Every finding on record at Mystic Healthcare & Rehabilitation Center, LLC

Based on review of the clinical record, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #1), who required the assistance of two staff for transfers, the facility failed to transfer the resident according to the plan of care resulting in a fall with major injury (left hip fracture) requiring surgical intervention. The findings include:Resident #1's diagnoses included hemiplegia and hemiparesis following a cerebral infarct affecting left side, abnormality of gait, muscle weakness, and bradycardia.The physician's order dated 2/9/26 directed an assist of two (2) using the ETAC [NAME] (turn aid with a functional design that offers safe patient turning with standing support during transfers).The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 14) and was dependent on staff for transfers in and out of bed and chair and required maximum assistance with the wheelchair.The Resident Care Plan dated 3/5/26 identified Resident #1 had a self-care deficit and was at risk for falls due to flaccidity on the left non-dominant side. Interventions directed assistance of two (2) with transfers in and out of bed and chair using the ETAC [NAME], provide two (2) staff for care at all times, keep call bell in reach, apply proper footwear, wheelchair for mobility, assist with bathing, dressing, and hygiene, and therapy services as needed.Review of the Resident Care Card (RCC) dated 4/22/26 identified Resident #1 required the assistance of two (2) staff with ETAC [NAME] for transfers.The nurse's note dated 4/22/26 at 11:49 AM identified Resident #1 was observed on the floor. NA #1 stated she was transferring Resident #1 to the wheelchair and had to assist Resident #1 to the floor. Resident #1 did not hit his/her head and reported left hip pain. The Director of Nursing (DON) and physician were contacted, and a left hip x-ray was ordered. Resident #1's family member was notified, and Resident #1 was assisted back to bed with the mechanical lift.The nurse's note dated 4/22/26 at 1:49 PM by the DON identified the left hip x-ray results identified an acute oblique nondisplaced intertrochanteric fracture on the left and diffuse osteopenia. The Advanced Practice Registered Nurse (APRN) was updated and directed to send Resident #1 to the Emergency Department (ED) for evaluation and treatment.The hospital Discharge summary dated [DATE] identified Resident #1 underwent a repair of the left intertrochanteric hip fracture and directed the facility to hold aspirin for two weeks and resume Eliquis.The nurse's note dated 4/26/26 at 4:40 PM identified Resident #1 returned to the facility after surgical repair of the left hip fracture. Orders were given to perform left hip x-rays on 5/24/26 and forward to the orthopedic specialist for review. Lab work was scheduled for the next day. Resident #1 reported a pain level of seven (7) out of ten (10) at the left hip and oxycodone five (5) milligrams (mg) was administered as directed by the physician's orders. Physical and Occupational Therapy were ordered. Physician's orders directed transfer status as a mechanical lift with the assistance of two (2).A written statement dated 4/22/26 by NA #1 identified she transferred Resident #1 using the stand-pivot method. NA #1 identified she engaged the wheelchair brakes and as Resident #1 was sitting down the wheelchair began to roll and Resident #1 began to go down so NA #1 pulled Resident #1 against her body and slid him/her down her leg until Resident #1 landed on the floor on his/her bottom. NA #1 then laid Resident #1 down and called for assistance.An interview with the DON on 5/5/26 at 12:00 PM identified she conducted the investigation into Resident #1's fall. The DON identified NA #1 worked at the facility for approximately one (1) month but worked at the facility several times prior as an agency staff member. NA #1 was oriented in proper transfer techniques upon hire. The facility requirement was for NA's to review the RCC for direction on transfer status and if the NA was uncertain, they should check with the nurse. After Resident #1 fell, the DON questioned NA #1 as to why she transferred the resident alone and did not use the ETAC [NAME] and NA #1 was unable to provide an answer. The DON interviewed Resident #1 who identified NA #1 did not use the equipment during the transfer. The DON further identified the facility terminated NA #1 for not following the facility policy or physician's order for transfers.An interview with COTA #1 (Certified Occupational Therapy Assistant) on 5/6/26 at 9:10 AM identified it was the facility policy for any resident that required assistance with transfers with equipment to have two (2) staff provide assistance for safety of the resident and if NA #1 had followed the policy and physician orders, Resident #1's fall could have been prevented. COTA #1 further identified she was working with Resident #1 to return to his/her prior baseline of transfers using the ETAC [NAME] and Resident #1 was fearful and nervous when attempting the transfers.An interview with NA #1 on 5/6/26 at 9:45 AM identified she worked with Resident #1 several times prior to 4/22/26. NA #1 identified she did not review the RCC for transfer orders and transferred Resident #1 based on what she recollected the transfer status was from previously working with Resident #1. NA #1 identified that while in the process of completing a stand-pivot transfer without the use of the ETAC [NAME] the wheelchair began to move and Resident #1 began to go down so NA #1 pulled the resident close to her and slid him/her down to the floor along NA #1's leg. Resident #1 landed on his/her bottom. The nurse then took over care.An interview with Resident #1 on 5/6/26 at 11:15 AM, in the presence of COTA #1 per Resident #1's request, identified in the past year, two (2) people assisted him/her with transfers except for the day of the fall.Review of the facility Safe Resident Handling/Transfer Policy identified while manual lifting techniques may be utilized, mechanical lifts are a safer alternative and should be used. Resident lifting and transferring will be performed according to the resident's individual plan of care, and two (2) staff members must be present when transferring a resident with a mechanical lift. Failure to maintain compliance with the policy may lead to disciplinary action up to and including termination. Review of facility documentation identified that a Plan of Correction was initiated immediately:Staff training was completed and included review of the facility Safe Resident Handling/Transfer Policy, including proper transfer techniques, use of mechanical lifts, and the correct place to find the residents' transfer status.Random audits to be completed weekly for four (4) weeks, then monthly for three (3) months to ensure staff compliance with appropriate transfers for residents.Audits to be reviewed at the monthly QAPI meetings.The Administrator and Director of Nursing are responsible for the plan.Facility was in compliance as of 4/27/26 The plan of correction was reviewed on 5/6/26 and the facility met all components for past non-compliance.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of nine (9) sampled residents (Resident #2) who were admitted to the facility over the prior ninety (90) days, the facility failed to conduct a thorough investigation following an elopement incident involving a resident with known wandering and exit-seeking behaviors, when the facility did not interview all potential staff witnesses to determine how Resident #2 exited the building unattended through the rear exit door. Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of nine (9) sampled residents (Resident #2) who were admitted to the facility over the prior ninety (90) days, the facility failed to conduct a thorough investigation following an elopement incident involving a resident with known wandering and exit-seeking behaviors, when the facility did not interview all potential staff witnesses to determine how Resident #2 exited the building unattended through the rear exit door.Resident #2's diagnoses included Alzheimer's Disease, traumatic subdural hemorrhage, cerebral infarction, depression, and generalized anxiety disorder.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 1), required maximum assistance with oral hygiene, toileting, showers, and bathing and self-propelled in a wheelchair.The Resident Care Plan dated 3/6/26 identified Resident #2 was at risk of wandering and elopement. Interventions directed to ensure Resident #2's picture was in the elopement risk binder at the reception desk, exercise and walk with resident to prevent restlessness, wanderguard (a wander management system designed to protect memory care residents against elopement) to left ankle, assist resident to find own room as appropriate, and provide diversional activities.The nurse's note dated 4/9/26 at 4:08 PM by the Director of Nurses (DON) identified on 4/9/26 at approximately 3:10 PM RN #1 entered her office which was across the hall from Resident #2's room and identified she saw Resident #2 seated in his/her wheelchair inside the room. Shortly thereafter, another resident yelled, He/She's outside. Recreation Assistant (RA) #1 identified that while walking on the unit, she observed Resident #2 outside through another resident's window. RA #1 immediately exited the unit through the therapy doors and was the first staff member to reach Resident #2. RN #1 approached Resident #2 from an alternate direction, and he/she was immediately assisted and escorted back into the building by staff. Resident #2's condition was assessed following the incident and no injuries were observed or reported at the time of return. The physician and a family member were notified. A psychiatric consult was ordered for Resident #2, and 72-hour monitoring was initiated as directed by the facility protocol.Interview and observation with the DON on 5/5/26 at 12:15 PM identified Resident #2 was unsafe to ambulate independently and had a wheelchair which he/she self-propelled, however Resident #2 often would get up and self-ambulate. Prior to 4/7/26 re-admission to the facility, Resident #2 had been identified as an elopement risk and had a wanderguard bracelet for safety due to exit seeking behaviors. Upon return from the hospital LPN #1 failed to complete an elopement assessment and obtain a new order for a wanderguard. On 4/9/26 at approximately 3:10 PM, RN #1 saw Resident #2 last in his/her room and then was alerted by another resident that Resident #2 was outside. Resident #2's wheelchair was found by the rear exit door of the building. The rear exit door was used by staff who parked behind the building and for vendors. Upon observation, after entering the key code to exit the first door, approximately three (3) seconds lapsed prior to the door re-locking. The DON identified the investigation concluded Resident #2 exited the back door after a staff member exited, prior to the door re-locking. The DON identified staff did not see Resident #2 exit when they used the rear exit door. The DON further identified she did not interview all staff that worked during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts on 4/9/26 to determine who entered and exited through the rear exit door that could have potentially seen Resident #2 by the door or left the door open. The DON identified she did not conduct a thorough investigation at the time of the event.The facility Reporting/Investigating Resident Accident/Incidents Policy identified, in part, that all accidents and incidents would be thoroughly investigated by management.

Based on clinical record reviews, facility documentation, facility policy and interviews for three (3) of nine (9) sampled residents (Residents #2, #5, and #6) reviewed for elopement, he facility failed to conduct required wandering/elopement risk assessments upon admission and re-admission in accordance with facility policy and the admission process, resulting in delayed identification and implementation of elopement interventions, including Resident #2 who subsequently exited the facility unattended The findings include:1. Resident #2's diagnoses included Alzheimer's Disease, traumatic subdural hemorrhage, cerebral infarction, depression, and generalized anxiety disorder.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 1), required maximum assistance with oral hygiene, toileting, showers, and bathing and self-propelled in a wheelchair.The Resident Care Plan dated 3/6/26 identified Resident #2 was at risk of wandering and elopement. Interventions directed to ensure Resident #2's picture was in the elopement risk binder at the reception desk, exercise and walk with resident to prevent restlessness, wanderguard (a wander management system designed to protect memory care residents against elopement) to left ankle, assist resident to find own room as appropriate, and provide diversional activities.The nursing admission assessment for dated 4/7/26 by LPN #1 failed to identify that a Wandering or Elopement assessment was conducted.Review of the clinical record identified the Elopement assessment was conducted on 4/9/26 and identified Resident #2 was at risk of elopement.The nurse's note dated 4/9/26 at 4:08 PM by the Director of Nurses (DON) identified on 4/9/26 at approximately 3:10 PM RN #1 entered her office which was across the hall from Resident #2's room and identified she saw Resident #2 seated in his/her wheelchair inside the room. Shortly thereafter, another resident yelled, He/She's outside. Recreation Assistant (RA) #1 identified that while walking on the unit, she observed Resident #2 outside through another resident's window. RA #1 immediately exited the unit through the therapy doors and was the first staff member to reach Resident #2. RN #1 approached Resident #2 from an alternate direction, and he/she was immediately assisted and escorted back into the building by staff. Resident #2's condition was assessed following the incident and no injuries were observed or reported at the time of return. The physician and a family member were notified. A psychiatric consult was ordered for Resident #2, and 72-hour monitoring was initiated as directed by the facility protocol.Interview and observation with the DON on 5/5/26 at 12:15 PM identified Resident #2 was unsafe to ambulate independently and had a wheelchair which he/she self-propelled, however Resident #2 often would get up and self-ambulate. Prior to the 4/7/26 re-admission to the facility, Resident #2 had been identified as an elopement risk and had a wanderguard bracelet for safety due to exit seeking behaviors. Upon return from the hospital, LPN #1 failed to complete an Elopement assessment and obtain a new order for a wanderguard. The DON identified an Elopement assessment should have been completed upon re-admission to the facility as directed by the admission Checklist and LPN #1 failed to follow the facility admission process.Interview with LPN #1 on 5/6/26 at 1:50 PM identified she worked with Resident #2 prior to the hospital admission and was aware Resident #2 was at risk for elopement. LPN #1 identified Resident #2 wore a wanderguard prior to the hospitalization. LPN #1 identified an Elopement assessment should have been performed immediately upon re-admission due to Resident #2's history of wandering and elopement risk. She further identified she forgot to complete the Elopement assessment and to obtain the wanderguard order.2.The Nursing admission assessment for Resident #5 dated 2/9/26 by LPN #1 failed to identify that a Wandering or Elopement assessment was conducted. Resident #5's Elopement assessment was conducted two (2) days after admission on [DATE].3.The Nursing admission assessment for Resident #6 dated 2/11/26 by LPN #1 failed to identify that a Wandering or Elopement assessment was conducted. Resident #6's Elopement assessment was conducted five (5) days after admission on [DATE].Interview with the DON on 5/5/26 at 12:15 PM identified all residents should have an Elopement assessment performed on admission and readmission to the facility according to the facility policy and admission Checklist. The facility Elopement Policy identified, in part, that residents will be assessed for risk of elopement and unsafe wandering upon admission to the facility.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of nine (9) sampled residents (Resident #2) reviewed for elopement, the facility failed to implement existing elopement interventions for a severely cognitively impaired resident with known wandering and exit-seeking behaviors, resulting in Resident #2 exiting the facility unattended through a secured rear exit door without staff knowledge. The findings included:Resident #2's diagnoses included Alzheimer's Disease, traumatic subdural hemorrhage, cerebral infarction, depression, and generalized anxiety disorder.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 1), required maximum assistance with oral hygiene, toileting, showers, and bathing and self-propelled in a wheelchair.The Resident Care Plan dated 3/6/26 identified Resident #2 was at risk of wandering and elopement. Interventions directed to ensure Resident #2's picture was in the elopement risk binder at the reception desk, exercise and walk with resident to prevent restlessness, wanderguard (a wander management system designed to protect memory care residents against elopement) to left ankle, assist resident to find own room as appropriate, and provide diversional activities.The nurse's note dated 4/7/26 at 11:15 PM identified Resident #2 was re- admitted from the Behavioral Health hospital on 4/7/26. Resident #2 was interacting appropriately with nursing staff and was adjusting well.The Social Service Note dated 4/9/26 at 11:47 AM identified a readmission Interdisciplinary Team Meeting (IDT) was held and Resident #2's family member attended by phone. The team discussed a plan to increase Resident #2's ability to walk with staff safely to assist in expelling some energy. They discussed a long-term plan of transferring Resident #2 to a secure dementia unit due to wandering and agitation.The nurse's note dated 4/9/26 at 4:08 PM by the Director of Nurses (DON) identified on 4/9/26 at approximately 3:10 PM RN #1 entered her office which was across the hall from Resident #2's room and identified she saw Resident #2 seated in his/her wheelchair inside the room. Shortly thereafter, another resident yelled, He/She's outside. Recreation Assistant (RA) #1 identified that while walking on the unit, she observed Resident #2 outside through another resident's window. RA #1 immediately exited the unit through the therapy doors and was the first staff member to reach Resident #2. RN #1 approached Resident #2 from an alternate direction, and he/she was immediately assisted and escorted back into the building by staff. Resident #2's condition was assessed following the incident and no injuries were observed or reported at the time of return. The physician and a family member were notified. A psychiatric consult was ordered for Resident #2, and 72-hour monitoring was initiated as directed by the facility protocol.The untimed psychotherapy note dated 4/9/26 identified Resident #2 had been struggling with increased anxiety and agitation and returned from hospitalization two days prior, at which point Resident #2 had been calm and fatigued, but on 4/9/26 Resident #2 was struggling with confusion, anger and agitation. Resident #2 was observed outside by another resident and was brought back inside. The provider met with the DON and administrator and communicated concerns that a more appropriate setting for Resident #2 would be a locked memory care unit. The facility has been seeking a bed for Resident #2. The wanderguard on his/her ankle was placed.Interview and observation with the DON on 5/5/26 at 12:15 PM identified Resident #2 was unsafe to ambulate independently and had a wheelchair which he/she self-propelled, however Resident #2 often would get up and self-ambulate. Prior to the 4/7/26 re-admission to the facility, Resident #2 had been identified as an elopement risk and had a wanderguard bracelet for safety due to exit seeking behaviors. Upon return from the hospital, LPN #1 failed to complete an elopement assessment and obtain a new order for a wanderguard. On 4/9/26 at approximately 3:10 PM, RN #1 saw Resident #2 last in his/her room and then was alerted by another resident that Resident #2 was outside. Resident #2's wheelchair was found by the rear exit door of the building. The rear exit door was used by staff who parked behind the building and for vendors. Upon observation, after entering the key code to exit the first door, approximately three (3) seconds lapsed prior to the door re-locking. The DON identified the investigation concluded Resident #2 exited the back door after a staff member exited, prior to the door re-locking. The DON further identified staff did not see Resident #2 exit behind them when they used the back door.Interview with NA #5 on 5/6/26 at 1:08 PM identified prior to Resident #2 being hospitalized he was aware Resident #2 was an elopement risk and had worn a wanderguard at the facility. On 4/9/26 NA #5 clocked out of work at 3:03 PM and prior to exiting the back door, saw Resident #2 self-propelling down the hallway from his/her room towards the exit door. NA #5 redirected Resident #2 into the recreation room and prior to leaving ensured he/she was settled. NA #5 proceeded to put the code in to exit the back door, exited the building and went to the car. NA #5 did not see Resident #2 exit the building.Interview with NA #3 on 5/6/26 at 1:23 PM identified she was aware Resident #2 had a wanderguard prior to going to the hospital and redirected Resident #2 when Resident #2 attempted to follow a staff member out of the building. NA #3 identified on 4/9/26, she clocked out a few minutes after 3:00 PM and passed NA #5 in the hall when he was on the way to the time clock to punch out. NA #3 then exited to the car through the back door. NA #3 was giving NA #5 a ride home, so she turned around in the car to see if he was coming and saw him through the windows in the recreation room bringing Resident #2 into the room. At around 3:05 PM, she saw NA #5 wheel Resident #2 to a table with other residents and then exit the building to the car. NA #3 and NA #5 began to exit the parking lot when NA #3 received a call from the DON asking if she saw Resident #2 exit the building.The facility Elopement Policy identified, in part, that residents who exhibited wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered care plan.

Based on clinical record reviews, facility documentation, facility policies and interviews for four (4) of four (4) sampled residents (Residents #1, #2, #3, and #4), reviewed for a safe environment, the facility failed to ensure the environment was safe from accidents or hazards, when a food cart containing meal trays was stored outside of the locked kitchen door overnight and was accessible to cognitively impaired residents, who were prescribed modified diets and had wandering behaviors, which created a choking hazard. Additionally, one (1) of four (4) sampled residents (Resident #1) experienced a choking episode requiring the Heimlich maneuver after accessing food from the unattended tray chart. This failure resulted in the finding of Immediate Jeopardy. The findings include: 1.Resident #1's diagnoses included dementia, chronic obstructive pulmonary disease, and dysphagia.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe short and long-term memory recall deficits (Brief Interview for Mental Status (BIMS) score of 2), was dependent on staff for eating and was independent with transfers in and out of bed and ambulation.The Resident Care Plan dated 1/30/26 identified Resident #1 was at risk of weight loss, exhibited wandering behaviors and was at risk of elopement. Interventions directed to provide a regular, pureed diet with thin liquids, provide cues to eat slowly, encourage the resident to remain upright after meals, offer snacks between meals and bedtime as appropriate, engage the resident in purposeful activities, and identify triggers for wandering.Physician's orders dated 2/8/26 directed a regular, pureed texture diet with thin liquids.Physician's orders dated 2/8/26 directed a Wanderguard (an electronic monitoring device that alerts staff when at-risk (wandering) individuals approach or attempt to exit secured areas) for wandering and elopement risk.2.Resident #2's diagnoses included cerebral infarction, chronic obstructive pulmonary disease, and diabetes type two (2).The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had severe short and long-term memory recall deficits (Brief Interview for Mental Status (BIMS) score of 7), was independent with eating, and required moderate assistance from staff for transfers and ambulation.The Resident Care Plan dated 1/30/26 identified Resident #2 exhibited impaired nutrition and was at risk for wandering and elopement. Interventions directed a low concentrated sweet (LCS) diet, mechanical soft texture, and thin liquids, offer food in small portions, assist the resident to find his/her room on the unit, apply a Wanderguard Bracelet, and provide diversional activities as needed.Physician's orders dated 2/8/26 directed LCS, mechanical soft texture diet, thin liquid consistency.Physician's orders dated 2/8/26 directed a Wanderguard for wandering and elopement risk.3.Resident #3's diagnoses included dementia, diabetes type two (2), and dysphagia.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had severe short and long-term memory recall deficits (Brief Interview for Mental Status (BIMS) score of (6), required set up assistance for meals, and used a wheelchair for mobilization.The Resident Care Plan dated 1/30/26 identified Resident #3 exhibited an alteration in nutrition status and was at risk for wandering and elopement. Interventions directed a LCS, no added salt (NAS), mechanical soft texture diet, and thin liquids, speech consults as needed, apply a Wanderguard Bracelet and provide diversional activities.Physician's orders dated 2/8/26 directed LCS, NAS, mechanical soft texture diet with thin liquids.Physician's orders dated 2/8/26 directed a Wanderguard for wandering and elopement risk.4.Resident #4's diagnoses included schizophrenia, anxiety, and dysphagia.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had moderate short and long-term memory recall deficits (Brief Interview for Mental Status (BIMS) score of 11), was independent with eating, bed mobility, transfers, and ambulation.The Resident Care Plan dated 1/30/26 identified Resident #4 exhibited an alteration in nutrition status, was at risk for choking due to poor dental hygiene, and was at risk for wandering and elopement. Interventions directed a regular, mechanical soft texture diet, and thin liquids, speech consultations as needed, a Wanderguard Bracelet, and to provide diversional activities.Physician's orders dated 2/8/26 directed a regular, mechanical soft texture diet with thin liquids.Physician's orders dated 2/8/26 directed a Wanderguard for wandering and elopement risk.The nurse's note dated 2/8/26 at 8:02 AM by RN #1 (the 11:00 PM to 7:00 AM Supervisor) identified at approximately 4:45 AM, LPN #1 (the 11:00 PM to 7:00 AM charge nurse) reported that Resident #1 ate a piece of a peanut butter sandwich that he/she took from the food cart, located outside the locked kitchen door, and choked on it. The Heimlich maneuver was performed by LPN #1 and Resident #1 expelled the contents of the sandwich from his/her mouth. Resident #1 returned to baseline after eating the food from the food cart.The APRN note dated 2/10/26 identified the APRN was asked to see Resident #1 due to a choking episode on 2/8/26. Resident #1 was referred to Speech Therapy for further evaluation and a chest x-ray was ordered to rule out aspiration.The APRN note dated 2/12/26 identified results of the chest x-ray were positive for bronchitis, and the physician directed antibiotics be started, a duo-neb treatment for three (3) days, to continue with aspiration precautions and follow-up with the Speech Pathologist.Interview with the Director of Food Service on 3/16/26 at 12:00 PM and 3/17/26 at 9:45 AM identified the facility process for collecting meal trays was to take a food cart room to room, collect meal trays, scrape remaining food into the garbage attached to the side of the food cart and then return the food cart containing dirty dishes to the kitchen. When dietary staff left their shift at 7:30 PM, they would leave an empty food cart outside the locked kitchen door for staff to return remaining dishes not previously collected. The expectation was that the remaining food would be scraped into the garbage attached to the food cart. There was no cover on the food cart or attached garbage. The supervising nurse had access to the kitchen keys and was expected to lock the dirty food cart inside the kitchen, however, the food cart was not consistently locked in the kitchen. The Director of Food Service identified he previously reported to Administration that the food cart was not being stored inside the locked kitchen once the remaining meal trays were collected. The Director of Food Service further identified that a resident wandering, unattended, had the potential to access food from the food cart or attached garbage when the cart was left outside the kitchen door.Interview with NA #1 (the 11:00 PM to 7:00 AM nurse aide) on 3/16/26 at 12:50 PM identified that sometime after 3:00 AM on 2/8/26, she was walking down the hall and saw Resident #1 by the food cart next to the locked kitchen door choking. NA #1 alerted LPN #1 who performed the Heimlich maneuver. NA #1 further identified Resident #1 habitually wandered up and down the hallway during the 11:00 PM to 7:00 AM shift looking for food. Resident #1 had the ability to open the unit double doors and walk past the kitchen door which was beyond the double doors. NA #1 identified there were multiple occasions when she observed Resident #1 attempt taking food off the dirty food cart and one occasion when she witnessed Resident #1 take a bite of a sandwich from the food cart. NA #1 did not report the incidents because she thought staff were aware of the behavior. NA #1 was not aware Resident #1 was prescribed a pureed diet.Interview with SLP (Speech Language Pathologist) on 3/16/26 at 1:00 PM identified Resident #1 was admitted to the facility on a pureed diet due to a history of choking which required the Heimlich maneuver. All subsequent evaluations conducted by the SLP further identified a pureed diet was appropriate and the diet could not be upgraded due to a high risk of choking and aspiration.Interview with RN #1 on 3/16/26 at 2:20 PM identified the 2/8/26 shift was her first shift worked at the facility. RN #1 was not aware that a food cart was left outside of the locked kitchen door for the purpose of collecting meal trays and that she should have locked the food cart in the kitchen. RN #1 received facility training prior to working at the facility but the meal tray collection process was not a part of the training. Interview with Dietary Aide (DA) #1 (6:00 AM to 2:00 PM shift) on 3/17/26 at 10:06 AM identified his first task in the morning was emptying the plates from the food cart that was left in the hallway outside the locked kitchen doors overnight. DA #1 identified that sometimes food was left on the plates and sometimes food had been scraped into the garbage attached to the food cart. The garbage did not have a lid.Interview with the Director of Nursing (DON) on 3/16/26 at 2:10 PM and on 3/17/26 at 11:00 AM identified she was aware Resident #1 wandered throughout the building and wore a Wanderguard. The DON identified no one reported Resident #1 was seeking out food when wandering or that Resident #1 had previously taken a bite out of a sandwich retrieved from the food cart. NA #1 had not reported prior observations of Resident #1 attempting to take food or eat food from the food cart and NA #1 should have reported these incidents to a licensed nurse. The DON further identified it was reported to her on different occasions that the food cart was being left outside the locked kitchen door and she addressed the issue with staff on more than one occasion. The DON identified it was the responsibility of the Supervisor to lock the food cart in the kitchen. She identified that 2/8/26 was RN #1's first shift worked at the facility and she received facility training prior to working.Review of the Building Specific Orientation Tour dated 2/7/26, provided to RN #1 prior to her first shift worked at the facility, did not identify training related to meal tray collection and food cart storage in the kitchen.Although attempted, an interview with LPN #1 was not obtained.The facility policy titled Safe and Homelike Environment identified, in part, that in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment which includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk.The facility policy titled Elopements and Wandering Residents identified, in part, that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy further identified the facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Although requested, the facility did not provide a policy to include food cart storage or proper disposal of food.

Based on clinical record review, facility documentation/policies, and interviews for one (1) of four (4) residents (Resident #1) reviewed for care plan implementation, the facility failed to ensure staff followed the resident's person-centered care plan and Resident Care Card, which directed a pureed diet and monitoring during meals for aspiration, as evidenced by staff providing snacks without knowledge of a resident's prescribed diet and the failure to prevent access to food inconsistent with the prescribed diet. The findings include: Resident #1's diagnoses included dementia, chronic obstructive pulmonary disease, and dysphagia.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe short and long-term memory recall deficits (Brief Interview for Mental Status (BIMS) score of 2), was dependent on staff for eating and was independent with transfers in and out of bed and ambulation.The Resident Care Plan dated 1/30/26 identified Resident #1 was at risk of weight loss, exhibited wandering behaviors and was at risk of elopement. Interventions directed to provide a regular, pureed diet with thin liquids, provide cues to eat slowly, encourage the resident to remain upright after meals, offer snacks between meals and bedtime as appropriate, engage the resident in purposeful activities, and identify triggers for wandering.The Resident Care Card (a quick-reference tool that summarizes a resident's specific daily needs, safety requirements, and personal preferences for NAs to use during care) dated 2/8/26 directed a puree diet and to monitor Resident #1 during meals for aspiration. The RCC further directed to remove food from the whole room due to Resident #1 potentially food seeking from the roommate.Physician's orders dated 2/8/26 directed a regular, pureed texture diet with thin liquids.The nurse's note dated 2/8/26 at 8:02 AM by RN #1 (the 11:00 PM to 7:00 AM Supervisor) identified at approximately 4:45 AM, LPN #1 (the 11:00 PM to 7:00 AM charge nurse) reported that Resident #1 ate a piece of a peanut butter sandwich that he/she took from the food cart, located outside the locked kitchen door, and choked on it. The Heimlich maneuver was performed by LPN #1 and Resident #1 expelled the contents of the sandwich from his/her mouth.The APRN note dated 2/10/26 identified the APRN was asked to see Resident #1 due to a choking episode on 2/8/26. Resident #1 was referred to Speech Therapy for further evaluation and a chest x-ray was ordered to rule out aspiration.The APRN note dated 2/12/26 identified results of the chest x-ray were positive for bronchitis, and the physician directed antibiotics be started, a duo-neb treatment for three (3) days, to continue with aspiration precautions and follow-up with the Speech Pathologist.Interview with NA #1 (the 11:00 PM to 7:00 AM nurse aide) on 3/16/26 at 12:50 PM identified that sometime after 3:00 AM on 2/8/26, she was walking down the hall and saw Resident #1 by the food cart next to the locked kitchen door choking. NA #1 alerted LPN #1 who performed the Heimlich maneuver. NA #1 further identified Resident #1 habitually wandered up and down the hallway during the 11:00 PM to 7:00 AM shift looking for food. NA #1 identified she previously observed Resident #1 attempt taking food off the dirty food cart and witnessed Resident #1 take a bite of a sandwich from the food cart. NA #1 did not report the incidents because she thought staff were aware of the behavior. NA #1 was not aware Resident #1 was prescribed a pureed diet and further identified she would give Resident #1 snacks (typically chocolate pudding) during the night.Interview with the Director of Nursing (DON) on 3/16/26 at 2:10 PM and on 3/17/26 at 11:00 AM identified she was unaware that Resident #1 previously took a bite out of a sandwich retrieved from the food cart. NA #1 had not reported prior observations of Resident #1 attempting to take food or eat food from the food cart and NA #1 should have reported these incidents to a licensed nurse.Review of the Care Planning- Interdisciplinary Team policy directed, in part, that staff shall follow the plan of care and Care Card as applicable.

Based on clinical record review, facility documentation/policies, and interviews for one (1) of four (4) residents (Resident #1) reviewed for a safe environment, the facility failed to ensure nursing staff were aware of a resident's prescribed diet and failed to ensure staff reported observed unsafe eating behaviors, resulting in a cognitively impaired resident accessing food inconsistent with the prescribed diet and experiencing a choking episode. The findings include: Resident #1's diagnoses included dementia, chronic obstructive pulmonary disease, and dysphagia.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe short and long-term memory recall deficits (Brief Interview for Mental Status (BIMS) score of 2), was dependent on staff for eating and was independent with transfers in and out of bed and ambulation.The Resident Care Plan dated 1/30/26 identified Resident #1 was at risk of weight loss, exhibited wandering behaviors and was at risk of elopement. Interventions directed to provide a regular, pureed diet with thin liquids, provide cues to eat slowly, encourage the resident to remain upright after meals, offer snacks between meals and bedtime as appropriate, engage the resident in purposeful activities, and identify triggers for wandering.Physician's orders dated 2/8/26 directed a regular, pureed texture diet with thin liquids.Physician's orders dated 2/8/26 directed a Wanderguard (an electronic monitoring device that alerts staff when at-risk (wandering) individuals approach or attempt to exit secured areas) for wandering and elopement risk.The nurse's note dated 2/8/26 at 8:02 AM by RN #1 (the 11:00 PM to 7:00 AM Supervisor) identified at approximately 4:45 AM, LPN #1 (the 11:00 PM to 7:00 AM charge nurse) reported that Resident #1 ate a piece of a peanut butter sandwich that he/she took from the food cart, located outside the locked kitchen door, and choked on it. The Heimlich maneuver was performed by LPN #1 and Resident #1 expelled the contents of the sandwich from his/her mouth.The APRN note dated 2/10/26 identified the APRN was asked to see Resident #1 due to a choking episode on 2/8/26. Resident #1 was referred to Speech Therapy for further evaluation and a chest x-ray was ordered to rule out aspiration.The APRN note dated 2/12/26 identified results of the chest x-ray were positive for bronchitis, and the physician directed antibiotics be started, a duo-neb treatment for three (3) days, to continue with aspiration precautions and follow-up with the Speech Pathologist.Interview with NA #1 (the 11:00 PM to 7:00 AM nurse aide) on 3/16/26 at 12:50 PM identified that sometime after 3:00 AM on 2/8/26, she was walking down the hall and saw Resident #1 by the food cart next to the locked kitchen door choking. NA #1 alerted LPN #1 who performed the Heimlich maneuver. NA #1 further identified Resident #1 habitually wandered up and down the hallway during the 11:00 PM to 7:00 AM shift looking for food. NA #1 identified she previously observed Resident #1 attempt taking food off the dirty food cart and witnessed Resident #1 take a bite of a sandwich from the food cart. NA #1 did not report the incidents because she thought staff were aware of the behavior. NA #1 was not aware Resident #1 was prescribed a pureed diet and further identified she would give Resident #1 snacks (typically chocolate pudding) during the night.Interview with the Director of Nursing (DON) on 3/16/26 at 2:10 PM and on 3/17/26 at 11:00 AM identified she was unaware that Resident #1 previously took a bite out of a sandwich retrieved from the food cart. NA #1 had not reported prior observations of Resident #1 attempting to take food or eat food from the food cart and NA #1 should have reported these incidents to a licensed nurse.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 3 of 4 residents (Resident #3, Resident #11, and Resident #78) reviewed for nutrition, the facility failed to obtain admission weights, monthly weights and re-weights per the facility policy. The findings include: Resident #3's diagnoses included type 2 diabetes, malignant neoplasm of the lower stomach, and atrial fibrillation (irregular heart rhythm). The Minimum Data Set assessment (MDS) assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status of 8, indicating moderate cognitive impairment. The Resident Care Plan in effect from 7/13/25 through 1/14/26 identified dysphagia. Interventions included to maintain diet consistency per speech recommendation and/or physician order for LCS (low concentrated sweets) NAS (no added salt) regular texture and thin liquids and to check lung sounds every shift if indicated. The Resident Care Plan also indicated the resident had a cardiac diagnosis, with interventions that included staff to obtain vitals as ordered. A physician's order in effect for November 2025 directed to obtain the resident's weight monthly on the day shift starting on the first and ending on the first every month. Interview with Licensed Practical Nurse (LPN) #6 on 1/14/26 at 12:08 PM, identified she was unable to locate a weight for Resident #3 in the electronic medical records for November, and could not find a note indicating why the resident wasn't weighed. LPN #6 stated she had been the staff member who obtained the resident's weight in October and December of 2025 but could not remember why she had not obtained Resident 3's weight in November. She stated the Director of Nurses (DNS) sent out notices that reminded nursing staff to obtain the weights that had not been obtained during a month but was unable to recall if she had received a notice to obtain Resident #3's weight in November 2025. Interview with the DNS on 1/14/26 at 12:14 PM identified that per facility policy the residents should be weighed, at minimum, every month. The DNS stated that she did send out a monthly reminder to nursing staff indicating which residents still needed a monthly weight, that Resident #3 should have been weighed in November, and that the facility must have dropped the ball. Review of facility policy for Weight Assessment and Intervention indicated, in part, that the nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Resident #11's diagnoses included Sepsis, Dysphagia (difficulty swallowing) and Dementia. A review of the hospital Discharge summary dated [DATE] identified a weight on 12/19/25 at 5:00 AM of 68.9 Kilograms (151.90 pounds). A clinical Nursing admission assessment dated [DATE] at 9:58 PM failed to identify an admission weight was obtained (left blank). A physician's order dated 12/20/25 directed to obtain a weight on admission and then weekly every evening shift on Fridays for 4 consecutive weeks post admission then reassess. A review of the Nutrition assessment dated [DATE] identified an admission weight was pending and a documented hospital weight of 152 pounds was noted. The baseline Resident Care Plan dated 12/21/25 identified that a nutritional status/diet problem. Interventions included diet/fluids as ordered regular high moisture, mechanical soft, thin liquids, assist with feeding, determine likes/dislikes, and provide speech therapy as needed. The admission Minimum Data Set assessment dated [DATE] identified Resident #11 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 6 and required total assistance with eating, dressing, transfers, bed mobility and a weight was coded as 152 pounds. The Resident Care Plan dated 12/31/25 identified dysphagia. Interventions included a speech consult as ordered, diet consistency per speech recommendation and physician's order, assist with feeding however may refuse assistance, check lungs sounds every shift if indicated, and crush all medications as indicated. A physician's order dated 12/31/25 directed to obtain and record current weight, provide an Ensure supplement 3 times a day, provide Promod Liquid protein once a day for hypoalbuminemia (low albumin) 30 milliliters every day. A review of the weights and vital sign summary report in the electronic medical record (EMR) failed to indicate that the facility had obtained an admission or subsequent weight. An interview and record review with Licensed Practical Nurse (LPN) #3, (the MDS Coordinator), on 1/12/26 at 9:29 AM indicated that weights were documented in the electronic medical record and that no weight had been documented in Resident 11's clinical record. She indicated that the admission nurse was responsible to obtain the weight on admission, and subsequent nursing staff were responsible to ensure the admission weight had been obtained. This was then reviewed in the morning clinical meeting and also reviewed during at risk meetings. The MDS Coordinator could not explain why the weight was not obtained or documented. An interview and record review with Registered Nurse (RN) #2 (Supervisor), on 1/12/26 at 10:24 AM indicated that in the admission MDS dated [DATE], a weight of 152 pounds was recorded. This information was identified in the Dietician note dated 12/21/25 that the weight was documented from the hospital Discharge Summary. The policy for obtaining weights was upon admission and then weekly for 4 weeks then monthly as documented in the physician's orders. RN #2 could not explain why the medical record failed to identify an admission weight. Subsequent to surveyor inquiry, Resident #11's weight was obtained on 1/12/26 at 10:56 AM via a mechanical lift scale and was noted as 133 pounds (a loss of 19 pounds). An interview with the Dietician on 1/12/26 at 11:54 AM indicated that the weights were only documented in the EMR. The policy for obtaining weights was upon admission and weekly for 4 weeks then monthly. The Dietician could not explain why the medical record failed to identify any weights for Resident #11. The Dietician indicated that she had entered the weight in the MDS assessment from the hospital weight because there was no admission weight obtained by the facility. Further, using a hospital weight was an acceptable facility practice, and a report and review of resident weights was discussed during the At-Risk meeting A review on 1/12/26 at 12:05 PM of the At-Risk meeting report dated 12/24/25 identified that Resident # 11 was a new admission on [DATE] and was missing his/her admission weight. An interview with the Director of Nursing (DNS) on 1/12/26 at 1:33 PM indicated the policy for obtaining admission weights was upon admission and then weekly times 4 weeks then monthly. The DNS further indicated there was no good reason Resident #11's wasn't obtained, the team met to discuss this, but it was her responsibility to ensure that this was completed. A physician's order dated 1/14/26 directed to weigh on admission and then continue to weigh for 4 consecutive weeks post admission then reassess: once a day every Tuesday for 4 weeks. A Dietician note dated 1/14/26 at 7:48 AM identified an admission weight of 133 pounds was obtained on 1/12/26 and orders were obtained to continue weekly weights for 4 weeks and follow up any progress or changes. An interview with the Dietician on 1/14/26 at 10:08 AM indicated that she did not know why it took so long to obtain an admission weight. She further indicated that she told the team at the At-Risk meeting that the admission weight was needed but was unable to explain why it was never obtained. The Dietician indicated that she would consider getting a reweight, but it took so long to get the first weight, it was not feasible. She indicated she was not concerned about the 12.5% weight change from the hospital to present because Resident #11 was receiving supplements, liquid protein, consuming 50-100% of meals and a pressure ulcer had resolved. An interview with the DNS and the Director of Clinical Services, Registered Nurse (RN) #5 on 1/14/26 at 10:20 AM identified that the weight of 133 pounds should have been accurate, but a reweight to confirm accuracy should be conducted per the policy, and the weight loss of 12.5 % was concerning. Additionally, laboratory work and notification of the physician or Advanced Practice Nurse Practitioner and family should be completed. A significant change MDS assessment would be considered if the weight change was confirmed, laboratory results were abnormal, or a change in the plan of care was needed. A review of the admission of a resident policy, dated revised May 2023 directed, in part, within 24 hours of admission, a height and weight would be obtained. A review of the weighing and measuring policy directed, in part, weight was usually measured upon admission and monthly during the resident's stay. Documentation of the weight and the signature of the person recording the data. Reporting significant weigh loss to the nurse supervisor. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: percentage of body weight loss = usual weight minus actual weight divided by usual weight multiplied by 100. 1 month = 5% weight loss was significant, greater than 5% was severe. Report other information in accordance with facility policy and professional standards of practice. 3.Resident #78's diagnoses included chronic combined systolic and diastolic heart failure, diabetes mellitus, and end stage renal disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #78 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, was independent for eating, dressing and transfers. Additionally, the MDS identified Resident #78 weighed 201 pounds. The Resident Care Plan dated 11/11/25 identified nutritional status was compromised secondary to end stage renal disease. Interventions included a daily fluid restriction, and weights per the physician's order. The discharge MDS assessment dated [DATE] identified Resident #78 had a discharge with an anticipated return from the hospital and weighed 208 pounds. Review of the hospital Discharge summary dated [DATE] at 10:50 AM identified Resident #78's weight at time of hospital discharge was 86.9 kilograms (191.6 pounds). A physician's order dated 1/6/26 directed to obtain Resident #78's weight on admission, then continue to weigh for 4 consecutive weeks on the day shift on Wednesdays. The clinical admission Nursing assessment dated [DATE] at 1:48 PM failed to identify a weight was obtained upon re-admission for Resident #78 (the weight section was blank). A review of the weight and vitals summary identified Resident #78 had a weight obtained on 12/7/25 of 208 pounds and a weight on 1/9/25 (3 days after readmission) of 192.9 pounds, a 15.1 pound (7.26 %) weight loss in 1 month (the resident was readmitted from the hospital on 1/6/25). Review of Resident #78's nurses notes dated 1/6/26 to 1/13/26 failed to identify a weight had been obtained upon readmission, or that there was documentation of a 15.1 pound (7.26 %) weight loss in 1 month. Interview and record review with the Dietician on 1/13/26 at 9:48 AM identified she performed nutritional assessments within 2 weeks of admission/readmission from the hospital and did not get notifications from the Nursing Department on weight loss but tracked the weight loss as needed after she reviewed weights in the electronic health record. Resident #78's record review with the Dietician identified that a readmission weight should have been obtained on 1/6/26, and that she had not seen Resident #78 yet (7 days post re-admission), but was planning to tomorrow, and planned on checking in with the hemolytic treatment center on the weight obtained on 1/9/26. Interview and record review with the Director Nurses (DNS) on 1/13/26 at 10:19 AM identified it was facility policy to obtain weights upon admission, then weekly for 4 weeks, then monthly with the responsibility being a team effort among nurse aids and unit nurses. Review of Resident #78's clinical record identified that there was no readmission weight obtained but there should have been. Additionally, the 1/9/26 weight was not obtained by the facility, but a hemolytic treatment center obtained weight was used as the facility readmission weight. The DNS identified that although there was a significant weight loss since discharge (15.1 pounds, 7.26% in one month), Resident #78 had not yet been seen by the Dietician who was due to be in tomorrow. The DNS added that nursing does not notify the Dietician of weight fluctuations, but weight loss tracking is the Dietician's responsibility, which she reviewed in the electronic health record. Review of the Weighing and Measuring the Resident Policy directed in part that weight is obtained upon admission and monthly. Review of the Weight Assessment and Intervention Policy directed in part that nursing staff will obtain resident weights upon admission. Additionally, any weight change of 5% or more since the last weight will be retaken the next day for confirmation and if verified, nursing will contact the Dietician immediately.

Based on observations, interviews, and facility policy for 2 of 2 medication storage carts and 2 of 2 medication rooms reviewed for medication storage, the facility failed to label open medications appropriately. The findings include:Interview and observation with Licensed Practical Nurse (LPN) #4 on 1/13/26 at 9:35 AM of unit D-wing's medication cart identified the following:CoQ10 100 milligram (mg), 1 open bottle with no open dateDocusate Sodium 100 mg, 2 open bottles with no open dateBiotin 1000 micrograms (mcg), 1 open bottle with no open dateAcidophilus Probiotic, 1 open bottle with no open dateMelatonin 5 mg, 1 open bottle with no open dateMelatonin 3 mg, 1 open bottle with no open dateMelatonin 1 mg, 1 open bottle with no open dateGeri-Knot, 1 open bottle with no open dateBisacodyl 5 mg, 1 open bottle with no open dateProbiotic, 1 open bottle with no open dateNaproxen Sodium, 1 open bottle with no open date Fish Oil 1000 mg, 1 open bottle with no open date Calcium 600 mg,1 open bottle with no open date Eye Relief Ophthalmic Solution, 1 open bottle with no open date Latanoprost Ophthalmic Solution, 1 open bottle with no open date Albuterol Sulfate Inhalation Aerosol 90 mcg, 9 open with no open date Fluticasone Propionate Nasal Spray 50 mcg, 1 open with no open date Fluticasone Propionate HFA Inhalation 110 mg, 1 open with no open date Bevespi Aerosphere, 1 open with no open date.LPN #4 indicated that open medications should be labeled with open date per facility policy. LPN #4 identified that it is the responsibility of the nurse who opens the medication bottle to label it with the open and expiration date. LPN #3 indicated that the nurse assigned to the medication cart should check to ensure all medications are labeled appropriately when starting their shift. LPN #4 identified that he had not been labeling medications as he opened them due to time constraints and that he would label medications when he opens a new bottle in the future. Interview and observation with LPN #5 on 1/13/26 at 10:40 AM of unit C-wing medication cart identified the following:Melatonin 3 mg, 1 open bottle with no open dateMelatonin 1 mg, 1 open bottle with no open dateCalcium 500 mg,1 open bottle with no open dateGeri-Knot, 1 open bottle with no open dateDelsym, 1 open bottle with no open dateLPN #5 identified that open medications should be labeled with open date and expiration per policy and that it is the responsibility of the nurse who opens the medication to label with open date and expiration date. LPN #5 indicated that she did not check the cart like she normally did when starting her shift to ensure all open medications were labeled appropriately.Interview and observation with the Director of Nursing (DNS) on 1/14/26 at 10:40 AM of unit A/B and C/D medication rooms identified the following:Humalog 100ml vial, open with no open or expiration dateAcetylcysteine Solution 20%, open with no open or expiration dateTubersol (Mantoux), 2 vials open with no open or expiration dateAzelastine Hydrochloride ophthalmic solution 5 %, open with no open or expiration dateThe DNS identified that open medications should be labeled with open date and expiration in the medication rooms and medication carts per policy. The DNS indicated that it is the responsibility of the nurse who opens the medication to label with open date and expiration date. The DNS indicated that insulin and eye drops should have expiration dates of 28 days after the opening date. The DNS could not identify why the facility policy was not being followed. Additionally, the DNS indicated that all nursing staff would be re-educated on the proper labeling of opened medications.Review of the storage of medications policy, dated 10/1/15 directed in part that when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.

Based on observations, interviews, review of the clinical records and policy, for the only sampled resident (Resident #2) reviewed for urinary catheters, the facility failed to provide a privacy covering for a urinary collection bag, and for 2 of 4 sampled residents (Resident #9 and Resident #73) reviewed for dignity, the facility failed to ensure dignified treatment was maintained. The findings include:1. Resident #2's diagnoses included flaccid neuropathic bladder, retention of urine, and hematuria (blood in urine).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment, required set up for eating and was dependent on staff for toileting and transfers. The Resident Care Plan dated 11/21/25 identified Resident #2 had alteration in urinary elimination related to a urinary catheter (urine drainage tube). Interventions included assessing urine output, change the urinary catheter and bag per the physician's orders, and monitor for leakage.A physician's order dated 12/4/25 directed the insertion of a urinary catheter.Observations from the hallway on 1/7/26 at 10:16 AM and 1/8/26 at 9:30 AM identified Resident #2 in the bed by the door, with the urinary collection hanging at the foot of the bed. Yellow urine was noted in the bag which was without the benefit of a privacy cover.Interview and observation with Nurse Aid (NA) #1 on 1/8/26 at 11:48 AM identified Resident #2's urinary collection bag remained unchanged and in view from the hallway. Although NA #1 indicated the facility policy on urinary collection bags included hanging the bag on the bedside and emptying it during the shift, she did not indicate a privacy cover was needed or that the urinary collection bag should have been out of view.Interview and observation with Licensed Practical Nurse (LPN) #2 on 1/8/26 at 11:54 AM identified Resident #2's urinary collection bag remained unchanged and in view from the hallway. He identified the facility policy directed following the physician's orders for changing urinary collection bags and for flushing. LPN #2 identified that urinary collection bags are kept on the side of the bed, as observed, but he failed to indicate that that Resident #2's urinary collection bag should have been covered or out of view for privacy. Interview and observation with Registered Nurse (RN) # 4 on 1/8/26 at 11:56 AM identified Resident #2's urinary collection bag remained unchanged and in view. RN #4 failed to identify facility policy on urinary collection bags, stating she would have to check since she had only been working at the facility for 2 months.Interview with the Director of Nurses (DNS) on 1/8/26 12:06 PM identified the facility policy directed urinary drainage bags to hang to gravity, stay covered, and physician's orders were to be followed. Subsequent to surveyor inquiry, the DNS indicated that staff would be educated and a privacy cover would be applied to the collection bag.Interview with the Clinical Regional, Nurse, RN #3 on 1/8/26 at 1:53 PM identified that there were no privacy bags available in the facility but were ordered.Review of the Catheter Irrigation policy dated 10/16/25 directed in part that privacy bags will be available and catheter drainage bags will be covered at all times when in use.2. Resident #9's diagnoses included radiculopathy, asthma and anxiety.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, and required set up help for eating, dressing, and transfers.The Resident Care Plan dated 12/1/25 identified Resident #9 needed social enrichment in the environment of choice. Interventions included assessing and discussing resident needs, interests, and ability to participate in activities of choice and 1:1 visit.Interview with Resident # 9 on 1/13/26 at 9:52 AM identified he/she was out of the room frequently and has heard staff on the 3:00 PM to 11:00 PM refer to residents as inmates as well as conversations between NA's complaining about having to provide care to residents and stating they were not babysitters. Additionally, Resident #9 identified she did not bring it up to anyone's attention because when he/she has brought up concerns in the past he/she was told by staff that she/he were overstepping.3. Resident #73's diagnoses included suspected adult neglect (hospital diagnosis), anxiety, and neuropathy.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #73 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment, required set up for eating and substantial/maximal assistance for hygiene, dressing and transfers. The MDS did not identify any signs or symptoms of delirium or behaviors.The Resident Care Plan dated 1/4/26 identified Resident #73 had the potential for impaired psychosocial wellbeing related to long term care placement, diagnosis of alcohol dependence, and loss of independence and autonomy. Interventions included to involve Resident #73 in daily activities, encourage participation in activities, and encourage the resident to verbalize his/her feelings.Interview with Resident #73 on 1/7/26 at 1:46 PM identified that when he/she talked to the Nursing Aids (NAs) they turn away and ignore me or just walk away, they think I can't hear them, but I can hear them. On one occasion a couple months ago, I heard the nurse in the hallway telling someone that she just had to get the inmate his/her medication prior to coming into my room. Although Resident #73 could not identify the nurse, and stated he/she did not tell anyone, he/she teared up when recalling the incident.Interview with the Director Nurses (DNS) on 1/13/26 at 10:19 AM identified that although she was not aware of any resident referred to as an inmate it would be an undignified way to treat residents. Subsequent to surveyor inquiry, the DNS indicated that staff would be educated on dignity.Review of the Residents' [NAME] of Rights directed in part that residents have the right to be treated with consideration, respect, and full recognition of dignity and individuality.

Based on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 2 Residents (Resident #56) reviewed for falls, the facility failed to notify a representative/emergency contact following a fall. The findings include:Resident #56's diagnoses included fracture of sacrum, difficulty in walking, and diastolic (congestive) heart failure. The Resident Care Plan dated in effect on 12/ 26/25 identified Resident #56 was a fall risk related to left hip pain. Interventions included ensuring appropriate footwear was worn, keeping the bed in the lowest position, and frequent rounding for safety and redirection.A Reportable Event form dated 12/26/25 identified Resident #56 had an unwitnessed fall at 6:45 PM but failed to indicate the resident's family was notified.A post fall evaluation dated 12/26/25 at 8:56 PM identified Resident #56 had an unwitnessed fall, but the responsible party had not been notified as no next of kin was listed due to Resident #56 being newly admitted .The admission Minimum Data Set assessment dated [DATE] identified Resident #56 was moderately cognitively impaired, required setup or clean-up assistance for eating, and partial/moderate assistance for transfers.An interview with Person #1 on 1/7/26 at 10:34 AM identified that he/she was the emergency contact for Resident #56. Person #1 indicated that he/she was not informed of Resident #56's fall on 12/26/25. Further Person #1 found out that Resident #56 had fallen only after requesting copies of his/her medical records and reading staff's documentation.A interview and medical record review with the Licensed Practical Nurse (LPN) #4 on 1/13/26 at 9:46 AM identified that the facility policy directed notification of a resident representative/emergency contact following a fall, and the unit nurse or supervisor was responsible to ensure notification. LPN #4 indicated that if the information for an emergency contact was not listed in the resident's electronic health record, he would look at other records to find the contact information. LPN #4 indicated that if he was unable to locate a contact, he would let the supervisor know. LPN #4 identified that he was working during the time of Resident #56's fall and did not know why the family had not been contacted.A interview and medical record review with the Director of Nursing (DNS) on 1/13/26 at 1:00 PM identified that it was the facility policy to notify a resident's family member of a fall, even if the resident was competent, and that it was the responsibility of the nursing supervisor to ensure notification had been completed and documented. Review of the hospital demographics form dated 12/23/25 identified contact information for Resident #56's emergency contact and that the date listed next to the form in the electronic health record, 12/23/25, was the date that the form was scanned into Resident #56's clinical record. The DNS indicated Resident #56's representative/emergency contact information at the time of the fall was in the clinical record and could not identify why the family member was never notified.A review of the facilities Fall Prevention program policy dated 10/16/25 directed in part that when any resident experiences a fall, the family will be notified.

Based on clinical record review, interviews, and facility policy for 1 of 3 sampled residents (Resident #3) reviewed for discharge, the facility failed to revise the Resident Care Plan (RCP) to include interventions for triggers related to a diagnosis of Post Traumatic Stress Disorder (PTSD). The findings include:Resident #3's diagnosis included diabetes, anxiety, and PTSD.The Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status score of 10 indicating moderate cognitive impairment and required assistance with bathing and transfers.Review of Resident #3's Resident Care Plan dated 7/3/25 through 1/14/26 failed to identify a diagnosis of PTSD with interventions that included the triggers related to PTSD or how to assist the resident when expressions or indications of distress that the resident has experienced due to PTSD trauma.Review of psychiatric provider notes from 7/8/25 through 1/7/26 identified a diagnosis of PTSD.Interview with Registered Nurse (RN) #3 on 1/13/26 at 1:45 PM identified that social services should have been responsible to ensure the RCP for PTSD was included in the clinical record, but that responsibility for RCP was building specific. RN #3 indicated that the facility did not currently have a policy related to PTSD but was working to create one, and that a PTSD RCP should have been implemented. Interview with Licensed Practical Nurse (LPN) #3, the Minimum Data Set Coordinator, on 1/14/26 at 10:45 AM identified that she was responsible for updating the RCP. LPN #3 was unsure of the policy but would be reviewing, and she must have overlooked implementing a RCP for PTSD for Resident #3. In the past the social worker had not been a part of the behavioral care planning, but going forward the facility planned on utilizing social services to implement behavioral RCP's such as PTSD.Interview with the Administrator on 1/14/26 at 2:45 PM identified that the facility process was to print out the PASRR level II, upload the document into the clinical record, and create a RCP for PTSD. The Administrator indicated that in the event of a PTSD episode the facility would have reached out to a provider as needed.

Based on observation, review of the clinical record, facility policy and interviews for 1 of 7 sampled residents (Resident #41) reviewed for medication administration, the facility failed to ensure a physician order for a subcutaneous injection was administered properly. The findings include: Resident #41's diagnoses included gastroenteritis (stomach/intestinal inflammation) and colitis (inflammation of the colon). The admission Minimum Data Set assessment dated [DATE] identified Resident #41 had a Brief Interview of Mental Status score of 15 indicating Resident #41 was cognitively intact and required maximal assistance with eating, bathing, and personal hygiene. The Resident Care Plan dated 12/17/25 identified that due to the gastrointestinal inflammation Resident #41 was on a tube feed 14 hours per day and received medication through a Gastrostomy Tube (tube that goes directly into the stomach). Physician orders in effect 12/17/25 to 1/13/26 directed to administer Octreotide Acetate Injection Solution 100 micrograms per milliliter (mcg/ml) subcutaneously (into the fatty layer of the skin) 2 times a day for diarrhea. Observation and interview on 1/13/26 at 7:50 AM identified LPN #6 drawing up an Octreotide Acetate injection for Resident #41 using an intramuscular syringe with a 1-inch, large bore (diameter) needle. As LPN #6 crossed the door threshold prior to reaching Resident #41, the surveyor intervened and asked to speak with LPN #6 outside of Resident #41's room. LPN #6 reviewed the physician's order and noted that she had drawn up the medication using the incorrect type of needle. LPN #6 discarded the previous syringe and drew up the Octreotide Acetate 100 mcg using the correct 1 milliliter syringe with a 5/8 of an inch smaller bore needle for a subcutaneous injection. Interview with DNS on 1/14/26 at 9:50 AM stated that per facility policy a subcutaneous injection should not be given with an intramuscular size needle. Facility policy stated specific instructions based on the type of injection ordered for drawing up medications with dosage, syringe type, appropriate needle size, infection control, and injection site selection and care.

Based on observations, interviews, review of the clinical record, and policy for the only sampled resident (Resident #73) reviewed for activities, the facility failed to ensure activities were offered to a dependent resident. The findings include:Resident #73 diagnoses included suspected adult neglect (from the hospital), anxiety, and neuropathy (nerve pain).The Resident Preferences Evaluation (completed upon admission) dated 1/29/25 identified Resident #73 found it very important to have books, newspapers and magazines to read, keep up with the news, and do his/her favorite activities (favorite activities were not specified).The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #73 had a Brief Interview of Mental Status (BIMS) score of 13 indicating no cognitive impairment, required set-up assistance for eating and partial/moderate assistance for dressing and transfers. Additionally, the MDS identified Resident #73 found it important to have books, newspapers and magazines to read, keep up with the news and do his/her favorite activities.The Resident Care Plan dated 1/4/26 identified Resident #73's quality of life should be maintained or improved by providing activities of interest. Interventions included 1:1 visits, assess and discuss resident needs, interest and ability to participate in activities of choice, and staff encouragement to participate in activities of choice by reminding the resident of activity time and location, assisting with care to be ready for the activity, provide transportation to the activity, and provide materials needed for individual bedside activities as needed.Observation and interview on 1/7/26 at 1:46 PM with Resident #73 identified him/her in bed watching television. The resident did not have access to reading materials in the room and an activity calendar was posted on the wall. Resident #73 identified that he/she had been in bed all day and staff never offered to have him/her attend activities. Additionally, Resident #73 identified he/she would have liked to attend activities, however, was unable to get there on his/her own due to the inability to self-propel the wheelchair. Resident #73 indicated that he/she was unaware staff would have assisted in bringing him/her to the activity programs as he/she was never offered to attend.Observations on 1/12/26 at 9:46 AM and 1/13/26 at 10:16 AM identified Resident #73 alone, awake, in bed, the television was turned off and there were no reading materials in the room.Interview and review of participation records with the Therapeutic Recreation Director (TRD) 1/12/26 at 12:42 PM identified that activities offered/attended were tracked on a participation calendar for each resident. A review of the January 2026 participation calendar identified Resident #73 had a 1:1 visit on 1/1/26 and was not offered any other activities during the month. Review of participation calendars for previous months identified an average of 3 to 4 activities daily as follows: In October 2025 Resident #73 was active/observed in an activity 8 times, had 1:1 visits 11 times with the therapeutic recreation staff and refused 5 activities. In November 2025 Resident #73 was active/observed in 2 activities, had 1:1 visits 4 with therapeutic recreation staff and refused 7 activities. In December 2025 Resident #73 was active/observed in 3 activities, had 1:1 visits 7 times with therapeutic recreation staff and refused 1 activity. The TRD identified that the Recreation Department was responsible for inviting residents to activities and that Resident #73 was not offered activities on a daily basis. Additionally, the TRD identified that Resident #73 was not offered more activities because, unfortunately, this happened when residents had refusals, they just trail off (referring to the decline in activities offered and attended by Resident #73). The TRD also identified that she was not aware Resident #73 expressed interest in attending more activities, was under the impression that he/she would have to self-transport him/herself, or that he/she was unable to self-transport. The TRD stated the Recreation Department would have to do better, and now that they were aware, they would work with the Nursing Department to get Resident #73 to offer more activities.Review of the Activities policy dated October 2025 directed, in part, to provide ongoing programs to support residents in their choice of activities to support physical, mental and psychosocial well-being. Additionally, residents are encouraged, not mandated to attend, and all staff will assist residents to and from activities when necessary.

Based on review of the clinical record, facility policy, observation and interviews for 1 of 3 sampled residents (Resident #98) reviewed for pressure ulcers, the facility failed to follow physician orders to offload the resident's heels and failed to follow physician orders for the appropriate treatment of a wound. The findings include: Resident #98's diagnoses included severe protein-calorie malnutrition, dementia and pressure ulcer to their left ischium. The Nursing admission assessment dated [DATE] identified Resident #98 was alert and oriented to person and presented as chronically disoriented and confused. The Resident Care Plan identified Resident #98 was at risk for alteration in skin integrity. Interventions included using pressure redistribution devices as ordered, and perform treatments as ordered.A. A physician's order dated 1/5/26 directed to elevate bilateral heels off the bed with pillows or use foam boots to prevent heel ulcers. Observation on 1/7/26 at 1:45 PM, and on 1/8/26 at 11:31 AM identified that Resident #98 was lying in bed without the benefit of his/her heels being offloaded. Resident #98's Resident Care Plan was revised on 1/9/26 to include an increased risk for alteration in skin integrity. Observation on 1/12/26 identified that Resident #98's heels had been offloaded. Review of facility policy for Prevention of Pressure Ulcers/Injuries indicated, in part, to select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight and overall risk factors, and reposition the resident more frequently as needed, based on the condition of the skin and the resident's comfort. B. A physician's order dated 1/9/26 directed to cleanse the left ischium wound (backside section of the hip bone) with wound cleanser, apply Triad to the peri-wound, apply Santyl to the base of the wound, secure with a dry clean dressing, change daily and PRN (as needed) if soiled or dislodged every evening shift for pressure ulcer of left buttock. A physician's order dated 1/9/26 directed the nursing staff to cleanse the wound to the left lower leg with wound cleanser, apply silver hydrogel to the base of the wound, secure with dry clean dressing, change every other day and PRN if soiled and dislodged every evening shift for a skin tear to the right hand and left lower leg.Observation and interview with Licensed Practical Nurse (LPN) #1 on 1/12/26 at 1:34 PM identified that she applied the silver hydrogel (for the leg) and not Santyl as directed to the resident's left ischium bed, followed by a dry clean dressing. LPN #1 indicated that she thought the ischium area was the resident's hip which had previously healed. LPN #1 then applied silver hydrogel to Resident #98's left lower leg as ordered. Subsequent to surveyor inquiry, LPN #1 indicated that she had not followed the physician's order for Santyl to the ischium as directed and removed the resident's previously applied left ischium wound dressing. LPN #1 then performed wound care using the correct medication, Santyl, as directed. LPN #1 failed to apply Triad paste, as ordered, to the resident's peri-wound area during either of the ischium wound care treatment observations. LPN #1 indicated that she followed the wrong treatment orders for Resident #98 because she believed the ischium was Resident #98's hip and not the area she was treating. Interview with the facility wound nurse Registered Nurse (RN) #1 at 2:09 PM identified the left ischium was located on the resident's left lower buttock and was where Resident #98's wound was located. RN #1 stated she spoke with LPN #1 prior to her demonstrating wound care for Resident #98 and went over the wound care treatment procedure. RN #1 also stated that she instructed LPN #1 that if she was unsure of anything pertaining to the resident's orders, to find a supervisor for clarification prior to proceeding with care and that LPN #1 would be re-educated following the incorrect provision of wound care. Review of facility policy for Wound Care indicated, in part, to verify that there is a physician's order for this procedure, and apply treatments as indicated.

Based on clinical record review, interview, and review of facility policy, for 1 of 5 sampled residents (Resident #74) reviewed for unnecessary medications, the facility failed to ensure that behavior monitoring was being performed with antipsychotic medication administration. The findings includeResident #74's diagnosis included dementia with behavioral disturbance, substance abuse, and diabetes.The Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status score of 12 indicating moderate cognitive impairment and required assistance with bed mobility and transfers. Further review of the MDS failed to identify a psychiatric diagnosis for the use of an antipsychotic medication.Review of the Resident Care Plan in effect from January 2025, through January 14, 2026, identified a behavioral disturbance. Interventions directed to conduct behavioral monitoring.A physician order dated 1/18/25 directed to administer Seroquel (an antipsychotic) 50 milligrams at bedtime for schizophrenia. The order was discontinued on 2/26/25. The antipsychotic medication order was subsequently re-written to be administered for a diagnosis of dementia with behavioral disturbance.Review of the clinical record from January 2025 through January 14, 2026, failed to indicate behavioral monitoring had been routinely conducted.Interview with Corporate Nurse, Registered Nurse (RN) #3 on 1/13/26 at 2:20 PM identified that the previous Director of Nursing (DNS) had mistakenly added a diagnosis of schizophrenia and discontinued behavioral monitoring in January 2025. When the mistaken diagnosis was corrected, the DNS failed to reimplement behavioral monitoring for Resident #74. RN #3 indicated that she had conducted a clinical record and Medication Administration Record review from January 2025 through January 2026 and was unable to find that Resident #74 had routine behavioral monitoring with the use of Seroquel for a diagnosis of dementia with behavioral disturbance. RN #3 indicated that the facility policy indicated that behavioral monitoring was required with the use of Seroquel for dementia. Review of the antipsychotic medication use policy identified that antipsychotic medications prescribed for behavioral symptoms would include documentation for target behaviors and expected outcomes.

Based on review of the clinical record, observations, interviews and facility policy for 2 of 3 sampled residents (Resident #11 and Resident #98) reviewed for Resident #11 reviewed for infection prevention practices, the facility failed to wear appropriate Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP), and for Resident #98 reviewed for pressure ulcers, the facility failed to follow appropriate hand hygiene practices. The findings include: 1.Resident #11 's diagnoses included Sepsis, Dysphagia (difficulty swallowing) and Dementia. A physician's order dated 12/20/25 directed to administer Ertapenem sodium injection solution reconstituted 1 gram intravenously once a day for Sepsis until 1/16/26 at 100 milliliters/hour over 30 minutes via a Peripherally Inserted Central Catheter. (PICC) The baseline Resident Care Plan dated 12/20/25 identified enhanced barrier precautions related to current antibiotic (intravenous) therapies. Interventions included handwashing between residents and as needed during care of this resident, staff to utilize gloves, facemask, when anticipated contact with body substances other PPE to be worn as necessary, medications as ordered. A physician's order dated 12/22/25 directed EBP related to a Peripherally Inserted Central Catheter (PICC) line and IV antibiotics The admission Minimum Data Set assessment dated [DATE] identified Resident #11 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 6 and required total assistance with eating, bathing, dressing, toileting, transfer, and bed mobility. Observation and interview with LPN #1 on 1/7/26 at 11:34 AM, identified LPN #1 in Resident #11's room which was marked with Enhanced Barrier Precautions (EBP) sign visible outside the door directing when performing high contact resident care activities which include device care: central lines, PICC lines, midline catheters, gowns and gloves were to be worn, and face masks may be needed when performing activities with risk of splashing or spraying. A supply cart was available and noted outside the entry containing PPE. LPN #1 was observed flushing and accessing Resident #11's PICC line with gloves, but without the benefit of wearing a gown. LPN #1 identified that she was flushing and disconnecting the antibiotic that ran via the PICC line because it had finished. Review of the EBP sign at the doorway identified that a gown and gloves were required when performing high contact care activities. LPN #1 stated oh I have to wear a gown. I just had gloves, then returned to Resident #11's room without applying a gown and finished flushing and disconnecting the tubing from the PICC line. Interview with Registered Nurse (RN) #3 and the Director of Nursing (DNS) on 1/7/26 at 12:30 PM identified that a gown and gloves should have been worn when disconnecting and flushing a PICC line. The DNS indicated that she would be educating LPN #1as well as educating all nursing staff immediately related to EBP and high contact activities. Review of the Enhanced Barrier Precautions policy directed, in part, enhanced barrier precautions require the use of gown and gloves for certain residents during specific high contact resident care activities in which there is an increased risk for transmission of multidrug resistant organisms. High contact resident care activities include device care and wound care. 2. Resident #98's diagnoses included severe protein-calorie malnutrition, dementia and pressure ulcer to the left ischium. The facility's Nursing admission assessment dated [DATE] identified that Resident #98 was alert and oriented to person and presented as chronically disoriented and confused. The Resident Care Plan identified a pressure ulcer to his/her bottom. Interventions included applying a pressure redistribution device as ordered, perform treatments as ordered, and perform frequent repositioning every shift to prevent skin breakdown A physician's order dated 1/9/26 directed to cleanse wound to left ischium with wound cleanser, apply Triad to peri-wound, Santyl to base of the wound, secure with a dry clean dressing, change daily and PRN (as needed) if soiled or dislodged every evening shift for pressure ulcer of left buttock, unstageable. Observation on 1/12/26 at 1:34 PM of Licensed Practical Nurse (LPN) #1 performing Resident #98's wound care identified that during the initial treatment to the left ischium, she had applied the incorrect medication to the wound. Following a treatment to the left lower extremity and prior to re-treatment of the left ischium using the correct medication, LPN #1 removed her gloves and placed on a new pair of gloves without the benefit of cleansing her hands. Interview with the facility wound nurse Registered Nurse (RN) #1 on 1/12/26 at 2:09 PM identified LPN #1 should have cleansed her hands prior to placing a new pair of clean gloves during Resident #98's wound care procedure. RN #1 stated that is unacceptable and that LPN #1 would be re-educated. Review of facility policy for Wound Care indicated, in part, to wash and dry your hands thoroughly (prior to wound care), then put on gloves.

Based on clinical record reviews, interviews and facility policy during a review of the Facility Quality Assurance Performance Improvement Plan (QAPI), the facility failed to initiate a QAPI subsequent to identifying that staff had not been following physician orders or their policy for obtaining resident weights. The findings include:Please also reference F692An interview with the Director of Nursing (DNS) on 1/12/26 at 1:33 PM indicated the policy for obtaining admission weights directed upon admission, then weekly times 4 weeks then monthly. The DNS further indicated there was no good reason for failing to follow the facility policy or physician orders, the team met to discuss weights, but it was her responsibility to ensure compliance.An interview with the DNS and the Director of Clinical Services (RN # 5) on 1/14/26 at 12:15 PM identified that the Quality Measures for weights had not been triggered. Additionally, the DNS indicated that the facility had not identified the problem with obtaining accurate weights prior to the survey team identifying the problem. The Director of Clinical Services indicated that the facility does run core reports and sends the reports to the regional staff for review, however the QAPI for this issue had not been started but will be started immediately.Interview and review of the QAPI/QAA program with the Administrator on 1/14/2026 at 11:52 AM identified that the facility is moving towards the Point Click Care (PCC) Electronic Health Record (EHR) event monitoring module. Currently the QAPI program utilizes different sources of information with a focus on root cause analysis to meet quality measurement goals. This is the method that the QAPI team utilized to decide what Performance Improvement Plans to work on.Review of the QAPI policy directed, in part, we monitor existing QI/QM results, internal monitors for falls, medication errors, pressure ulcers, incident reports, and infection reports. The Quality-of-Care Team meets monthly with the Medical Director and others to address care concerns. Our QAPI plan includes policies and procedures used to identify and monitor our performance, establish goals and thresholds for our performance measurement, resident, staff and family input. Additionally, identifying and prioritizing problems and opportunities for improvement, systematically analyzing underlying causes of systemic problems, adverse events and developing corrective action or performance improvement activities. The administrator has responsibility and is accountable to the Governing Board and our corporation for ensuring that QAPI is implemented throughout our organization. All department managers, the administrator, the director of nursing, infection control and prevention officer, medical director, consulting pharmacist, resident and or family representative if appropriate and 3 additional staff will provide QAPI leadership by being on the Quality Assessment and Assurance committee. The QAA committee will meet monthly. Our center will conduct Performance Improvement Projects that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention. Identifying potential topics for PIPS will be considered are high risk, high volume, or problem prone areas that affect health outcomes, quality of care and services and areas that affect staff. The QAA committee will prioritize topics for PIPs based on current needs of the residents and center. Root cause analysis is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from verbal mistreatment. The findings include:Resident #1 was admitted with diagnoses that included stroke with resultant hemiplegia and hemiparesis (loss of movement on one side of the body), anxiety, and major depression. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 (was alert and oriented), and was dependent for toileting, transfers and bed mobility. The Resident Care Plan (RCP) dated 8/18/2025 identified Resident #1 was frequently incontinent of bowel and bladder was long term placement. The RCP directed to provide incontinent care upon request, toilet upon request and staff to provide emotional support. A facility investigation (A &I) report dated 8/28/2025 at 9:00 AM identified an allegation of staff-to-resident abuse regarding care provided by NA #1. NA #2 reported that on 8/27/2025, he heard NA #1 ask Resident #1 why are you even sh******, you don't eat anything we give you. When I heard I had you on my assignment, I was pissed. A facility A & I summary dated 9/2/2025 identified NA #1 denied the allegation and Resident #1 reported he/she did not remember the incident. Further, the summary identified the allegation of abuse was unsubstantiated, however NA #1's communication style and tone was inconsistent with the facility expectations. Interview with NA #2 on 9/16/2025 at 10:12 AM identified he went to assist NA #1 around dinner time on 8/27/2025 when Resident #1 asked for assistance to go to the bathroom. NA #3 was with him as well as she was on orientation. As he entered into the room, he observed NA #1 at the foot of Resident #1's bed facing Resident #1. NA #1 said in a loud voice, why are you even sh******, you don't eat the food here. NA #2 stated he thought Resident #1 looked stunned. NA #2 stated NA #1 told Resident #1 that she was pissed when she found out Resident #1 was on her assignment. NA #1 told Resident #1 that he/she needed to use the bedpan and not go to the bathroom. NA #2 stated he told NA #1 that she shouldn't talk to a resident that way, and left to report the incident to the charge nurse (LPN #1) and the supervisor. NA #2 continued that he told the supervisor that NA #1 had yelled and was rude to Resident #1, and stated he later apologized to Resident #1 for NA #1's behavior. Interview with NA #3 on 9/16/2025 at 10:25 AM identified that she was orienting with NA #2 when they went to assist NA #1 to provide care for Resident #1. NA #3 stated she left the room and NA #1 and NA #2 stayed to assist Resident #1 to the bathroom. As she walked out of Resident #1's room and into the hallway, she heard NA #1 say loudly, why do you want to sh**, you don't even want to eat the food here. NA #2 later told her they needed to tell the supervisor and they both reported that NA #1 had yelled at Resident #1. Interview with NA #1 was not obtained during the survey. Interview with RN #1/nursing supervisor, on 9/16/2025 at 11:19 AM identified NA #2 notified her on 8/27/2025 around 10:00 PM that NA #1 was rude to Resident #1 and she did not ask for any specific information regarding the interaction because she was aware that NA #1 had been reported in the past as loud and directive in her communications with residents and that it had been addressed by the DON previously. She could not recall if NA #2 had identified that NA #1 was yelling or directive and he did not report that NA #1 had used vulgar language. RN #1 asked LPN #1 if any resident had complained about a staff member and LPN #1 reported no resident complaints were made. RN #1 stated she asked NA #1 if any residents had complaints and NA #1 had replied no. RN #1 stated she reminded NA #1 that the residents don't always know her style and that she needed to be mindful of her approach. RN #1 identified that if staff were observed to be yelling, directive towards residents or using vulgar language, she would consider that abusive. Interview with the DON on 9/16/2025 at 12:19 PM identified NA #2 had reported to her on 8/28/2025 at 9:00 AM that on 8/27/2025 evening at 5:00 PM, NA #1 had yelled at Resident #1 and had asked Resident #1 why did he/she need to sh** as he/she didn't eat the food and that NA #1 was pissed that she had Resident #1 on her assignment. The DON stated the facility investigation did not substantiate abuse, but determined that NA #1's communication style was inconsistent with the facility's expectations and terminated her employment. The facility's Reporting Abuse to Facility Management Policy directed in part, that it is the policy of the facility not to condone any form of resident abuse or neglect by anybody including staff members. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance, The facility's Resident Rights policy, dated July 2021, directed in part that the resident's living quarters are treated as their home and residents have the right to be free from verbal, sexual, physical, or mental abuse.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for abuse and neglect, the facility failed to ensure staff reported an allegation of abuse timely. The findings include: Resident #1 was admitted with diagnoses that included stroke with resultant hemiplegia and hemiparesis (loss of movement on one side of the body), anxiety, and major depression. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 (was alert and oriented), and was dependent for toileting, transfers and bed mobility. The Resident Care Plan (RCP) dated 8/18/2025 identified Resident #1 was frequently incontinent of bowel and bladder was long term placement. The RCP directed to provide incontinent care upon request, toilet upon request and staff to provide emotional support. A facility investigation (A &I) report dated 8/28/2025 at 9:00 AM identified an allegation of staff-to-resident abuse regarding care provided by NA #1. NA #2 reported that on 8/27/2025, he heard NA #1 ask Resident #1 why are you even sh******, you don't eat anything we give you. When I heard I had you on my assignment, I was pissed. A facility A & I summary dated 9/2/2025 identified NA #1 denied the allegation and Resident #1 reported he/she did not remember the incident. Further, the summary identified the allegation of abuse was unsubstantiated, however NA #1's communication style and tone was inconsistent with the facility expectations. Interview with NA #2 on 9/16/2025 at 10:12 AM identified he went to assist NA #1 around dinner time on 8/27/2025 when Resident #1 asked for assistance to go to the bathroom. NA #3 was with him as well as she was on orientation. As he entered into the room, he observed NA #1 at the foot of Resident #1's bed facing Resident #1. NA #1 said in a loud voice, why are you even sh******, you don't eat the food here. NA #2 stated he thought Resident #1 looked stunned. NA #2 stated NA #1 told Resident #1 that she was pissed when she found out Resident #1 was on her assignment. NA #1 told Resident #1 that he/she needed to use the bedpan and not go to the bathroom. NA #2 stated he told NA #1 that she shouldn't talk to a resident that way, and left to report the incident to the charge nurse (LPN #1) and the supervisor. NA #2 continued that he told the supervisor that NA #1 had yelled and was rude to Resident #1, and stated he later apologized to Resident #1 for NA #1's behavior. Interview with NA #3 on 9/16/2025 at 10:25 AM identified that she was orienting with NA #2 when they went to assist NA #1 to provide care for Resident #1. NA #3 stated she left the room and NA #1 and NA #2 stayed to assist Resident #1 to the bathroom. As she walked out of Resident #1's room and into the hallway, she heard NA #1 say loudly, why do you want to sh**, you don't even want to eat the food here. NA #2 later told her they needed to tell the supervisor and they both reported that NA #1 had yelled at Resident #1. Interview with RN #1/nursing supervisor, on 9/16/2025 at 11:19 AM identified NA #2 notified her on 8/27/2025 around 10:00 PM that NA #1 was rude to Resident #1 and she did not ask for any specific information regarding the interaction because she was aware that NA #1 had been reported in the past as loud and directive in her communications with residents and that it had been addressed by the DON previously. She could not recall if NA #2 had identified that NA #1 was yelling or directive and he did not report that NA #1 had used vulgar language. RN #1 asked LPN #1 if any resident had complained about a staff member and LPN #1 reported no resident complaints were made. RN #1 stated she asked NA #1 if any residents had complaints and NA #1 had replied no. RN #1 stated she reminded NA #1 that the residents don't always know her style and that she needed to be mindful of her approach. RN #1 identified that if staff were observed to be yelling, directive towards residents or using vulgar language, she would consider that abusive. Interview failed to identify that RN #1 notified the DON of the allegation of abuse, initiated an incident report or removed NA #1 from the schedule/unit to protect residents from potential abuse. Interview with the DON on 9/16/2025 at 12:19 PM identified NA #2 had reported to her on 8/28/2025 at 9:00 AM that on 8/27/2025 evening at 5:00 PM, NA #1 had yelled at Resident #1 and had asked Resident #1 why did he/she need to sh** as he/she didn't eat the food and that NA #1 was pissed that she had Resident #1 on her assignment. The DON stated RN #1 should have notified her of the allegation on 8/27/2025 when NA #2 reported the allegation, and she did not know why she was not notified. The facility's Reporting Abuse to Facility Management Policy directed in part, that it is the policy of the facility not to condone any form of resident abuse or neglect by anybody including staff members. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance. All personnel should promptly report incidents of abuse or suspected abuse to the DON, Administrator or nurse supervisor. If such incidents are discovered after hours, the Administrator /designee and the DOB/designee must be called at home. Review of facility documentation review identified staff education was initiated on 8/28/2025 and included directing staff to report allegations immediately, and allegations are required to be reported promptly to supervisor, DON or Administrator. Audits were initiated on 8/28/2025 and a QAPU staff meeting was held on 9/4/2025, to review the quality initiative. Based on review of facility documentation, past non-compliance was identified.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for injuries of unknown origin, the facility failed to ensure the resident was free from accidents resulting in sustaining several burn wounds from a hot beverage spill and the failure to implement an ordered intervention to prevent further injury. The findings include: Resident #1's diagnoses included dementia without behavioral disturbances, generalized muscle weakness and polyneuropathy (peripheral nerve disorder that causes multiple nerves throughout the body to malfunction at the same time which can cause numbness, pain, tingling or a burning sensation). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 10) and was independent with eating, bed mobility, transfers and ambulation. A nurse's note dated 3/10/25 at 3:03 AM identified Resident #1 had an unwitnessed fall in his/her bathroom. The note did not identify alterations in skin integrity related to the fall. A nurse's note dated 3/14/25 at 9:00 AM identified Resident #1 was found sitting upright on the floor next to his/her bed and a 1.25 cm superficial scrape to the base of the left thumb. The note did not identify any further alterations in skin integrity related to the fall. Review of the clinical record identified no further falls from 3/14/25 through 3/16/25. A nurse's note dated 3/17/25 at 12:51 PM identified Occupational Therapist (OT) #1 reported a 16 cm by 7 cm skin tear to Resident #1 ' s right inner thigh, further described the affected area as bright red in color and tender to touch and indicated the nursing supervisor, wound nurse and APRN were notified. Review of the clinical record failed to identify the cause of the inner thigh wound, wound treatment and monitoring or preventative interventions initiated after the discovery of the right thigh wound. Review of the March 2025 Documentation Survey Report (Nurse Aide flowsheets/ documentation) identified Resident #1 received a shower on 3/24/25 by NA #4 and no skin areas were observed. An OT treatment encounter note dated 3/25/25 identified Resident #1 was grimacing in pain with peri care and stated he/she burned the genitals after spilling hot chocolate in the groin area. The note indicated nursing was notified to address the burn/wound. A skin/wound note dated 3/25/25 at 12:15 PM identified the wound nurse was notified of a new wound discovered to Resident #1 ' s genitals measuring 2 cm by 1 cm by 0.5 cm and was tender to touch. The note reported that the area was cleansed, Silvadene (topical antimicrobial cream used for the treatment of burns) was applied, the area was covered with a dry, clean dressing and Resident #1 was referred to the wound care physician. A wound care physician's note dated 3/26/25 identified wound #1 was located on the right anterior (front), medial (towards the middle) thigh and the genital area and that the largest of the two (2) wounds (right thigh) was measured at 5.5 cm by 11.5 cm by 0.2 cm full thickness burn (a severe burn destroying all layers of skin and may have also damaged underlying tissues). It identified that the wound was compromised of 1-24 percent (%) epithelial tissue (restoration of the skin barrier/growth of new epithelial cells after a damaged skin area), 1-24 % granulation tissue (new pink or red tissue that forms in the healing process of wounds) and 50- 74 % slough (nonhealing tissue that needs to be removed from the wound for healing to take place) with a moderate amount of serous drainage (a clear fluid that drains from wounds and is a sign of healing) and Resident #1 reported a pain level of three (3) out of ten (10) to the area(s), signifying mild pain. The note identified that the treatment recommendations included to cleanse the wound, apply Silvadene to the wound and cover with a dry clean dressing daily. The note identified Resident #1 reported the wounds to the right thigh and genitals were from spilling hot chocolate on him/herself. Review of the facility Reportable Event (RE) Report dated 3/26/25 at 3:00 PM identified that on 3/17/25 at 12:00 PM an injury of unknown origin was discovered to Resident #1's right thigh and was potentially caused by a fall. The RE identified that on 3/25/25, an additional wound was discovered to Resident #1 ' s genitals while OT #1 was performing Activities of Daily Living (ADLs) with Resident #1, and a wound consult was placed. The RE identified the wound physician evaluated the wounds on 3/26/25, classified the wounds to the right thigh and genitals as burns and recommended a burn consult, follow-up with the wound nurse and daily dressing changes. The RCP and Resident Care Card (RCC) were updated to include the use of a sippy cup for drinks at all times. A physician's order dated 3/27/25 directed for Resident #1 to utilize a sippy cup with all meals for all drinks. The burn center consultation dated 4/2/25 identified that the genital wound was noted with a 1 cm by 0.7 cm by 0.1 cm superficial burn which was very tender to touch. The right medial thigh burn was identified as a 11 cm by 4.5 cm by 0.1 cm full thickness burn with yellow and brown devitalized tissue (non-functional, essentially dead tissue) noted at the surface and pink tissue was noted to the base and the devitalized tissue was debrided (removal of dead/damaged tissue) with a blade. The note reported that the full thickness burns to the right thigh and to the genitals would benefit from a moist topical treatment, debriding agent to the right thigh and pain control. The burn center consultation dated 4/14/25 identified that the genital wound was healed but the right thigh revealed a deep burn wound with adherent (stuck to, hindering the healing process) yellow and black eschar (dead tissue). The note reported operative (surgical) management of the wounds was discussed with Resident #1, but he/she preferred to continue with local wound care and avoid surgery. Observation of Resident #1 on 4/17/25 at 8:58 AM identified Resident #1 in his/her room, laying in bed with an over the bed table positioned to the right side of the bed. A maroon mug was on the table without a cover displaying a brown liquid inside, an open cup of orange juice with a straw was next to the mug, a red liquid was noted all over the floor and LPN #2 was in the doorway and stated she was waiting for housekeeping to clean up the spill. Further observation at 11:50 AM identified two (2) open maroon mugs on the over the bed table containing a brown liquid filled to about 0.5 inches from the top, which Resident #1 identified as hot chocolate, and an open cup of a brown carbonated beverage with a straw, which Resident #1 identified to be cola. Interview with LPN #2 on 4/17/25 at 11:52 AM identified that she was not aware Resident #1 was care planned to have all liquid beverages in a sippy cup and that her assignment sheet did not indicate the need for a sippy cup. Interview and observation with NA #1 on 4/17/25 at 11:52 AM identified he provided Resident #1 with hot chocolate and cola for lunch and was unaware Resident #1 required a sippy cup for all meals, and reported the intervention was not on the RCC. NA #1 was observed taking the drinks off Resident #1's over the bed table and obtaining the correct cups. Review of the RCC failed to identify Resident #1 required a sippy cup for all fluids during all meals. Interview with OTA #1 (Rehab Director) on 4/17/25 at 12:00 PM identified she was unaware Resident #1 had a new order (dated 3/25/25) for a sippy cup at all times. She identified she should have been notified of the order so she could have notified the kitchen to ensure Resident #1 received adaptive equipment. She identified that the order did not go through the proper process and was not showing up on the RCC so the NA's would not be aware of the intervention. Interview with the DNS on 4/17/25 at 12:08 PM identified that following the new intervention of the sippy cup, the Dietary Director told her she needed a physician's order and that the order was entered incorrectly. She reported she did not think to notify the therapy department. Interview with the Director of Dietary on 4/17/25 at 12:18 PM identified that coffee and hot water are placed into the designated carafes for about thirty (30) minutes prior to them being served and they should be served between 160 and 190 degrees Fahrenheit. The temperature obtained from the beverage cart on the B wing identified the hot water to be 161.5 degrees Fahrenheit and the coffee to be 156 degrees Fahrenheit. He identified an adaptive feeding equipment list is generated from orders that are entered into the electronic health record, and then the adaptive equipment (cups and silverware) are added to meal delivery carts for NA's to utilize as ordered. He identified he did not recall the DNS notifying him that Resident #1 required an adaptive cup and reported Resident #1 was not on his list. Review of the Adaptive Equipment Tally Report dated 4/17/25 failed to identify Resident #1 on the list for adaptive meal equipment. Interview with OT #1 on 4/17/25 at 12:25 PM identified she discovered the right thigh and genital wounds during therapy sessions. She reported that on 3/17/25, she assisted Resident #1 to the bathroom and observed a large, open, reddened wound to the right inner thigh. She indicated she was aware Resident #1 had recent falls but thought a skin tear was unlikely due to the location of the wound. She identified she documented a skin tear due to not knowing what to call the wound and indicated she immediately reported the wound to LPN #1 and RN #1. She identified Resident #1 ' s sheets were soiled but was unsure if that was due to a spill or stool. OT #1 identified she did not observe the area to the genitals on 3/17/25. OT #1 identified that on 3/25/25 she was assisting Resident #1 with a sponge bath and Resident #1 said, ouch and stated the area hurt due to spilling hot chocolate. Interview with the DNS on 4/17/25 at 3:48 PM identified the burns should not have occurred on 3/17/25 or 3/25/25 and that a full investigation into the injuries of unknown origin should have been completed after each incident. The DNS reported that a full body skin assessment should have been completed after the 3/17/25 incident and the charge nurse should complete an assessment after a change in condition/accident. She identified the intervention for Resident #1 to utilize a sippy cup at all meals should have been followed but she was unaware of the process for implementing adaptive equipment at the time she entered the order. Although attempted, interviews with MD #2 (wound physician), RN #3 (prior DNS) and NA #4 were not obtained. Although requested, a facility Accident and Investigation (A & I) dated 3/17/25 was not provided. Review of the Investigating Injuries of Unexplained Injuries policy dated 5/2006 directed, in part, that any allegation of occurrence of an injury of unknown origin will be reported immediately but no later than within 24 hours of the allegation or occurrence to the Department of Public Health (DPH). An investigation will be initiated and conducted by the Administrator or his/her designee. Should a resident be observed with unexplained injuries, the nurse on duty must assess the resident and complete an accident/incident form and record such information into the resident's clinical record. Residents must be assessed immediately and an investigation initiated. A written report will be filed with DPH within 72 hours. The results of the investigation will be reported to DPH within five (5) working days of the allegation or occurrence. Every effort is made to determine the cause of an injury of unknown origin and so documented. Although requested, a policy on hot beverage serving temperatures was not obtained.

Based on a clinical record review, review of facility documentation, staff interviews and review of the facility policy for one sampled resident (Resident #1) who was reviewed for change in condition, the facility failed to ensure that life saving measures were provided when the resident was found to be unresponsive and not breathing which resulted in the finding of Immediate Jeopardy. The finding includes: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record identified an Advance Directives document signed and dated [DATE] that identified Resident #1 desired Cardiopulmonary Resuscitation (CPR). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact. The Resident Care Plan dated [DATE] identified Resident #1 Code status was Full Code. Interventions indicated resident and/or responsible health care decision maker verbalized understanding regarding discussion of Advance Directive care plan. The [DATE] physician's order directed a code status of Full Code, administer cardiopulmonary resuscitation. Review of the clinical record dated [DATE] at 10:29AM identified Resident #1's blood pressure was ,d+[DATE]. Review of the facility's vital signs documentation dated [DATE] at 6:10 PM identified Resident #1's vital signs included: Temperature 97.3, Pulse 100, Respiration 20, Pulse Oximeter 92%, and Blood Pressure ,d+[DATE]. The nurses' note dated [DATE] at 9:00 PM identified Resident #1 was alert and lethargic with stable vital signs, able to make needs known with no changes from earlier shift. The nurses' note identified Resident #1's blood sugar was monitored as ordered and indicated narcotics were held secondary to patient's lethargy. Review of Resident #1 Certificate of Death identified that the resident was pronounced deceased by RN #1 on [DATE] at 11:00 PM. Review of the Reportable Event Report dated [DATE] at 6:30 AM indicated Resident #1 was found unresponsive in his/her room at approximately 10:55 PM on [DATE]. The report identified that LPN#1, (charge nurse) paged RN #1 (nursing supervisor) who responded by 11:00 PM and determined Resident #1 was 'too far gone' and did not initiate CPR. Review of R #1's clinical record failed to identify documentation of assessments and any actions taken by the nursing staff when RN #1 and LPN #1 determined that Resident #1 was unresponsive, not breathing and was without a pulse. An interview with the Director of Nursing (DON) on [DATE] at 12:10 PM identified that she was made aware of the incident surrounding Resident #1's death in the morning of [DATE] at 6:30 AM when she called the facility. The DON indicated she initiated an investigation, reported the incident to the State Agency, called the medical examiner, initiated education on code response, and suspended both the nurses involved. The DON stated during her interview with RN #1 on [DATE], RN #1 indicated he was aware that Resident #1's code status was Full code but upon assessment on [DATE] at 11:00 PM the resident was blue, cold, had fixed pupils and no pulse and he did not perform CPR on Resident #1 as the patient was too dead. The DON stated that in an interview with LPN #1, LPN #1 indicated that when she saw Resident #1, the resident looked dead, had no heart rate and no respirations. The DON indicated LPN #1 stated she paged RN #1 to the resident's room, and she did not initiate CPR. The DON stated that LPN #1 reported that RN #1 responded to Resident #1's room and stated the resident was 'too far gone'. During additional interview with the DON on [DATE] at 2:40 PM the DON identified that LPN #1 and RN #1 should have initiated CPR at the time the resident was found unresponsive, a code blue should have been called, and staff should have called 911. Interview with LPN #1 on [DATE] at 1:30 PM indicated she saw Resident #1 at 8:30 PM on [DATE] did the resident's blood glucose which was 182 mg/dl, and indicated the patient was receiving 2 liters of oxygen with oxygen saturation of 92%. LPN #1 indicated she was called to Resident #1's room between 10:45 PM and 10:50 PM by Nurses' aide (NA) #1 who stated the resident had 'passed'. LPN #1 stated the resident was not breathing and had no heart rate she then informed RN #1. LPN #1 indicated she was aware Resident #1 was a full code but stated she did not start CPR as she was not aware she should have initiated CPR on a resident that was not breathing and had no heart rate. LPN #1 indicated that when RN #1 responded to the page RN #1 assessed the resident but did not start CPR and did not direct LPN #1 to start CPR. LPN #1 indicated that after the incident the DON provided education on the steps to take when a patient who was a full code becomes unresponsive. An interview with NA #1 on [DATE] at 2:05 PM identified she saw Resident #1 at 10:00 PM and indicated the resident looked 'normal, appeared to be asleep and was breathing. NA #1 indicated she went into the resident's room at approximately 10:30 PM and removed an empty cup the resident had in his/her hand however she could not verify that the patient was breathing as she did not pay attention to his/her respirations at that time. NA #1 stated the cup was easily removed from the resident's hands with no resistance. NA #1 indicated she entered Resident #1's room to perform care between 10:45 PM and 10:50 PM and upon entering the room the resident didn't look right, looked different and was not breathing. NA #1 indicated she called the charge nurse (LPN #1) who immediately saw Resident #1 and then exited the room stating she was going to call the nursing supervisor. NA #1 indicated the nursing supervisor (RN#1) responded, entered Resident #1's room and requested NA #1 clean the resident up as he/she had passed away. Interview with MD #1 (Medical Director) on [DATE] at 10:15 AM indicated he saw Resident #1 on [DATE] and [DATE] and the resident's overall condition and baseline were 'not the best but his assessment was Resident #1 was not in imminent danger of dying'. In an interview with RN #1 on [DATE] at 11:48 AM, RN #1 indicated he was called to Resident #1's room at approximately 10:50 PM on [DATE] and found LPN #1 and NA #1 standing by the door and he was told that Resident #1 had expired. RN #1 indicated his assessment noted Resident #1 was cold, pale, with no carotid pulse and fixed pupils with no movements. RN #1 indicated he did not start CPR, did not call a code and did not call 911 as it was 'unethical and disrespectful to perform CPR on a patient who has been dead for a while'. RN #1 stated he pronounced Resident #1 deceased and notified the on-call Advance Practice Registered Nurse. RN #1 indicated he did not use a light source when he checked the resident' s pupils, he did not attempt to use an Automated External Defibrillator (AED) on the resident and did not determine if the resident had rigor mortis. RN #1 indicated that after the investigation by the facility and his realization of the facility's policies, RN #1 indicated he made a mistake and stated he should have initiated CPR on Resident #1 at the time he assessed the resident. Review of the personnel files of RN #1 and LPN #1 identified both staff had current Basic Life Support (BLS) certification. The facility Staff failed to provide resuscitative measures to Resident #1 with an advance directive that identified the resident desired CPR and pronounced the resident as deceased , without a physician's order, when the resident was assessed as pulseless and not breathing. This resulting in a finding of Immediate Jeopardy. Review of the facility's Emergency Procedure Cardiopulmonary Resuscitation policy directed if an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless: it is known that a DNR order that specifically prohibits CPR and or external defibrillation exist for this individual or there are obvious signs of irreversible death (e.g. rigor mortis). Subsequent to the identification of Immediate Jeopardy by the State agency on [DATE] the facility provided a Plan of Correction to include the education of all staff at the beginning of the shift on providing or withholding resuscitation services and emergency cardiopulmonary resuscitation, mock drill of code blue to be completed by [DATE], code blue drills to be completed on all shifts and weekly audits of advance directives. During the onsite visit on [DATE], the surveyor reviewed the implementation of the revised action plan. The plan included staff re-education on facility policies on Advance Directives, Full code status, Do Not Resuscitate (DNR), and RN may pronounce were completed. Re-education also included information on the role and responsibilities of honoring the residents advanced directives, following the MD/APRN orders, and clinical and legal guidelines related to documentation in the clinical record of a resident with a change in condition. The facility documented the completion of a Code Blue mock drill and daily audits of the electronic medical record (EMR) for residents with acute changes in condition along with new advance directives and changes in code status were initiated. The plan of correction further indicated that audits of EMR documentation will be conducted 5 days/week for one (1) month then weekly times two (2) months, mock drills will be conducted weekly until all scheduled nursing staff had participated, then randomly of each shift for 3 months. Interviews and review of facility documentation validated that substantial compliance was reached effective [DATE] and Immediate Jeopardy has been removed.

Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #56) reviewed for pressure ulcers, the facility failed to provide care according to professional standards to prevent the development of a pressure ulcer. The findings include: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pressure sore risk assessment dated [DATE] identified Resident #56 was bedfast, completely immobile, nutrition was probably inadequate, and friction & sheer was a potential problem. The assessment identified Resident #56 was at significant risk to develop a pressure sore. The annual MDS assessment dated [DATE] identified Resident #56 had moderately impaired cognition, required extensive assistance of 2 staff with bed mobility, dressing and toilet use, was incontinent of bowel and bladder, and was free of pressure ulcers. The care plan dated 12/21/18 identified Resident #56 was at risk to fall related to cognition, impaired mobility and vision impairment. Interventions included to provide current seating system, which includes a tilt in space wheelchair with pressure relief cushion, bilateral leg rests and pelvic positioning belt to increase safety and comfort. Additionally, transfer the resident via a hoyer lift, and provide needed assistance or supervision with mobility and toileting if needed. The care plan identified Resident #56 was noncompliant with daily care needs. Interventions included to discuss objections, reasons, fears, ideas, inform resident about risks of non-compliance, offer alternatives, give positive feedback, accept resident's right to refuse and show respect for decisions. Review of the (MONTH) 2019 documentation survey report v2, (31 days or 93 shifts), for turning and repositioning, 37 shifts lacked documentation that Resident #56 was turned/repositioned, and 23 shifts lacked documentation that Resident #56 was assisted with bed mobility. Review of the (MONTH) 2019 documentation survey report v2, (6 days or 18 shifts), for turning and repositioning, 6 shifts lacked documentation that Resident #56 was turned/repositioned, and 5 shifts lacked documentation that Resident #56 was assisted with bed mobility. A wound assessment, (weekly), dated 2/7/19 identified Resident #56 was identified with a new left buttock stage II pressure ulcer that measured 2.0cm by 1.0cm by 0.1cm. Minimal bleeding was noted, and Triad was applied. A facility acquired pressure ulcer investigation tool dated 2/8/19 identified Resident #56 developed a facility acquired pressure ulcer on the coccyx. Additionally although a turning and repositioning program was in place, it was not done because Resident #56 is non-compliant and refuses. Further, a low air loss mattress was added on 2/8/19. The root cause analysis of the pressure sore development was identified as a general decline, poor oral food and fluid intake and decreased [MEDICATION NAME] level. A nurse's note dated 2/11/19 identified Triad was applied to Resident #56's open area on the left buttocks, and the resident would be seen by the wound nurse tomorrow. A wound assessment, (weekly), dated 2/12/19 identified Resident #56's left buttock stage II pressure ulcer measured 3.5cm by 2.2cm by 0.1cm. Moderate sero sanguineous drainage and the peri skin is dry and intact. Additionally, the treatment was changed to Calcium Alginate Ag, and the note clarified that the area is on the coccyx, not the left buttock as previously documented. Review of the wound physician visit report dated 2/12/19 identified Resident #56 had an acute stage 2 pressure ulcer and initial measurements were 3.5cm by 2.2cm by 0.1 cm with 50% [MEDICATION NAME] with moderate sero-sanguineous drainage, and the peri-wound is dry and intact. Recommendations included Calcium Alginate Ag followed by a dry clean dressing, pressure off loading in bed and frequent incontinent care. A physician's order dated 2/13/19 directed to cleanse the wound on the coccyx with wound cleanser, pat dry, apply Calcium Alginate Ag and cover with a dry clean dressing daily. Additionally, provide the resident with pressure off loading to the coccyx every shift. A wound assessment, (weekly), dated 2/19/19 identified Resident #56's coccyx had deteriorated to an unstageable pressure ulcer that measured 3.0cm by 4.5cm by 0.2cm with 75% slough present. Subsequent to physician notification, a new treatment with Santyl was ordered. Review of facility documentation identified the resident's weight on 3/5/19 was 115.6 pounds. A wound physician report dated 2/19/19 identified an acute unstageable pressure injury obscured full thickness skin and tissue loss and measured 3.0 cm x 4.5 cm x 0.2 cm deep. Observation of Resident #56 on 4/1/19 at 11:55 AM identified the resident positioned in bed on his/her back. Interview and review of facility documentation with the MDS Coordinator, (RN #2), on 4/3/19 at 1:15 PM identified that she was responsible for the development of the resident's care plan and was unable to find a current care plan that addressed preventative measures for skin prior to the development of the stage pressure ulcer on 2/7/19. RN #2 indicated she had resolved the previous at risk skin integrity care plan on 12/18/18 but indicated she should have only eliminated part of the care plan, not the entire skin care plan, and that there was no longer a current care plan for skin integrity until following the development of Resident #56's pressure ulcer on 2/7/19. Subsequently, a care plan was developed on 2/13/19 related to skin integrity. Interview and review of facility documentation with the wound nurse, (RN #3) on 4/3/19 at 1:39 PM identified although the physician was notified of Resident #56's pressure ulcer on 2/7/19 according to the weekly wound assessment, there was no physician's order for the Triad paste. RN #3 indicated an order should have been obtained. Additionally, RN #3 identified that Resident #56's off-loading of the coccyx began on 2/13/19 when the physician wrote the order. Intermittent observations of Resident #56 on 4/4/19 at 9:28 AM to 12:15 PM identified the following: The alternating pressure mattress was set to (Static 325) and was not alternating. Resident #56 was lying on his/her back with pillows on either side, and the head of the bed was elevated. Subsequent observations at 9:47 AM and 10:11 AM identified the resident had not changed position and/or the mattress settings was at Static 325. Observation at 10:40 AM identified a nurse aide was noted in the room with the resident, and at 11:14 AM Resident #56 remained on his/her back, the head of the bed was noted to be lower with pillows on either side of the resident, and the bed setting unchanged. Observation at 12:15 PM identified Resident #56 remained in the same position with no change in the bed setting. Interview and review of facility documentation with the DNS on 4/4/19 at 10:40 AM identified that although there was intermittent documentation that Resident #56 was provided with turning and re-positioning, the DNS was unable to provide evidence that staff provided consistent turning and re-positioning prior to the development of the pressure ulcer on 2/7/19. The DNS identified that the nurse aides should be documenting that the resident was turned and re-positioned every shift per the facility policy. Additionally, the DNS was unable to provide evidence that staff provided Resident #56 education on the need for turning and positioning, and/or that the resident had documented occurrences of refusals. Interview, observation and review of facility documentation on 4/4/19 at 12:20 PM with LPN #1 identified that she was unaware of the settings for the air mattress, but indicated it has been set that way since the resident received the mattress. LPN #1 identified that according to the physician's order, the resident was supposed to be off loaded from his/her coccyx. LPN #1 identified that she was unaware that the resident had not been repositioned off his/her back since 9:28 AM (almost 3 hours earlier) but the resident may have refused as he/she often refuses care. Another nurse aide entered the room and repositioned the resident onto his/her right side. Interview with the resident's assigned nurse aide, (NA #4) on 4/4/19 at 12:23 PM identified that Resident #56 had been cooperative with care and the only thing he/she refused during the shift was mouth care. NA #4 did not identify why the resident had not been re-positioned off his/her back and identified that nurse aides are not allowed to touch the air mattress settings. Interview and review of facility documentation on 4/4/19 at 3:02 PM with MD #1 identified that he was not sure if there needed to be physician directed settings for the air mattress, but that the wound nurse and wound physician would make that determination. Additionally, if there was a physician's order to provide off-loading to the coccyx, although the resident could not be off loaded at all times, MD #1 would expect the facility to follow the orders. Review of the manufacturer's operation manual for the air mattress identified that it is recommended that the patient be repositioned periodically while using the mattress. Adjust the mattress' internal pressure according to the patient's weight by using the weigh button on the control panel. Care givers should always perform a hand check by placing their hands underneath the patient's pelvis area to check if there is sufficient air support to ensure the patient is not bottoming out. The weight range is from 100 to 325 pounds. Alternating mode has a cycle time of 10 minutes and the mattress is to be set to 325 pounds during transfers. Review of the pressure ulcer policy identified turning and re-positioning is done at a minimum of every 2 hours. Review of the turning and re-repositioning schedule in bed identified the schedule is designed to maintain skin integrity while in bed, nursing assistants are responsible for tuning and repositioning the resident per the schedule, the staff nurse is responsible for oversight and monitoring and positioning residents on pressure ulcers should be avoided. Although Resident #56 was assessed to be at significant risk to develop a pressure ulcer, required extensive assistance of 2 staff with bed mobility, had a documented general decline, poor oral food/fluid intake, decreased [MEDICATION NAME] level, and a history of refusing turning and re-positioning, the facility failed to ensure staff provided consistent turning and re-positioning, and/or failed to provide Resident #56 education on the risks of non-compliance with turning and re-positioning, and/or failed to offer alternatives and/or failed to document the residents refusals with turning and re-positioning, and/or failed to notify of the physician of the refusals. Additionally, on 2/7/19 when Resident #56 was identified with a new stage II pressure ulcer, the facility failed to obtain an order for [REDACTED]. for the settings. Although Resident #56 weighed 115.6 lbs., intermittent observations on 4/4/19 at 9:28 AM to 12:15 PM identified the mattress was set to static 325, and Resident #56 was not re-positioned off his/her back for almost 3 hours.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #44 and Resident #58) reviewed for accidents, the facility failed to ensure interventions and adequate supervision to prevent falls with a resulting femur fracture, and/or failed to investigate the resident's concern regarding his/her leg getting caught during a Hoyer transfer and/or failed to provide staff with re-education to ensure safe Hoyer transfers which resulted in a [MEDICAL CONDITION]. The findings include: Resident #44's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified Resident #44 had moderately impaired cognition, required extensive assistance with bed mobility, transfers and toilet use, required limited assistance with walking in room, utilized a walker and wheelchair, and had a history of [REDACTED]. a. A reportable event form dated 2/25/18 at 2:00 PM identified Resident #44 had an unwitnessed fall while self-transferring from the wheelchair to the bathroom. Resident #44 sustained no injury. The facility intervention directed to conduct a bowel and bladder diary for 72 hours to re-evaluate elimination patters to establish prompted toileting plan. Interview with the DNS on 4/4/19 at 11:45 AM identified that although the bowel and bladder intervention was placed on the care plan, the diary was never initiated. b. A reportable event form dated 3/10/18 at 5:15 PM identified Resident #44 had an unwitnessed fall when he/she lost his/her balance walking between the recliner chair and the bed. Resident #44 sustained no injury. The investigation identified that the nurse aide did not follow the care card, and the room was identified to be cluttered. Additionally, although Resident #44 had moderately impaired cognition, corrective action included to reinforce teaching the resident to call for assistance. Interview with the DNS on 4/4/19 at 11:45 AM identified that the intervention to address the fall placed on the care plan on 3/12/19 was to conduct a bowel and bladder diary for 72 hours to develop prompted toileting based upon elimination patterns. The DNS identified that the bowel and bladder diary was incomplete, and that the facility did not evaluate the information to determine an outcome and/or make a determination on toileting patterns. c. A reportable event form dated 3/26/18 at 3:20 PM identified Resident #44 had an unwitnessed fall and was found on the floor in the bathroom. Resident #44 sustained no injury. Interview with the DNS on 4/4/19 at 11:45 AM identified that the intervention to address the fall was to toilet the resident on last rounds on the 7:00 AM to 3:00 PM shift. Although written on the reportable event form, the interventions was not placed on the care plan, and staff were not aware of the intervention. d. A reportable event form dated 3/30/18 at 3:20 PM identified Resident #44 had an unwitnessed fall, and found next to his/her roommate's bed. Resident #44 sustained a skin tear to the left forearm and small abrasion. The care plan update included to provide the resident a visual reminder to call for assistance. e. A reportable event form dated 3/31/18 at 11:23 AM identified Resident #44 had an unwitnessed fall and sustained no injury. The care plan was updated to include encouraging the resident to attend activities and encourage call bell use. f. A reportable event form dated 4/18/18 at 11:00 AM identified Resident #44 had an unwitnessed fall and sustained no injury. Interview with the DNS on 4/4/19 at 11:45 AM identified the care plan was updated to include using a visual reminder to call for assistance. The DNS identified that the previous sign, must have been missing so the facility repeated the intervention. g. A reportable event form dated 7/13/18 at 2:15 PM identified Resident #44 had an unwitnessed fall, and was found at the bottom of the recliner by a nurse aide. Resident #44 stated he/she was trying to get up and go to the bathroom. Resident #44 sustained bruises to the left leg, lateral and posterior calf. The intervention included to place Dycem in the recliner chair, and check the resident every 15 minutes. The supervisor's investigation identified that every 15 minute safety checks and alarms were in place. The alarm, however, was placed at an angle where it did not catch the resident's movement. NA #4's statement identified that Resident #44's motion alarm was on. Interview with the DNS on 4/4/19 at 11:45 AM identified the record failed to reflect when the resident had the motion alarm placed, and/or that the motion alarm was identified on the plan of care, and/or that the resident was on 15 minute checks. h. A reportable event form dated 7/19/18 at 5:20 AM identified Resident #44 had an unwitnessed fall and sustained no injury. The report identified the motion sensor did not alarm at the time of the fall, and the care plan was updated to include ensuring placement and function of the motion sensor. i. A reportable event form dated 7/22/18 at 1:45 PM identified Resident #44 had an unwitnessed fall when he/she attempted a self-transfer and sustained pain to the right shoulder and a purpura opened on the left forearm. Interview with the DNS on 4/4/19 at 11:45 AM identified that the care plan was updated to conduct a 72 hour bowel and bladder diary to establish elimination patterns to develop a prompted toileting plan. The DNS identified that the bowel and bladder diary was incomplete, and that the facility did not evaluate the information to determine an outcome and/or make a determination on toileting patterns. j. A reportable event form dated 8/3/18 at 4:00 PM identified Resident #44 had an unwitnessed fall when he/she lost his/her balance and was found on the floor. The care plan was updated to include mounting the motion sensor on the wall, and 15 minute checks were continued. k. A reportable event form dated 8/12/18 at 7:45 PM identified Resident #44 had an unwitnessed fall when he/she attempted a self-transfer from the recliner to bed without the use of the walker. Resident #44 hit the back of his/her head on the bedside table, ice was applied and the care card was updated to include putting the resident back to bed early after 7:00 PM. The investigation identified that although the care plan directed the use of a motion sensor, the motion sensor was off. Interview with the DNS on 4/4/19 at 11:45 AM identified that he/she believed that the staff had forgotten to turn the alarm back on. l. A reportable event form dated 8/25/18 at 3:02 PM identified Resident #44 had an unwitnessed fall and was found on the floor. Interview with the DNS on 4/4/19 at 11:45 AM identified that the intervention from 3/26/18 to toilet the resident on last rounds during the 7:00 AM to 3:00 PM shift was never placed on the care plan. Additionally, the DNS identified that the alarm was again in the off position when the resident fell and, according to the nurse aide statement dated 8/26/18, he/she had forgotten to recheck if the alarm was on before leaving the shift on 8/25/18. m. A reportable event form dated 9/27/18 at 2:15 PM identified Resident #44 was witnessed lowering him/herself to the floor. The care plan was updated to offer toileting every hour when awake. The investigation identified that the resident had a tabs alarm and that the resident was identified as disconnecting the alarm. Interview with the DNS on 4/4/19 at 11:45 AM identified she was unaware the resident had a tabs alarm. Additionally, the DNS could not identify documentation of the tabs alarm in the clinical record. n. A reportable event form dated 11/20/18 at 1:45 PM identified Resident #44 had an unwitnessed fall and was found sitting on the bathroom floor. Resident #44 stated he/she slipped when he/she tried to stand up from the toilet. No injury was sustained. Interview with the DNS on 4/4/19 at 11:45 AM identified the care plan was updated to include remaining within eyesight or visualization of the resident in the bathroom after meals. The DNS identified that residents who have alarms and/or are at high risk should not be left alone in the bathroom without staff. o. A reportable event form dated 11/28/18 at 2:00 PM identified Resident #44 had an unwitnessed fall and was found on the floor in the bathroom. The resident was noted to have bitten his/her right inner lip. The care plan intervention to remain with the resident when he/she was in the bathroom was repeated. A statement by NA #5 dated 11/28/18 identified she put the resident on the toilet and left the room. Interview with the DNS on 4/4/19 at 11:45 AM identified NA #5 did not remain with the resident and was in the hallway at the time the resident fell . p. A reportable event form dated 12/6/18 at 10:30 AM identified Resident #44 was witnessed sliding out of the recliner chair onto the floor. Resident #44 was attempting to self-transfer. The care plan was updated to assist the resident back to bed after breakfast. Interview with the DNS on 4/4/19 at 11:45 AM identified although the care plan directed to utilize a motion sensor, it was not in place at the time of the fall because she had done a facility wide alarm reduction project. The DNS identified that the resident no longer had a motion sensor at the time, but could not identify the date of the alarm removal. q. A reportable event form dated 1/16/19 at 6:30 AM identified Resident #44 had an unwitnessed fall and was found on the floor, lying on his/her right side under the bedside table against the wall next, with his/her head on the legs of the bedside table. The care plan was updated to include keeping the bed in low position. The resident had a full range of motion in all four extremities with some discomfort of the left hip. A left hip x-ray at the facility on 1/16/19 identified a left subcapital femur fracture with minimal displacement and angular deformity. The resident was sent to the hospital and underwent surgery to repair the femur fracture. A statement by NA #6 dated 1/16/19 identified Resident #44 was a little bit agitated/restless when he/she rang and wanted to get up but was not steady so NA #6 provided the resident a bed pan and removed it when the resident was done. NA #6 indicated the resident was unstable to walk. The documentation failed to reflect that NA #6 notified the charge nurse that Resident #44 was agitated/restless and/or not steady to walk. Interview with the DNS on 4/4/19 at 11:45 AM identified between 2/16/18 through 1/16/19, 11 months, Resident #44 had a total of 17 falls, and on 1/16/19 fell and sustained a left [MEDICAL CONDITION]. Additionally, the clinical record failed to reflect when the resident's motion sensor was removed. Additionally, the DNS identified that the resident had changed rooms since the left [MEDICAL CONDITION] and no longer had an alarm in the room. Although it was requested, the facility failed to provide documentation that 15 minute checks were consistently completed. Although Resident #44 had moderately impaired cognition, poor safety awareness and 16 falls between 2/16/18 through 1/15/19, the facility failed to ensure interventions were implemented correctly and consistently, failed to communicate care plan interventions to staff, and failed to provide adequate supervision to prevent the resident from repeated falls. Subsequently, on 1/16/19, despite being agitated/restless and unsteady, Resident #44 was left in bed without the benefit of supervision and had an unwitnessed fall and sustained a left subcapital femur fracture with minimal displacement and angular deformity which required surgical intervention. 2 Resident #58's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A quarterly MDS assessment dated [DATE] identified Resident #58 had intact cognition, and required total assistance with transfers, toilet use and bathing and had no pain. The corresponding care plan identified a problem with self-care deficit related to MS. Interventions included to provide assistance with care utilizing two staff members and to transfer the resident with a mechanical lift with the assistance to two staff members. A nurse's notes dated 11/17/18 at 9:48 PM identified Resident #58 was complaining of left upper leg pain upon movement. Additionally, the resident stated it (left upper leg) may have been injured during a transfer with Hoyer lift earlier in the day. physician's orders [REDACTED]. A nurse's notes dated 11/18/18 at 7:23 PM identified Resident #58 was complaining of left upper leg pain upon movement and a muscle rub was applied with little effect. A review of the Supervisor/24 hour Resident Status Communication Summary Report dated 11/17, 11/18, 11/19, 11/20, and 11/22/18 identified Resident #58 complained of left upper leg discomfort. Additionally, the Supervisor/24 hour Resident Status Communication Summary Report dated 11/23/18 identified Resident #58 continued to complained of left leg pain and a request was made for the APRN to come and evaluate the resident. An APRN note dated 11/19/18 identified Resident #58's chief complaint was her/his follow up for a vitamin D level. The APRN note also identified Resident #58 complained of left upper leg pain upon movement and indicated his/her left upper leg was caught on the Hoyer lift when he/she was transferred on 11/17/18, and an order was obtained for a muscle rub as needed to area. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A nurse's note dated 11/24/18 at 1:26 PM identified Resident #58 received Tylenol 650mg for complaint of pain. A nurse's note dated 11/24/18 at 7:00 PM identified Resident #58 continues to complain of left femur pain. Tylenol and muscle rub give as needed and a new order for an X-ray was obtained. A radiology report dated 11/24/18 identified Resident #58's left hip x-ray identified a slightly separated comminuted intertrochanteric/sub-trochanteric fracture. A nurse's note dated 11/25/18 at 9:44 AM identified Resident #58 stated that his/her left foot was caught during a Hoyer transfer to bed a few days ago, or it may have occurred 2 ½ weeks ago. Additionally, Resident #58 reported that it happened again yesterday morning (11/24/18). Resident #58 states he/she has pain 10/10 with movement. A reportable event form dated 11/25/18 at 9:00 AM identified Resident #58 reported yesterday (11/24/18) his/her foot was caught on the bottom of the Hoyer lift during a transfer. The report further identified statements from NA #2 and NA #3 that identified during a transfer on 11/24/18 (day shift) Resident #58's foot became stuck under the Hoyer lift. The facility investigation dated 11/25/18 identified NA #3 indicated that while she was assisting NA #2 with the Hoyer lift for Resident #58 from the power chair to the bed, the resident's foot dropped in between the front pedal of the power chair, and the base of the Hoyer lift. Resident #58 said my foot at which time NA #2 and NA #3 stopped the transfer, and attempted to correct the problem. NA #3 indicated after the incident, Resident #58 never said anything else about her/his leg. Further review of the facility investigation dated 11/25/18 identified that on 11/24/18 during a transfer of Resident #58, NA #2 indicated she and NA #3 began to lift Resident #58 up via a Hoyer lift when the resident's foot got stuck under the Hoyer lift. NA #2 and NA #3 stopped the transfer, lowered the Hoyer lift and dislodged Resident #58's foot. NA #2 further indicated she and NA #3 did not inform the nursing staff of what had happened because Resident #58 seem fine after the incident. Interview with Resident #58 on 4/3/19 at 11:38 AM identified he/she sustained an injury during a Hoyer lift transfer on the evening shift on 11/17/18. Resident #58 further indicated that during the transfer the 2 staff members had his/her legs split, each leg on either side of the middle bar (states they should have had my legs together on one side) and when they spun him/her around his/her left leg got caught and twisted on the bar and pulled on his/her hip. Interview with RN #5 and review of facility documentation and Resident #58's clinical record on 4/3/19 at 1:08 PM identified she initiated a reportable event form on 11/25/18 because the resident reported his/her foot had been caught and hurt the day before (11/24/18) during a transfer. RN #5 also indicated she was unable to explain why she was unaware that an incident had occurred earlier in the week (11/17/2018) despite it being documented on the supervisor communication summary report. Interview with NA #2 on 4/3/19 at 1:25 PM identified that during a transfer with a Hoyer lift on 11/24/18, Resident #58's foot got stuck under the bottom of the hoyer Lift and the resident yelled stop. NA #2 further indicated the license staff was made aware that Resident #58 complained of left upper leg pain during the previous week and that she (NA #2) had heard that something happened to the resident on the evening shift the week before. Interview and review of Resident #58's clinical record and facility documentation with the DNS on 4/4/19 at 10:24 AM she indicated that she was unaware that an incident/accident occurred on 11/17/18 and was unable to provide documentation that an incident report and/or an investigation was completed for the 11/17/18 accident. Interview with the Nursing Supervisor, (RN #4) on 4/4/19 at 1:04 PM identified when she became aware that Resident #58 was injured during a transfer (as reported by the resident) she should have initiated a reportable event form and an investigation. RN #4 indicated she should have reported the resident's injury to DNS on 11/17/18 when she became aware of the injury. Interview and review of facility documentation with the ICN/Staff Development nurse (RN #3) on 4/4/19 at 8:37 AM identified facility staff were provided training on 12/1/18 related to the safe transferring (utilizing a hoyer/mechanical lift) of Resident #58 subsequent to the resident's injury and licensed staff was directed to observe the resident's transfer to ensure safety. Interview with APRN #1 on 4/4/19 identified she became aware of Resident #58's complaint of pain (due to a transfer) during morning report on Monday morning 11/19/18. APRN #1 indicated that staff had asked her to look in on Resident #58 for his/her complaint of left hip pain. APRN #1 indicated that on 11/19/18, the resident reported to her that the staff caught his/her leg (twisted up) on the Hoyer lift. APRN #1further indicated that she conducted an assessment on Resident #58 which identified some pain but no visible bruising. Interview and review of the radiology report dated 11/24/18 with MD #3 on 4/4/19 at 11:25 AM indicated Resident #58's comminuted intertrochanteric/subtrochanteric fracture was an acute (new) fracture. MD #3 further indicated that the type of fracture occurs from a rotational/bending type force, not spontaneous and that something happened to the extremity. Interview with RN #4 on 4/4/19 at 1:04 PM indicated that although the resident informed her that he/she had pain in the left upper leg and the pain occurred due to a hoyer lift transfer RN #4 did not follow the facility policy for initiating a reportable event form and investigation because she thought it had occurred on the previous shift and that the day nurse had completed the paper work. Review of the hoyer (mechanical) lift policy procedure identified the hoyer lift will be used to transfer residents who are unable to assist with transfers and that the goal is to safely and comfortably transfer residents and to prevent resident's injuries. The facility failed to protect Resident #58 from injury when they did not investigate the resident's concern regarding his/her leg getting caught during a hoyer transfer on 11/17/18, and subsequently, failed to provide staff with re-education to ensure safe hoyer transfers to prevent injuries. Additionally, on 11/25/18 at 9:44 AM, Resident #58 stated that again, during a hoyer transfer, his/her left foot was caught in the hoyer (11/24/18) and indicated he/she has pain 10/10 with movement. Subsequently, Resident #58 was diagnosed with [REDACTED].

Based on clinical record reviews, observations, review of facility documentation and interviews for one of three sampled residents (Resident #1) who was dependent on staff and required a mechanical lift with transfers in and/or out of the bed and chair, the facility failed to ensure the appropriate number of staff conducted a mechanical lift transfer and/or failed to inspect the lift sling to ensure the sling was intact and had no worn areas, to prevent a fall with injuries. The findings include: Resident #1's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decision regarding tasks of daily life, required total care of two (2) persons with turning side to side while in bed, transfers in and/or out of the bed and chair, was non-ambulatory and weighed 213 pounds. The Resident Care Plan dated 8/1/18 identified the resident was a risk for falls related to forgetfulness and poor safety awareness. Interventions directed the use of a custom wheelchair and a Hoyer lift with the assistance of two (2) persons for all transfers. The nurse aide care card directed Hoyer lift transfers with the assistance of two (2). The nurse's note dated 9/21/18 at 7:00 AM identified while NA #1 was transferring the resident from the bed to the custom wheelchair via a Hoyer lift, the Hoyer sling strap broke causing Resident #1 to fall to the floor. A laceration was noted on the bridge of the resident's nose, behind the head and behind the left ear. Pressure was applied to the nose followed by ice and the resident was transferred to the emergency department for evaluation. Resident #1 returned to the facility at 11:30 AM with two sutures on the bridge of the nose. Neurological assessments were initiated per facility policy and were within the resident's normal baseline. The Fall Investigation Sheet identified the fall was caused by the failure of the Hoyer sling strap. The facility's investigation of the incident identified the 7AM-3PM nurse aide, Nurse Aide (NA) #1, conducted the Hoyer transfer without the assistance of another person as directed in the care plan and nurse aide care card. In an interview conducted by the Administrator on 9/21/18 at 12:36 PM, NA #1 identified that prior to transferring the resident he checked the Hoyer lift but he failed to check the sling to ensure its integrity. NA #1 indicated that although he never had a problem transferring the resident, he should have asked for assistance from another staff member. Interview with the Administrator on 11/28/18 at 9:00 AM identified that the facility had been in the process of replacing all mechanical lifts and slings since (MONTH) (YEAR). The Administrator stated the Hoyer lift and sling utilized with Resident #1 had not been replaced prior to the incident and subsequent to the incident on 9/21/18 Resident #1's sling has been replaced. Interview and review of the clinical record and facility documentation on 11/29/18 at 9:00 AM with the Director of Nursing (DON) identified that prior to 9/21/18 the slings were checked by the nursing and the laundry departments to ensure they were in good repair. The DON stated although the slings were checked, she was unable to provide documentation that reflected when the slings were checked. The DON indicated that NA #1 should have checked the sling prior to use to ensure it was in good working order and he should never attempt a mechanical lift transfer without the assistance of another person. An observation on 11/29/18 at 1:00 PM identified Resident #1 was transferred from the wheelchair to the bed with the assistance of three nurse aides and prior to lifting the resident from the chair, the sling was checked before securing the straps to the lift. Subsequent to the incident, the facility developed and implemented a plan of correction on 9/21/18 and review of the facility's documentation identified the facility was in compliance on 10/1/18 and no further incidences have occurred from 9/21/18 through 11/29/18. The plan of correction was reviewed: -All current mechanical lift slings have been inspected for integrity -Resident #1 had been evaluated and received treatment at the hospital -The defective sling was removed from circulation. -Nursing has been educated on proper safety use of mechanical lifts and slings -Laundry and nursing will be educated to inspect mechanical lift slings weekly while laundering and prior to application for the lift use of transferring residents -Weekly audits will be conducted on mechanical lift sings for ninety (90) days and the results of the audits will be submitted to the Quality Assurance Performance Improvement Committee for review and recommendations. -A new policy and system was developed in the facility's quality assurance program that included a Sling Condition sign off sheet. Mechanical lift competencies were conducted on all nurse aides The Director of Nurses or designee will monitor for compliance.

Based on review of the clinical record, review of facility documentation and interview for one of four sampled residents with a history of falls (R#158) the facility failed to ensure the safety of the resident when attempts were made to reposition the resident. The findings include: Resident # 158's [DIAGNOSES REDACTED]. An annual MDS dated [DATE] identified the resident had short and long term memory problems, was severely cognitively impaired, and required extensive assistance with ADL's. Further review of the MDS identified the resident was not steady moving from a seated to standing position and/or surface to surface transfer and required the assistance of two for transfers. The RCP dated 3/24/12 identified the resident at risk for falls related to lack of safety awareness and impulsivity. Interventions directed the use of a chair alarm and a seatbelt while seated in a wheelchair. Nurse's Note dated 6/21/11 identified that at 2:53 PM the resident was found lying on the floor on his/her left side with a laceration to the left temple area. The resident complained of left hip pain and was transferred to he ER for evaluation. At 8:40 PM the facility was notified that the resident was admitted to the hospital with [REDACTED]. Interview and review of the clinical record on 7/10/12 at 10:15 with the Director of Rehabilitation identified that the last Rehabilitation Screen dated 11/16/10 identified the resident had an existing deficit in balance and transfer ability. Interview,and review of the clinical record, and review of facility documentation on 7/10/12 at 10:30 AM with the DNS identified that while the NA#1 attempted to reposition the resident in his/her wheelchair, NA#1 released the resident's seatbelt and went around the back of the wheelchair, leaving the resident unprotected. Consequently, the resident lurched forward resulting in a fall to the floor. NA#1 received an Employee Warning for failure to follow the care card and apply alarm and lap belt released prior to resident boost. Review of NA# 1's statement dated 6/21/11 identified that when she came around to reposition the resident, she unclipped the seat belt and noticed R#158 was slouched and the resident's bottom was at the edge of the wheelchair. NA#1 indicated that she went around to boost R#158 back in the wheelchair the resident reached forward for the bed and fell forward on her face.

Based on review of clinical record, staff interview, and facility documentation for 2 of 4 residents reviewed for accidents (R#11), the facility failed to ensure that appropriate supervision was provided to a resident at high risk for falls, and/or failed to maintain the environment in a hazard free manner. The findings include: 1. Resident #11's [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident with impaired cognition, required extensive assist with transfers, toilet use, and personal hygiene, and had unsteady balance while walking, moving from a seated position to a standing position, and with transfers. A care plan dated 2/21/11 identified a risk for falls due to an impaired sense of balance and unsteady gait. Interventions included to provide needed assistance or supervision with mobility and toileting if needed. Review of facility documentation dated 2/23/11 at 6:00 PM identified NA#1 assisted R#11 to the bathroom, and closed the door leaving it slightly open. Moments later, NA#1 heard a thump and found the resident on the floor complaining of left hip pain. R#11 was sent to the hospital for evaluation and was identified with a left hip fracture. Review of nursing notes from 2/17/11 through 2/23/11 identified R#11 was exhibiting more confused behavior, and was attempting to self transfer out of bed and chair. Interview with NA# 1 on 6/2/11 at 2:30 PM identified R#11 had poor safety awareness and frequently would attempt to get out of the bed, and chair unassisted. NA#1 further indicated R#11 utilized a chair alarm while in the wheelchair, and a pressure alarm while in bed. On 2/23/11, NA#1 transferred R#11 to the toilet. He closed the door leaving it open a crack, and while he was talking with R#11's roommate, he heard a thump and found R#11 on the bathroom floor complaining of left hip pain. Interview and review of the clinical record with RN#2, the 3-11 PM supervisor, on 6/2/11 at 2:45 PM indicated that R#11 was confused and required an alarm sensor in the chair and bed due to the resident's poor safety awareness. RN#2 further indicated the resident should not have been left alone on the toilet. 2. A tour of the facility on 6/6/11 at 9:35 AM with the ESD identified the following: a. Adjacent to the A/B wings nurses station the corner wall paper guard was noted damaged and missing the bottom (approximately.) 2 feet. The edges were noted exposed and sharp. b. Hallway side rail in B-wing noted with sharp and exposed edges. c. Base molding on the B -wing hallway side of the nurses station noted dislocated from the wall into the hallway. d. The nurses station B-wing side counter wall corner (at entrance) noted damaged and lifted laminate with exposed and sharp edges.