review, observations, staff interviews and facility policy review, the facility failed to provide adequate supervision for one of one residents reviewed with a fall history to prevent a fall with injury to occur (Resident #14). The facility also failed to prevent two out of two cognitively impaired, wandering residents from exiting the facility unattended and unnoticed (Resident #18 and Resident # 22). This failure of supervision resulted in an Immediate Jeopardy (IJ) to the health, safety, and security of the residents. The facility reported a census of 53 residents. Findings Include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 shown diagnoses include Hypertension, Diabetes and [CONDITION(S)]. The MDS indicated Resident #14 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severe cognitive impairments. The MDS indicated the resident was independent with transfers and ambulation. Review of an incident report dated 10/4/22 at 7:20 PM, revealed Resident #14 was found on the floor of her room with no injury from the fall. A Progress Note dated 10/5/22 at 11:30 PM, revealed the resident complained of pain to left arm, wrist and thumb. A Progress Note dated 10/6/22 at 3:46 PM, identified the resident with noted swelling of left arm and continued to have complaints of pain. Notified the medical doctor and order for x-ray obtained. Review of X-ray Report dated 10/6/22 of the left forearm reveals a minimally displaced fracture of the left radial head (bone in forearm). Review of the emergency room Report dated 10/6/22 revealed Resident #14 had the radial head fracture placed in a splint and to follow up with the doctor on an outpatient basis. The Care Plan with a revision date of 10/11/22 indicated Resident #14 was at Risk for falls related to weakness, antidepressant and diuretic medication usage and history of falls at home. The Care Plan had an intervention dated 10/11/22 to ambulate with assist of one, gait belt and assist the resident with her left side. Review of the Physical Therapy Evaluation and Plan of Treatment completed by the Physical Therapist on 10/21/22, noted resident presents with history of falls, left arm pain with fracture, weakness, instability in gait, high fall risk, decreased functional mobility, balance, coordination and activity tolerance. Review of the Incident Report dated 10/23/22 at 1:15 PM, noted the resident laying down on stomach in the dining room with walker next to her. The Incident Report revealed the resident's left arm was in the sling. A Progress Note dated 10/23/22 at 1:15 PM, revealed the resident was sent out to the Emergency Department. It was noted resident had a large hematoma to left forehead extending to the eye. The Physician Note dated 10/23/22 from the emergency room (ER) visit revealed an intraparenchymal hemorrhage of the brain (brain bleed) and subarachnoid hemorrhage. Observation on 10/25/22 at 4:18 PM, Resident # 14 sitting in a recliner in her room. The resident's four wheeled walker in the room along with the hemi walker. Dark purple color noted to the left side of face starting on forehead down below her eye which is swollen shut and discoloration down into the neck area. During an interview on 10/26/22 at 1:48 PM, Staff C, Licensed Practical Nurse (LPN) stated she was working when Resident #14 fell on [DATE] and hit her head, it was toward the end of lunch. The resident had come around the corner and coming out of the dining room. She was using her four wheeled walker and her arm was in the sling. Staff C was standing at the carpet area right outside the dining room and I did not actually see the fall. There was staff in the dining room but no one seen the fall. She was supposed to be assist of one since her prior fall with a fracture. During an interview on 11/01/22 at 10:08 AM, Staff N, Physical Therapy Assistant (PTA) stated a resident with a sling should be using a quad cane, single tip cane or hemi-walker depending on the weight bearing status. Staff N stated after an arm fracture while using a sling would not be ideal to be using a four wheeled walker. During an interview on 11/01/22 at 11:13 AM, Staff O, Certified Nursing Assistant (CNA) reported I was working when Resident #14 fell on [DATE], did not see the fall, but I heard it and I was assisting someone to eat at the first row of tables in the dining room. Staff O stated heard the fall and I went over to see if Resident #14 was ok and I got the nurses to come over. She did have the four wheeled walker and her left arm in the sling, and she was supposed to be assist of one, but she got up by herself. During an interview on 11/01/22 at 3:26 PM, the Director of Nursing (DON) stated her expectation for the nurses after a fall occurs was to do an assessment of vital signs and document to determine how the resident is doing. The DON would expect the nurse to move the resident to safety and then notify the physician and family. There should be an intervention put in place to prevent further falls. The DON reported the Nursing Staff have a Stand-Up Meeting and the Restorative Nurse and Aide get together and talk about falls. The DON did not recall specifically addressing the resident using the four wheeled walker with her arm in a sling. The resident was non-compliant with the assist of one and was not the first time she got up by herself to ambulate with the four wheeled walker. 2. According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 shown diagnoses include Non-Alzheimer's Dementia. The MDS indicated Resident #22 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severe cognitive impairments. The MDS identified the resident needed supervision to limited assist of 1 staff with transfers, bed mobility, ambulation and locomotion in the corridors. The Care Plan listed a focus area of wandering initiated on 6/16/22 due to Resident #22 experiences wandering. The interventions directed staff to redirect resident away from doors as needed. Review of the resident's Progress Notes shown the following: a. On 9/19/22 at 3:06 PM, revealed Resident #22 made an attempt to go out the 600 Hall Door. The Resident in her wheelchair and staff was able to get her back inside the building and redirected. b. On 9/29/22 at 3:52 PM, revealed Resident #22 opened the door on the 600 Hall setting the alarm off. She had begun to stand up from her wheelchair and the nurse took her up front after the resident stated she wanted to go outside. c. On 10/1/22 at 3:45 PM, revealed a CNA observed the resident outside a window on the 200 Hall. Staff immediately went outside and brought the resident back inside. d. A late entry Progress Note from 10/1/22 at 3:35 revealed, Resident #22 seen outside a resident's window pushing her wheelchair. The alarm did not go off and the alarms had been checked in the past prior to when the resident went out the door. We did the door alarm 30 minutes. Resident appeared to have gone out the 300 hall and the outside door. During an observation on 10/26/22 at 2:42 PM with Staff D, CNA walked the area outside where Resident #22 went out the 300 hall door in her wheelchair down a hill on a sidewalk. She then turned left to go across a dirt path with a steep ravine next to it. Resident #22 then went up a sidewalk between the 200 and 300 hall and at the top turned right and walked along the building in a uneven grassy area pushing her wheelchair to where the staff seen her outside a window on the 200 hall. During an interview on 10/26/22 at 2:26 PM, Staff F, CNA stated remembered the day Resident #22 went outside. Staff F was going to help with a transfer in another hall and observed Resident #22 at the doors in the middle of the 300 hall we keep closed. From the time I last saw her to the time they called it was approximately 5 minutes. I saw her by the closed doors and I went to help on another hall. Staff F, then went out the 300 Hall Door to respond to the call and Resident #22 was already with the CNA outside. The CNA and Resident #22 were right in between the 200 and 300 doors on the sidewalk. When Staff F went out the 300 Hall Door to check on the resident the door did not alarm. Staff F reported she had asked someone to shut the door alarm off over the walkie-talkie while walking down there but it never did alarm. During an interview on 10/26/22 at 2:42 PM, Staff D, CNA stated on 10/1/22, she was in a resident's room on the 200 Hall with a resident and noticed Resident #22 outside the window. Staff D noticed the resident and went out the 200 Hall Door and retrieved Resident #22 and brought her back to the 300 Hall. Staff D denied hearing any alarms going off at the time of the incident. Staff D reported can hear alarms when in residents' rooms when they are going off and also can hear the alarms going off from other hallways. Resident #22 was by the gate outside the 200 Hall and I had to jump over the fence to go get her so she wouldn't go any further down. Staff D brought the resident back inside through the 300 Hall Door. Staff D didn't recall the alarm sounding when she brought the resident back inside. When the staff check the alarms they have one person stand at the alarm board then someone goes to each door and physically opens it. We let them know we are going to a certain door. The staff have always checked one door at a time. Staff D stated, didn't know how Resident #22 went out, thought she went out 300 Hall Door and went down the sidewalk and back up the sidewalk between the 200 and 300 Halls then came over the side of the building. Staff D reported the resident was in her wheelchair. During an interview on 10/26/22 at 3:41 PM, Staff G, CNA stated we checked the door alarms on 10/1/22 and then I went on break when Resident #22 went out the door. It was about 30 minutes later it came over the walkie-talkie she was outside. We check the door alarms with one CNA at the board and another CNA goes to a different door. We shut off and then we reset it and rearm it. Staff G reported actually don't know how long Resident #22 was outside I opened the door when I came back from break for the 2 CNA's who were out there and the door did alarm. During an interview on 10/27/22 at 8:10 AM, Staff H, Licensed Practical Nurse (LPN)/Agency Nurse stated regarding the incident on 10/1/22 with Resident #22, she reported I heard an alarm going off and heard a staff member say a resident got out. Then another nurse stated a resident had gotten out but she was back in the building. Staff H reported not receiving training on the door alarms when I started working here, I just follow the instruction from the other nurses. Staff H explained she never did any of the alarm checks and was never instructed on it. She never was educated on how to turn off the alarms or reset it, just knew how to turn off the alarm on the front door. During an interview on 10/27/22 at 10:25 AM, Staff I, Registered Nurse (RN) stated I was here the day Resident #22 eloped. I was down the 200 hall and came out into the hallway and was walking toward the center of the building. Staff D, CNA came out in hall and said Resident #22 was outside and the alarm was not sounding. The alarms were tested within the hour or half hour of the incident. When staff walk by the alarm panel, they should look for the green light. Training for the alarm system is basically the CNA does the testing so I cannot say I have done it. Staff I stated not heard any alarms and I cannot recall hearing any alarms. I have never had any training on testing or resetting the alarms I may have had some formal training when I first started. After the incident Staff I reported not aware of any changes or education they have made to the alarm system. Staff I explained she worked every Saturday from 2-10 PM. During an interview on 10/27/22 at 11:30 AM, the Director of Nursing (DON) stated one of the staff saw Resident #22 out the window and they brought her back in. We determined from the statements gathered from staff, they were doing the door alarm checks around the time of the incident. I don't know for sure if Resident #22 went out during or after the door alarm checks, staff just saw her outside. I guess that would mean when they were checking the alarms. The DON explained the expectation when staff check the door alarms is 2nd shift checks with the box and the check list they coordinate times and notify which door they are going to open. After this incident with Resident #22, the procedure was to walk back and forth to know which door alarm was being tested . Staff should shut the alarm off and then can proceed. The person actually running the board would be putting in the codes to make sure it is alarmed. The DON stated if the alarms are on the color of the light is red. During an interview on 10/27/22 at 4:39 PM, the Administrator said when Resident #22 exited the facility, they talked to the staff and they said it was during the alarm checks. Then the one CNA said they saw her 5 minutes before and it takes them some time to test all the doors. The Administrator reported she thought staff did not reset the main alarm after the door alarm checks, but feels like staff could have seen the resident while they were checking, or the alarms could have been turned off. That's why staff tell each other on the walkie-talkie what door they are at so that could make sure they were counting the correct one. Review of the policy the facility provided titled Wander Guards dated 11/15/18, directed residents will be monitored for the need for a wander guard security bracelet. Those residents with impaired decision making and known exit seeking shall wear guard bracelet and identification. 3. The Minimum Data Set (MDS) Assessment for Resident # 18 dated 6/2/22, listed diagnoses of non-Alzheimer's Dementia and [CONDITION(S)], [CONDITION(S)], or [CONDITION(S)]. The MDS further reflected wandering behavior 1 to 3 days during the look back period. The Care Plan included a revision date 7/25/22, directed Resident # 18 ambulates independently with walker. The Care Plan identified a goal the resident will wander safely within specific boundaries. Wandering interventions included redirect resident from exit doors as needed. The Confidential Incident Report dated 8/2/22 at 11:15 AM, revealed Resident # 18 found outside by a dietary staff. The report continued the nurse went outside and saw Resident # 18 going to sit on a bench. The report revealed the door alarms failed to sound. The Health Status Note dated 8/2/2022 at 12:24 PM, reflected Resident # 18 tried to leave Coronavirus disease (COVID) unit at 1100 AM. Resident was not able to be redirected, family called at that time and unable to calm her down. At 11:15 AM dietary staff saw Resident # 18 outside through the window. The Incident Summary file included a staff statement dated 8/2/22, that read Staff K ex-Dietary Supervisor saw resident # 18 out the window. The Incident Summary file included a staff statement dated 8/2/22, that read Staff A Registered Nurse (RN) and a Certified Nurses Aid (CNA) went outside and observed Resident # 18 walking the dumpster (on the north west side of the building by the parking lot). The statement continued to read the building failed to alarm at the time resident # 18 exited. The Incident Summary dated 8/4/22, confirmed the facility door alarms failed to go off. On 10/27/22 at 6:55 AM, the fire door at the end of the 100 Hall is approximately 10-15 feet to the bench in the grass On 10/26/22 at 10:41 AM, Staff B, Registered Nurse (RN), stated Resident # 18 appeared very agitated and she kept trying to get from the COVID wing into the regular units. Staff B, stated it is normal for Resident # 18 to wander the halls of the facility. Staff B revealed she knew Resident # 18 to say before, that she was leaving the facility and she did exit seek before. Staff B indicated she thought resident # 18 exited out the door by the Assisted Living (AL) Unit. She revealed the door failed to sound an Alarm at the time. On 10/26/22 at 12:09 PM, Staff K ex-Dietary Supervisor, stated she saw Resident # 18 out the kitchen window. She reported it looked like Resident # 18 came out the door by the AL. She had her walker and she was in the grass, On 10/26/22 at 4:33 PM, Staff A, revealed she thought Resident # 18 exited the facility from the fire door by the entrance to the Assisted Living Center from the Nursing home. Staff A confirmed the door alarm failed to sound. She reported she thought the door alarm was not turned on. On 10/27/22 at 7:23 AM, the Director of Nursing (DON) reported during the facility investigation they found the door alarms were off at the time Resident #18 exited. On 10/27/22 at 4:03 PM, the Administrator confirmed the facility needed a different door alarm system. The State Agency informed the facility of the Immediate Jeopardy (IJ) on October 27, 2022 at 10:45 AM. The facility staff removed the Immediate Jeopardy (IJ) on October 27, 2022 through the following actions: a. Placing an additional door alarm on each of the 5 doors connected to the alarm system. b. Education was provided to the Housekeeping Staff responsible for checking the function of the alarms daily, and Nursing Staff to ensure the main alarm system is armed at the start of the shift. The scope lowered from J to G at the time of the survey after ensuring the facility

Based on observation, clinical record review, policy review and staff interviews, the facility failed to appropriately provide assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well- being. Clinical record review revealed the Nursing Staff failed to do a thorough assessment and implement interventions for 2 of 2 residents reviewed (Resident #50 and #106). The facility reported a census of 53 residents. Findings Include: 1. Resident #50's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. The MDS documented the resident required supervision while eating. The resident weighed 188 pounds (#) at the time of the MDS and had not had a significant weight loss (5% loss in 1 month or 10% loss in 6 months). The MDS identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's Weight and Vitals Summary documented weights of 183.8# on 8/12/22, 187.7# on 9/24/22 and 169.9# on 10/4/22. An additional weight on 10/6/22 was 169.9#. Progress Note written on 10/3/22 at 6:25 PM, explained the resident only took a few bites of her supper. Progress Note written on 10/26/22 at 11:22 AM, by the Dietician explained the resident had a 17 pound (#) weight loss related to decreased intakes. The family was notified by the dietician of the weight loss and decreased intakes. The Progress Notes failed to update the Primary Care Provider (PCP). No other Progress Notes in the Clinical Record noted regarding weight loss, decreased appetite or decreased intakes at meals. The last Dietary Assessment was dated 9/27/22 and identified the resident as at risk for malnutrition. The Care Plan included a goal of significant weight loss being prevented. The goal was initiated on 6/2/21. The Care Plan included interventions of monitor weight and assist with set up of meals as needed, both initiated on 6/2/21. The Care Plan failed to have any goals or interventions dated after the 10/4/22 weight loss. Facility Policy subject Significant and Severe Changes in Resident's Weight dated 4/2017 directed the Dietician to document the weight change, possible causes of the weight change and recommend nutritional interventions. The policy directed designated staff to notify the PCP and the family. During an interview on 11/2/22 at 10:39 AM, the Director of Nursing (DON) explained she would expect a physical assessment with that kind of weight loss. She explained the Dietician would be expected to look at what interventions were in place and what different interventions could be put into place. 2. Resident #106's MDS dated [DATE] documented a BIMS of 15 indicating no cognitive impairment. The MDS documented the resident had an indwelling catheter and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note written on 4/2/22 at 11:57 AM, explained the nephrostomy tube had come out and was lying on the resident's bed with the thread still intact. There was a small amount of red drainage in the bag. The on-call provider was notified and gave orders to cut the thread, apply an ABD (dressing) to the site, monitor through the weekend and follow up with PCP on Monday (4/4/22). The note explained the threads had been removed, the site washed and the dressing applied. The Clinical Record contained a set of vital signs on 4/3/22, but lacked documentation of assessment of the site, dressing changes, vital signs, or other physical assessment. The clinical record lacked documentation of the family being notified of the tube coming out. The resident did not have a physical assessment of any kind from the time the nephrostomy tube came out on 4/2/22 until going to the hospital on 4/4/22. The Clinical Record contained a Situation, Background, Appearance and Review (SBAR) form dated 4/4/22. form documented the resident was experiencing a function decline that had gotten worse. Vital signs were documented. The form also documented weakness, decreased urine output, a skin puncture and dizziness. The clinical record contained a transfer form dated 4/4/22 documenting the resident was sent to the hospital and the family was notified. The resident returned from the hospital on 4/11/22. During an interview with Staff L, Agency Registered Nurse (RN) on 10/26/22 at 4:39 PM, she explained she remembered the resident and remembered his nephrostomy tube coming out. She explained she spoke with the DON who was in the building and called the on-call provider. She further explained she followed the providers orders. She stated she may have taken vital signs and she may have completed a physical assessment, that if she did it would be documented in the electronic health record. (There was no physical assessment in the Electronic Health Record). She stated she didn't feel it was an emergency and the on-call provider did not feel it was an emergency. She explained if she had notified the family it would have been documented in the Progress Notes. (There was no documentation of the family being notified.) During an interview with Staff M, Registered Nurse/Traveling Nurse (RN) on 11/1/22 at 9:27 AM, she explained she had worked with the resident frequently and even though she was a Traveling Nurse she knew his baseline. She explained on 4/4/22 he had increased confusion. He had weakness that she was unable to determine if it was exacerbation of existing weakness or if he had something acute happening. She explained she was concerned he was having a stroke. She stated she was aware the nephrostomy tube had come out, it was passed along in morning report, but she did not assess the site prior to transfer. She explained she was aware he had a long-standing history of getting urosepsis easily but her primary concern was getting him to the next level of care where he could get the treatment and interventions he could not get in the facility. During an interview on 11/2/22 at 10:39 AM, the DON stated she would expect some sort of assessment once a shift. She stated she would expect the family to be notified when the nephrostomy tube came out.

Based on clinical record review, hospital record review, facility policy review, Primary Care Provider interview, and staff interviews the facility failed to provide quality of care in treatment and care for 1 of 3 residents reviewed with identified pressure ulcers. Resident #1 had identified skin impairments by the facility and upon arrival to the emergency room (ER) on 12/3/21, the resident had additional open wounds identified to the right lower abdominal fold, the left upper arm, the bilateral heels, and the left hip (areas A, B, C, & D). The facility failed to complete a thorough head to toe assessment and/or implement interventions that identified the areas A, B, C, or D. The facility records failed to contain an assessment of the 4 areas, included 2 of the areas with necrotic (dead) tissue to the upper arm and the hip (areas C & D). The facility reported a census of 58 residents. Findings Include: The Minimum Data Set (MDS) completed 11/5/21 for Resident #1 identified a Brief Interview for Mental Status (BIMS) score of 14 which indicated cognition intact. The MDS revealed the resident required limited physical assistance of 1 staff person for bed mobility, transfer, ambulation, dressing, toileting, and personal hygiene, and frequently incontinent of bowel and bladder. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reported the resident experienced pain frequently during the 5-day look back period, received scheduled pain medication, and the resident rated the worst pain at a 3 on a 00 to 10 pain scale with 10 being the worst pain imaginable. The MDS identified the presence of two Stage II pressure ulcers and application of ointment/medication other than to feet. The MDS identified the following descriptions of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The Care Plan initiated 3/25/20, identified the resident required assist with all activities of daily living (ADL's), and directed staff to provide assistance with cares in the morning and evening. The Care Plan initiated 3/25/20, identified the resident experienced bladder incontinence and directed the staff to assist the resident with incontinence care after each incontinence episode as requested, report any signs of skin breakdown (sore, tender, red, or broken areas), and to provide assistance with toileting as needed. The Care Plan revised on 12/3/21, identified the resident had an actual pressure ulcer related to history of pressure ulcer and incontinence and also identified the resident with two Stage II pressure ulcers to left inner thigh. The Care Plan interventions included: a. Staff to provide assistance with positioning as needed. b. Cares completed in the bathroom and standing up per the resident preference. c. The resident requested to sleep with brief on and educated on the importance of skin and being dry and cares completed. d. Assess the pressure ulcer and condition of skin surrounding weekly, treatment as ordered, monitor skin during cares and report further skin breakdown. e. Provide incontinence care after each incontinent episode, use moisture barrier product to perineal area as needed, and pressure reduction cushion to chair and mattress to bed. The emergency room (ER) Provider Notes dated 12/3/21, identified multiple skin impairments not identified by the facility. The ER notes provided pictures of the multiple skin impairments without descriptions and/or measurements: a. Area A (right lower abdominal fold): an open area with depth visualized by the partial thickness of the subcutaneous layer of skin being exposed. Skin surrounding the open area red in color. b. Area B (left upper arm wound): visualized top layer of skin peeled and black necrotic tissue present near the elbow. c. Area C (bilateral heels): documented blanchable (turns white when pressed) red intact skin d. Area D (left hip): visualized black necrotic area with white/yellow slough (dead tissue) present left outer side and lower half of the wound Unable to stage the multiple areas identified due to no measurements being obtained and no assessment documented in the ER provider notes. The facility document titled Baths dated 11/20/21, documented Resident #1 received physical assistance of one staff for bathing on 11/22, 11/24, 11/29, and 12/2/21. Review of the Clinical Records from November and December 2021, which included Progress Notes, Skin Assessments, and Treatment Administration Record (TAR), all lacked assessment and/or interventions for any of the identified skin areas of concern documented in the ER provider notes dated 12/3/21 (pictures labeled A, B, C, or D). The facility document titled Protocol for Skin Care: Management of Skin Breakdown and Pressure Ulcers dated 9/05, stated the plan to manage pressure ulcers include both prevention and treatment protocols. The management program would be put into effect when an at-risk or actual pressure ulcer problem identified. Prevention protocol included: a. Risk assessment. b. Pressure reduction. c. Skin care. d. Nutritional care. e. Movement of the resident. Management Protocol included: a. Assessment - purpose to evaluate the wound to determine appropriate treatment and response to treatment. Visual assessment with every dressing change and documented assessment at least weekly. b. Documented assessment included: date of onset/date updated; location; size in centimeters; depth; stage; condition of surrounding skin; presence of drainage, odor, & amount; condition of wound bed; current treatment and response; culture sent; undermining; pain; date of family, physician, and dietary notifications. The facility document titled Protocol Review Guide: Skin care dated 9/05, stated additional specifics for management of skin breaks and actual pressure ulcers. Assessment: a. Visual assessment - interview the Director of Nursing (DON) and staff for knowledge of the wound status. b. Documented assessment - every 7 days and record included: date; location; size in centimeters; stage; depth; and condition of the surrounding skin. In an interview on 12/8/21 at 9:17 AM, the emergency room (ER) Staff stated Resident #1 arrived at the ER and the Hospital Staff aware of skin issues to the inner thighs and the resident had initially refused an indwelling catheter. The ER Staff stated the Hospital Staff unaware of the numerous other wounds the resident had upon arrival. The ER Staff stated the nursing facility had been contacted and information requested related to treatment provided specifically to the open areas and wounds to the abdominal area and the arms. The ER staff stated the nursing facility sent 10-15 pages of Nurses' Notes and contained no mention of wounds to the arms or abdomen, or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 12/8/21 at 12:52 PM, Staff A, Certified Nurse's Aide (CNA) stated provided baths for Resident #1. Staff A stated the resident had large bump area to bilateral upper arms, caused difficulty getting clothing on arms. Staff A stated prior to the resident being transferred to the hospital, noted to have open sores on the underside of bilateral upper arms. Staff A stated the licensed nursing staff were aware of the open areas to the upper arms of Resident #1. Staff A reported the resident's buttocks red and when the brief removed, would stick to the buttocks and caused the area to bleed. Staff A stated unaware of any areas of concern to the resident's hips or abdominal fold. Staff A stated observed resident's abdominal folds and under breasts during their scheduled baths, and notified the licensed nurse of any identified concerns. In an interview on 12/8/21 at 1:06 PM, Staff B, Registered Nurse (RN) confirmed worked on 12/3/21, the day Resident #1 transferred to the local ER. Staff B stated provided the skin treatments to identified skin impairments for the resident. Staff B stated Resident #1 had a half dollar sized open area to left inner upper thigh and 2 open areas to left & right side of the pelvic area/buttocks. Staff B stated unaware of any open areas or impairments to the resident's upper arms, abdominal fold, or hips. Staff B stated pressure ulcers assessed every week by one nurse and all other skin tears & skin issues assessed by the Floor Nurse every week. Staff B stated nursing staff relied on the CNA's to report if the resident had any new areas of concern. Staff B stated did not complete Resident #1 treatment on 12/3/21, when transferred to the local ER. In an interview on 12/8/21 at 1:22 PM, Staff C, CNA stated worked overnights and provided assistance to Resident #1. Staff C stated assisted the resident up to the bathroom one time during the night and would provide cares, however, the resident complained of pain during cares. Staff C stated the resident had black scabbed areas to the top of bilateral legs/hip area, but unaware of reddened or open area to the abdomen. Staff C reported Resident #1's under arms were tender and the resident frequently scratched the under arms and noted to have black scabbed areas. In an interview on 12/8/21 at 1:50 PM, the Director of Nursing (DON) stated hired on as the DON last week and had worked the last few months on and off as a CNA and Charge Nurse on the floor. The DON stated she had not visualized the open areas to Resident # 1's inner thighs or buttocks in the last week and unaware of open areas to the resident's abdomen or upper arms. The DON stated she assisted Resident #1 to bed a few weeks ago, changed the resident into a gown and did not observe any areas of concern to the back of the arms. The DON stated assessments completed weekly for pressure ulcers and any identified areas of concern for all residents. The DON stated the previous week she implemented a Skin Sheet for the Bath Aide to complete and provide to the nurse following residents' baths. In an interview on 12/8/21 at 2:03 PM, Staff D, Licensed Practical Nurse (LPN) stated the last time worked with Resident #1 unaware of any areas of concern to abdominal folds, upper arms, or bilateral hips. In an interview on 12/9/21 at 8:41 AM, Staff E, RN reported Resident #1 had an area of red excoriation to the abdominal fold, appeared to be an area where pants rubbed. Staff E stated the resident did not have any open areas to the abdominal fold and unaware of any skin issues to the resident's upper arms or hips. In an interview on 12/9/21 at 9:37 AM, Staff F, CNA reported Resident #1 had open areas on bottom and inner thighs, that the nurse provided treatments to while the resident in the bathroom, but unaware of any open areas to the resident's abdomen. In an interview on 12//9/21 at 9:46 AM, Staff G, CNA confirmed she had cared for Resident #1 the week transferred to the ER. Staff G reported Resident #1 had open sores to bottom that were painful and did not like to have cares completed due to the open areas. Staff G stated the morning of 12/3/21, when Resident #1 transferred to the ER, open areas to inner upper left thigh had an area black in color. Staff G stated Resident #1's entire buttocks sore with various areas open and bleeding, and white and red in color. Staff G noted extreme redness to Resident #1's abdominal fold and attempted to apply baby powder as the resident would allow as the resident complained of the abdominal fold being tender and sore. Staff G reported she had informed Staff E , RN on 11/29/21 of Resident #1's red abdominal fold and told something would be gotten for the red area. Staff G stated on the morning of 12/3/21, observed a bruise with a black dark blue area to the back of the resident's left arm and red/ black scabbed areas to the resident's hips. Staff G stated Resident #1's heels red in color and the nurse on duty had applied lotion after being notified of the redness, but unable to recall the day. In an interview on 12/9/21 at 10:13 AM, Staff H, CNA stated last time cared for Resident #1 had noted open areas on buttocks and inner thighs and notified the nurse on duty due to being first time observed the open areas. Staff H explained attempted to provide cares for Resident #1, however, the resident complained of the open areas being painful. Staff H reported Resident #1's abdominal fold red and had been informed by the nurse, area not new. Staff H believed the red abdominal fold due to the incontinent products wore being wet with urine and laying in the abdominal fold and unaware of any areas to the resident's upper arms. In an interview on 12/9/21 at 11:15 AM, the DON reviewed the pictures contained in the ER Provider Notes and stated unaware of the areas noted on the abdominal fold (A), left upper arm (B), heels (C), or the left hip (D). The DON stated aware of the areas noted to the Resident #1's inner thighs from working the floor as a CNA. The DON stated she had no words for the identified areas of concerns not documented by the facility. The DON stated Resident #1 preferred cares to be completed in the bathroom while standing. In an interview on 12/9/21 at 11:38 AM, Resident #1's Primary Care Provider Physician Assistant (PA) confirmed he had seen the resident at the facility in November. The PA stated aware the resident had open areas to the inner thighs due to urine incontinence and a catheter had been encouraged, however, the resident initially refused and the open areas worsened. The PA stated wound care offered, however, believed the resident declined. The PA stated the resident's family visited and encouraged the catheter. The PA stated he had not observed the open areas to the inner thighs, relied on the Nursing Staff to assess and update him as needed. The PA stated unaware of any additional open areas or areas of concern to the upper arms, left hip, abdomen, or the heels. The PA stated aware the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The PA stated the resident did not request pain medication, but gave order to schedule the pain medication. In an interview on 12/9/21 at 11:42 AM, Staff I, CNA stated she cared for Resident #1 the week transferred to the ER and noted the resident with horrible sores to inner thigh areas and buttocks. Staff I reported the open areas were bleeding and the resident complained of pain with cares due to the open areas. Staff I stated the resident had redness across her abdomen and the Nursing Staff aware, but Staff I unaware of any areas of concern to hips or upper arms. In an interview on 12/13/21 at 8:24 AM, Staff J, CNA reported unaware of any open areas or areas of concern to Resident #'1 abdomen, hips, or upper arms, but facility staff aware of the open areas to buttocks. In an interview on 12/13/21 at 8:42 AM, Staff K, LPN reported Resident #1 had open areas to the right rear and inner thigh, inside the left thigh, and 2 areas to the upper buttocks. Staff K stated unaware of any areas of concern to the residents abdominal fold, hips, or upper arms. Staff K stated while treatments completed to thighs and buttocks would have observed areas to the abdomen. In an interview on 12/13/21 at 10:30 AM, Staff L, RN stated cared for Resident #1 beginning of December and at that time, the resident had open areas to right inner thigh and buttocks. Staff L reported unaware of any areas of concern to the hips, heels, or abdominal fold. Staff L stated the resident had black scabbed areas to left upper arm, near the elbow, however, no treatment ordered in December and not notified of any additional areas of concern for Resident #1. In an interview on 12/13/21 at 1:38 PM, the ER Provider reported Resident #1 arrived in the ER with open wounds identified to the abdominal fold, left hip, upper arms, and bilateral heels. The ER provider explained the wounds did not develop in 2 days and the wounds were chronic not acute. The ER provider stated the open wound in the abdominal fold, the left hip, and the bilateral heels were not related to the residents' history of cancer. The ER provider reported the resident did have a large mass in the left and right upper arm, with left being greater than the right; however, unable to determine if related to history of cancer without a biopsy. The ER provider stated the masses located in the upper arms felt like a lipoma mass located in the flap of the upper arm. The ER provider stated the abdominal wound a classic area of moist tissue being stuck together, with yeasty skin breakdown. The ER provider reported a wet incontinent product sitting in the abdominal fold for a prolonged period of time would have caused the breakdown. The ER provider commented, when the abdominal fold assessed initially, a white cloth present, stated someone had to place the cloth in the fold and be aware of the area. The ER provider reported she had spoken with 2 family members of the resident and inquired if the resident had an abdominal surgical wound and possible dehisced (opened up), and the family members denied. The ER provider stated the left hip wound revealed a classic decubitus pressure ulcer and the bilateral heels with a delayed response and revealed a deep purple, tissue injury. The ER provider expected the facility should have had devices in place to relieve pressure from the bony prominences, assisted with position change, and appropriate treatments in place. The ER provider reported the wounds Resident #1 had resulted from not being taken care of properly, that the areas did not develop in 2 days. In an interview on 12/13/21 at 2:07 PM, the DON reported being aware of Resident #1's open areas to inner thighs and buttocks, and that the resident followed by the nurse weekly to assess the pressure ulcers. The DON stated unaware of any open areas or wounds to Resident #1's arms, abdomen, hips, or heels, and expected any possible new areas identified to be reported to the nurse, and the nurse to assess and determine if the area new and/or worse. The DON explained with staff change out recently, would expect areas observed for the first time be reported to the nurse to determine if the area new. The DON stated when new open areas identified, a required Skin Sheet to be started, follow-up completed weekly with an assessment, and appropriate treatment in place for the area.