Every finding on record at Noble Horizons

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was treated with respect and dignity after a fall. The findings include: Resident #1 was admitted with diagnoses that included dementia. A resident care plan (RCP) dated 12/18/2025 identified Resident #1 was at risk for falls and required assistance for activities of daily living (ADL). Interventions included to anticipate Resident #1's needs and contact guard assist of two (2) for transfer. A significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/10/2026 identified Resident # 1 had a Brief Interview for Mental Status (BIMS) score of four (4), indicated he/she had severe cognitive impairment, was dependent for personal hygiene, bed mobility and for transfer, and had an indwelling catheter to drain urine. A facility reportable event (RE) dated 3/25/2026 at 9:30 AM identified the DON had received a statement via email from RN #1 (the 3 to 11 PM supervisor) who expressed concern that on 3/24/2026 at 10:00 PM NA #1 had stated I hope you learned your lesson and was laughing at Resident #1 after Resident #1 had fallen. A RE summary dated 4/1/2026 identified on 3/24/2026 at 10 PM, indicated that RN #1/supervisor was on the phone when he heard NA #1 making a comment If you keep leaning forward, I am going to let you fall. After a loud noise, RN #1 went out and observed Resident #1 on the floor and NA #1 laughed. Resident #1 had no recollection of events leading up to fall or interaction with staff after the fall. After the fall, NA #2 and NA #3 observed NA #1 laughing at Resident #1's fall and had notified the RN #1 of their concerns. The investigation determined the allegation was unsubstantiated; the resident was unharmed and not affected by this interaction and NA #1 was reeducated to professionalism in the workplace and proper communication/dialogue with residents. Interview and review of facility documents with NA #1 on 4/23/2026 at 10:16 AM identified she was assigned to Resident #1 on 3/24/2026 on the 3:00 to 11:00 PM shift. Resident #1 was fidgeting and staff kept him/her up in the wheelchair by the nurse's station to monitor. Resident #1 kept leaning forward in the wheelchair, but did not follow NA #1's directions and NA #1 got up and went behind Resident #1 to attempt to reposition Resident #1 in the wheelchair. Resident #1 leaned too far forward and fell to the left onto the floor. NA #1 stated Resident #1 was too big for her to reposition alone and she did not call for assistance. NA #1 denied telling Resident #1 that she would let the resident fall or hoping he/she learned his/her lesson, and denied laughing after the fall occurred. Interview and record review with NA #3 on 4/23/2026 at 11:29 AM identified on 3/24/2026 she observed Resident #1 on the floor and NA #1 was laughing, and NA #1 stated Resident #1 leaned too far forward and fell out of the wheelchair. NA #3 stated she told NA #1 that it was not funny and to stop laughing. Interview with NA #2 on 4/3/2026 at 2:17 PM identified on 3/24/2026 she observed Resident #1 on the floor and she saw NA #1 was laughing. When NA #2 asked NA #1 what was going on, NA #1 responded Resident #1 had fallen out of the wheelchair and NA #2 told NA #1 that making fun of the situation didn't help. Interview and record review with the DON on 4/23/2026 at 1:02 PM identified RN #1 reported she heard NA #1 say to Resident #1, If you keep leaning forward, I'm going to let you fall. RN #1 reported he then heard a loud noise and then heard NA #1 say I told you before. RN #1 then observed Resident #1 on the floor and NA #1 was observed in a reclined position with her feet elevated and did not appear to have made any attempt to prevent Resident #1's fall. NA #1 laughed following the incident and another NA responded, That's not funny. NA #1 then responded to Resident #1 stating I hope you learned your lesson. The DON stated the comments and laughing at a resident after a fall was disrespectful, and NA #1 should not have responded in that manner. Although attempted, RN #1 and LPN #1 (charge nurse) were unavailable for interview during survey. The facility's Resident [NAME] of Rights dated 6/3/2003 directed in part, that residents have the right to be treated with consideration, respect and full recognition of their dignity and individuality.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure staff reported an allegation of mistreatment timely. The findings include: Resident #1 was admitted with diagnoses that included dementia. A resident care plan (RCP) dated 12/18/2025 identified Resident #1 was at risk for falls and required assistance for activities of daily living (ADL). Interventions included to anticipate Resident #1's needs and contact guard assist of two (2) for transfer. A significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/10/2026 identified Resident # 1 had a Brief Interview for Mental Status (BIMS) score of four (4), indicated he/she had severe cognitive impairment, was dependent for personal hygiene, bed mobility and for transfer, and had an indwelling catheter to drain urine. A facility reportable event (RE) dated 3/25/2026 at 9:30 AM identified a Class B (abuse) event occurred. The RE indicated on 3/24/2026 at 10:00 PM there was an allegation of mistreatment, and the DON was not notified until she received a statement via email from RN #1 (the 3 to 11 PM supervisor) on 3/25/2026 at 9:30 AM. The email identified a concern that on 3/24/2026 at 10:00 PM NA #1 had stated I hope you learned your lesson and was laughing at Resident #1 after Resident #1 had fallen. A RE summary dated 4/1/2026 identified on 3/24/2026 at 10 PM, indicated that RN #1/supervisor was on the phone when he heard NA #1 making a comment If you keep leaning forward, I am going to let you fall. After a loud noise, RN #1 went out and observed Resident #1 on the floor and NA #1 laughed. Resident #1 had no recollection of events leading up to fall or interaction with staff after the fall. After the fall, NA #2 and NA #3 observed NA #1 laughing at Resident #1's fall and had notified the RN #1 of their concerns. The investigation determined the allegation was unsubstantiated; the resident was unharmed and not affected by this interaction and NA #1 was reeducated to professionalism in the workplace and proper communication/dialogue with residents. Interview and record review with the DON on 4/23/2026 at 1:02 PM identified she did not receive the email until the morning of 3/25/2026 about 9:30 AM (11 hours and 30 minutes after the incident was reported to have occurred). Upon reading the email, the DON immediately implemented the facility's abuse policy including suspending NA #1, and reporting the allegation to local and State authorities, the provider and family as required and initiated an investigation. The DON stated she did not know why RN #1 did not report the concerns when it occurred, and it should have been reported immediately. Although attempted, an interview with RN #1 was unable to be obtained during survey. The facility's Abuse policy dated 6/6/2024 directed in part, reports of alleged abuse by a resident or family member will be immediately reported to the DON, ADON, Administrator and/or supervisor. Verbal abuse was defined as the use or oral, written or gestured language that willfully includes disparaging and derogatory terms to the resident or within hearing distance. Examples include but are not limited to threats of hard and saying things to frighten a resident.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure repositioning was provided safely and adequate supervision was provided to prevent a fall. The findings include: Resident #1 was admitted with diagnoses that included dementia. A resident care plan (RCP) dated 12/18/2025 identified Resident #1 was at risk for falls and required assistance for activities of daily living (ADL). Interventions included to anticipate Resident #1's needs and contact guard assist of two (2) for transfer. A significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/10/2026 identified Resident # 1 had a Brief Interview for Mental Status (BIMS) score of four (4), indicated he/she had severe cognitive impairment, and was dependent for personal hygiene, bed mobility, moving side to side, and for transfers, and had a foley catheter for urinary drainage. Further, the MDS indicated Resident #1 was 67 inches (5 foot, 7 inches) tall and weight 199 pounds. A facility reportable event (RE) dated 3/24/2026 at 9:30 AM identified Resident #1 had a fall. Resident #1 was seated at the nurse's station with NA #1 seated next to him/her due to fidgeting behaviors. Resident #1 kept sliding forward in the wheelchair and leaning forward. RN #1 reported he heard NA #1 say to Resident #1, If you keep leaning forward, I am going to let you fall. NA #1 reported I got up to help him/her move back, but he/she just kept leaning forward. I was trying to hold him/her up while trying to pull Resident #1 back, but she/she was too heavy to move alone. Resident #1 fell forward and to the left side into a door headfirst. RN #1 was notified, and an assessment was completed. No injury was noted from the fall. A RE summary dated 4/1/2026 identified on 3/24/2026 at 10 PM, indicated that RN #1/supervisor was on the phone when he heard NA #1 making a comment If you keep leaning forward, I am going to let you fall. After a loud noise, RN #1 went out and observed Resident #1 on the floor and NA #1 laughed. Resident #1 had no recollection of events leading up to the fall or interaction with staff after the fall. After the fall, NA #2 and NA #3 observed NA #1 laughing at Resident #1's fall and had notified the RN #1 of their concerns. NA #1 explained she was sitting with two residents who were both trying to stand and both residents had been recently toileted. NA #2 and NA #3, the other NAs on the unit, were attending to another resident. Resident #1 kept sliding forward in her/his wheelchair and leaning forward. NA #1 attempted to redirect Resident #1 to not lean forward and to slide back in the wheelchair. NA #1 got up to try to help him/her move back, but Resident #1 just kept leaning forwards. NA #1 attempted to hold Resident #1 up while trying to pull him/her back, but Resident #1 was too heavy for NA #1. Resident #1 fell forward and to the left side into the door headfirst. Interview and review of facility documents with NA #1 on 4/23/2026 at 10:16 AM identified she was assigned to Resident #1 on 3/24/2026 during the 3:00 to 11:00 PM shift, and due to Resident #1's continued fidgeting, he/she was in a the wheelchair by the nurse's station. Resident #1 kept leaning forward in the wheelchair and seemed to be focused on the urinary catheter. NA #1 redirected Resident #1 multiple times to sit further back in the chair and to sit up. NA #1 stated the foley catheter was positioned correctly. At around 10:00 PM, NA #1 was sitting next to Resident #1, but when Resident #1 did not respond to directions to sit up or move back in the wheelchair, NA #1 got up and went behind Resident #1 to attempt to assist Resident #1 to mover her/his bottom to the back of the wheelchair. NA #1 stated Resident #1 was too far forward and fell to the left onto the floor and hit his/her head on the door. NA #1 then called for assistance. NA #1 stated Resident #1 was too big for her to reposition by herself and she did not call for assistance to reposition Resident #1. NA #1 stated she should have asked another staff member to assist her to reposition Resident #1, and she should not have tried to reposition Resident by herself. Interview failed to identify why NA #1 did not request assistance to reposition Resident #1, and failed to identify why NA #1 was sitting in a reclined position next to Resident #1 with her feet elevated after Resident #1 fell. Interview and record review with NA #3 on 4/23/2026 at 11:29 AM identified for NA #1 did not ask for assistance prior to attempting to reposition Resident #1 in the wheelchair on 3/24/2026. Interview with NA #2 on 4/3/2026 at 2:17 PM identified NA #1 did not ask for assistance prior to Resident #1's fall on 3/24/2026. Interview and record review with PT #1 on 4/23/2026 at 3:15 PM identified if Resident #1 was leaning too far forward, and was not responding to staff directions, two (2) staff were required to reposition him/her in the wheelchair. Interview and record review with the DON on 4/23/2026 at 1:02 PM identified Resident #1 required two (2) staff assistance for repositioning. On 3/24/2026, at about 10 PM, Resident #1 was leaning forward in the wheelchair and sliding, and NA #1 attempted to reposition Resident #1 without obtaining any additional staff assistance. RN #1 (shift supervisor) reported was in his office when he heard NA #1 say to Resident #1, If you keep leaning forward I'm going to let you fall. He then heard a loud noise and heard NA #1 state I told you before. Upon exiting the office, he observed Resident #1 on the floor. NA #1 was observed in a reclined position with her feet elevated and did not appear to have made any attempt to prevent Resident #1's fall. NA #1 laughed following the incident and another NA responded, That's not funny. NA #1 then responded to Resident #1 stating I hope you learned your lesson. The DON stated NA #1 should have requested assistance to reposition Resident #1, especially if Resident #1 had not been responsive to redirection and NA #1 would not have been able to reposition Resident #1 alone safely. Interview failed to identify why NA #1 did not request assistance to reposition Resident #1, and failed to identify why NA #1 was sitting in a reclined position next to Resident #1 with her feet elevated after Resident #1 fell. The facility Fall prevention policy dated 1/2020 is the policy of the facility to provide residents with a safe environment eliminating risk factors that led to a fall. A person-centered approach was used for each resident based on a thorough assessment of fall risk factors.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include documentation of an RN assessment after a fall. The findings include: Resident #1 was admitted with diagnoses that included dementia. A resident care plan (RCP) dated 12/18/2025 identified Resident #1 was at risk for falls and required assistance for activities of daily living (ADL). Interventions included to anticipate Resident #1's needs and contact guard assist of two (2) for transfer. A significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/10/2026 identified Resident # 1 had a Brief Interview for Mental Status (BIMS) score of four (4), indicated he/she had severe cognitive impairment, and was dependent for personal hygiene, bed mobility, moving side to side, and for transfers, and had a foley catheter for urinary drainage. Further, the MDS indicated Resident #1 was 67 inches (5 foot, 7 inches) tall and weight 199 pounds. A facility reportable event (RE) dated 3/24/2026 at 9:30 AM identified Resident #1 had a fall. Resident #1 was seated at the nurse's station with NA #1 seated next to him/her due to fidgeting behaviors. Resident #1 kept sliding forward in the wheelchair and leaning forward. RN #1 reported he heard NA #1 say to Resident #1, If you keep leaning forward, I am going to let you fall. NA #1 reported I got up to help him/her move back, but he/she just kept leaning forward. I was trying to hold him/her up while trying to pull Resident #1 back, but she/she was too heavy to move alone. Resident #1 fell forward and to the left side into a door headfirst. RN #1 was notified, and an assessment was completed. No injury was noted from the fall. A RE summary dated 4/1/2026 identified on 3/24/2026 at 10 PM, indicated that RN #1/supervisor was on the phone when he heard NA #1 making a comment If you keep leaning forward, I am going to let you fall. After a loud noise, RN #1 went out and observed Resident #1 on the floor. Resident #1 had no recollection of events leading up to the fall or interaction with staff after the fall. RN assessment was completed and no injuries were identified. Although attempted, an interview with RN was unable to be completed during the survey. Interview and record review with the DON on 4/23/2026 at 1:02 PM identified Resident #1 required two (2) staff assistance for repositioning. On 3/24/2026, at about 10 PM, Resident #1 was leaning forward in the wheelchair and sliding, and NA #1 attempted to reposition Resident #1 without obtaining any additional staff assistance and Resident #1 fell to the floor. The DON stated that RN #1 completed an RN assessment after the fall, but did not document the assessment. The DON stated she did not know why RN #1 did not document his assessment, and she expected staff to document assessments in the medical record. The policy Nursing Documentation dated 3/4/2014 directed in part, to complete nursing documentation to reflect the resident's assessment.

Based on facility documentation review, staff interviews, and observations, the facility failed to develop and implement a water management plan to prevent, identify, and mitigate Legionella contamination in the facility water system, resulting in Immediate Jeopardy to resident health and safety. Water testing performed in June 2024 and June 2025 identified multiple locations positive for Legionella, including Legionella pneumophila serogroups 1-14, at levels requiring immediate action in a high risk healthcare setting; however, facility leadership did not recognize the significance of the results, did not implement corrective measures, and did not communicate findings to the Infection Preventionist or Medical Director. During this period, 26 residents were diagnosed with pneumonia without evaluation for possible Legionella exposure. The facility's failure to establish a water management plan or to respond to known contamination created a likelihood of serious harm to residents, resulting in findings of Immediate Jeopardy. The findings include:A tour of the facility and review of facility documentation on 2/26/26 at 10:12 AM, identified the second floor consisted of 4 resident units, with one unit not in use, and a census of 61. Review of the facility's water sampling test results collected from June 2024 to June 2025 noted the following: a. Water sample report dated 6/3/24 at 9:00 AM identified water samples were collected from three (3) locations and revealed the Exam Room was positive for Legionella (non-Legionella pneumophila) with a result of 2 Colony Forming Units per milliliter (CFU/mL) and the Chapel was positive for Legionella pneumophila (serogroups 1–14) with a result of 96 CFU/mL. b. Water sample report dated 6/30/25 at 10:40 AM identified water samples were collected from three (3) locations and revealed the Dining room was positive for Legionella (non-Legionella pneumophila) with a result 62.5 CFU/ml and the Chapel was positive for Legionella pneumophila (serogroups 1–14) with a result of 148.5 CFU/mL. Interview with the Director of Physical Plant on 2/26/26 at 11:10 AM identified he had been employed at the facility since 2018. The Director of Physical Plant identified the facility did not have a water management plan and indicated he was not aware a water management plan was required. The Director of Physical Plant identified he was responsible for reviewing the water sample results. The Director of Physical Plant indicated he reviewed the water sample lab reports for June 2024 and June 2025 and noted that 2 of 3 water samples were positive for Legionella in both reports. The Director of Physical Plant indicated that because the results were not that high, he believed there was no Legionella growth in the water. The Director of Physical Plant identified he assumed the laboratory would have notified him if Legionella was present in the water. The Director of Physical Plant identified he did not do anything about the positive water sample results in June 2024 or June 2025. Interview with the Administrator on 2/26/26 at 11:40 AM identified he had been employed at the facility since 2018. The Administrator identified that the facility did not have a water management plan and he was not aware that one was required. The Administrator identified although the Director of Physical Plant shared the last annual water testing results, he was not aware they were abnormal results. Interview and review of facility documentation with RN #2 (Infection Preventionist) on 2/26/26 at 2:28 PM identified from 6/1/26 through 2/26/26 there were 26 residents with pneumonia. RN #2 identified she was not aware of the positive water samples. Interview with the Medical Director on 2/26/26 at 3:22 PM identified he was not aware the facility water samples in June 2024 and June 2025 were positive for Legionella or that the facility did not have a water management plan. The Medical Director identified he would have expected the facility to have a water management plan in place. Subsequent to the surveyor's inquiry, the Medical Director indicated that any resident with respiratory symptoms will be tested for Legionella using a urine antigen test. According to the Centers for Disease Control and Prevention (CDC) there is no safe level of Legionella, any result over 1 CFU/mL is considered high in a high-risk setting like a nursing home. Water sampled detected with Legionella pneumophila (serogroups 1–14) and non-Legionella pneumophila indicate that the water system is colonized with bacteria capable of causing severe respiratory illness, particularly in vulnerable elderly residents. CDC guidelines for healthcare facilities (including nursing homes) the detection of Legionella in water samples requires an immediate, structured response, particularly because these levels exceed the 1 CFU/mL threshold. Although requested a facility water management plan was not provided. The Immediate Jeopardy Template was presented to the Administrator on February 26, 2026, at 2:51 PM for F880 -Infection Control for failure to develop and implement a water management plan to prevent the potential development of Legionella related illnesses and failed to address high levels of Legionella species in the water constituted Immediate Jeopardy to the health and safety of the residents. An immediate removal plan was requested by the state agency. The facility submitted a removal plan on February 26, 2026 that included: -Remove all water pitchers from resident rooms -Ice has been purchased and will be utilized in-house -Remove ice from all machines, secure empty machines, tag out -Close off sink in Chapel, turn off water, and tag out -Dining room kitchen sinks to be secured and tagged out on the empty unit -Bottled water to be distributed to each resident -Temporary discontinuation of all showers. -Distribute hand sanitizers to units, fill wall mounted sanitizers -FCS to be on site this afternoon by 330-4pm to implement water management plan -Medical Director has been informed. -One resident currently has respiratory symptoms in -house and Dr. has ordered an antigen urine test -FCS will guide us for filters for all sinks/shower heads upon arrival -All shower heads will have filters and the faucets tested positive will also get filters. The immediate action plan was accepted by the state agency during an on-site visit on February 26, 2026, at 3:53 PM. Review of facility documentation, staff interviews, and observations validated the implementation of the removal plan. The Immediate Jeopardy was removed on 2/27/2026 at 10:00 AM

Based on record review, staff interviews, and facility documentation, the facility failed to ensure Resident #27 received the level of assistance identified in the care plan to prevent accidents, when staff provided only one person's assistance during a transfer despite the resident's assessed need for two person assistance. The MDS, therapy caregiver training, and the resident's care plan all directed that two staff assist with transfers using a walker; however, on 8/17/25 NA #1 attempted to transfer the resident alone, resulting in the resident losing balance, falling, and sustaining a right clavicle fracture that required pain management, orthopedic follow up, sling immobilization, and a change to mechanical lift transfers. The findings include:Resident #27 had diagnoses that included a stroke with memory, speech, and language deficits, dementia, and abnormalities of gait and mobility. The quarterly MDS assessment dated [DATE] identified Resident #27 had moderately impaired cognition, was dependent on staff for toileting and showering, and required maximum assistance with personal hygiene, dressing, and transfers.The RCP dated 7/15/25 identified Resident #27 was dependent on staff for transfers, with interventions that directed two (2) staff to assist with transfers using a rolling walker.Review of Resident #27's caregiver training record dated 7/15/25 identified Resident #27 required the assistance of two (2) staff with use of a walker for ambulating and transfers and for bed mobility, dressing, and bathing. NA #1 did not sign the training record.Review of the Facility's Accident and Incident Form dated 8/17/25 at 7:00 AM identified Resident #27 required the assistance of 2 staff for transfers and ADLs. On 8/17/25, during morning care NA #1 assisted Resident #27 to stand from the bed while pulling up his/her pants, reaching for the wheelchair, without the assistance of another staff member. Resident #27 subsequently fell hitting his/her head on the wall. Review of RN #7's nurse's note dated 8/17/25 at 7:14 AM identified she responded to Resident #27's room after a fall. NA #1 assisted Resident #27 to stand from the bed with one hand on Resident #27's arm; as she reached for the resident's pants, Resident #27 tilted to the right and fell into the wall near the doorway. Resident #27 hit the right side of his/her forehead and appeared to land on his/her right shoulder. Resident #27 did not lose consciousness and denied head or shoulder pain. Resident #27's hand grasps were equal and strong, arms and shoulders had full range of motion without discomfort, and legs were equal in length, and range of motion was intact. RN #7 indicated MD #2 and Person #2 were notified and no new orders were obtained.A facility written statement by NA #1 dated 8/17/25 identified NA #1 assisted Resident #27 to stand from the bed, pulled up the resident's brief and pants, took a step to turn with one hand on the resident, stepped behind the resident to get the wheelchair, grabbed the back of the resident's pants, and Resident #27 fell to the right side.A nurse's note dated 8/17/25 at 9:54 PM identified Resident #27 was status post fall and neurological assessment was within normal limits. Resident #27 reported right shoulder pain, which was relieved with scheduled Tylenol.A nurse's note dated 8/19/25 at 12:46 PM identified Person #1 requested an X-ray of Resident #27's right shoulder due to right shoulder pain following the recent fall. MD #1 was faxed awaiting response.The physician's order dated 8/19/25 directed an X-ray of the right shoulder and administer Tylenol Arthritis extended release 650 mg every 8 hours.A nurse's note dated 8/20/25 at 3:37 PM identified Resident #27's right shoulder X-ray results were pending.A nurse's note dated 8/21/25 at 4:49 AM identified Resident #27's right shoulder was firm to the touch and slightly swollen. Resident #27 reported tenderness and continued scheduled Tylenol Arthritis.Review of Resident #27's radiology report dated 8/22/25 at 12:28 PM identified a right clavicle fracture.A nurse's note dated 8/22/25 at 12:55 PM identified Resident #27's X-ray results were reviewed with MD #2; new orders were obtained for either an orthopedic consultation or transfer to the emergency room.A nurse's note written by RN #5 (former DNS) dated 8/22/25 at 1:01 PM identified Resident #27's X-ray showed an acute clavicle fracture. MD #2 was notified; he ordered a follow-up with an orthopedic specialist or transfer to the emergency room. Person #2 was notified he/she agreed with an orthopedic follow-up.A nurse's note dated 8/23/25 at 2:49 PM identified Resident #27 was non-weight bearing with the sling in place for a right clavicle fracture. Resident #27 requires assistance from two (2) staff for ADL's and transfers using a mechanical lift. Orthopedic consultation dated 8/25/25 identified Resident #27 was evaluated for a right clavicle fracture and instructed to continue wearing the sling as needed and to use the arm as tolerated. Follow-up X-rays were scheduled in three weeks, with the next appointment on 9/15/25.Interviews with Physical Therapist (PT) #1 and PT #2 on 2/27/26 at 9:50 AM identified therapy had treated Resident #27 before the fall on 8/17/25. PT #2 identified as of 7/15/25, Resident #27 required (2) staff for transfers and standing. PT #2 indicated on 7/15/25 therapy staff educated nursing staff on Resident #27's transfer status. PT #1 identified therapy completes caregiver training forms when a resident status changes, and emails it the Director of Nursing (DNS), supervisor, and care plan committee. PT #2 identified therapy is responsible for ensuring nursing staff receive education and sign the form to confirm they were informed of changes in a resident's level of care. PT #2 identified after the fall on 8/17/25, Resident #27 required a mechanical lift for transfers.Interview RN # 7 on 2/27/26 at 10:13 AM identified on 8/17/25 a nurse aide (NA) #1 was providing morning care and assisted Resident #27 stand from the bed to pull up his/her pants, Resident #27 fell to the right hitting his/her head on the wall. RN #7 indicated NA #1 activated the call light, so she responded to the room. RN #7 identified Resident #27 complained of right shoulder pain; but the resident had a history of right shoulder pain, so she was unsure whether the pain was new. RN #7 indicated Resident #27 could move both arms, but with movement his/her right shoulder was sore. RN #7 identified NA #1 did not follow the plan of care, the resident fell and sustained a clavicle fracture. RN #7 identified NA #1 should have had another staff member assist with the transfer.Interview with DNS on 2/27/26 at 10:39 AM identified she was not the DNS at the facility at the time of the fall. The DNS indicated she reviewed Resident #27's fall investigation and medical record. The DNS identified on 8/17/25, Resident #27 required assistance from two (2) staff for transfers, and NA #1 did not follow the plan of care for transferring, and the resident fell. The DNS identified NA #1 should have had another staff member assist with the transfer. The DNS further identified that she expects that all nurse aides review a resident's plan of care prior to providing care.Although attempted, interviews with RN #5 (prior DNS) and NA #1 were not obtained. Review of the facility Care Giver Training (CGT) Policy identified this will provide recommendations and guidance for activities of daily living status. When a care giver training is provided by rehab the nursing supervisor will update the care plans for the specific care area. Once the CGT has been updated with the care plan and new orders have been written, the supervisor will respond to rehab's email that the care plan was updated.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #97) reviewed for hospitalizations and had multiple hospitalizations, the facility failed to ensure the resident and/or resident representative were provided with the written information regarding the bed hold policy at the time the resident was sent to the hospital and failed to ensure the ombudsman was notified of discharges at least monthly. The findings include:1.Resident #97 was admitted to the facility in November 2023 with diagnoses that included heart failure, dementia, and pneumonia.The annual MDS assessment dated [DATE] identified Resident #97 had severely impaired cognition and was dependent on staff for all activities of daily living.The Resident Care Plan dated 12/11/24 identified Resident #97 as a long-term care resident and had some confusion with interventions that included orient the resident to the facility, staff, and routine.a. The nurse's note dated 2/2/25 at 1:42 PM identified Resident #97 was sitting in the wheelchair with his/her representative. Resident #97's had a temperature of 100.1 degrees Fahrenheit, oxygen saturation of 73% on room air, pale skin, and rhonchi in the left lung. Oxygen was applied and the Advanced Practice Registered Nurse (APRN) was notified. The resident was transferred via ambulance at 2:40 PM. A physician's order dated 2/2/25 directed to transfer Resident #97 to the hospital for evaluation and treatment.Review of the Census Report identified Resident #97 was transferred to the hospital on 2/2/25. Review of the nurse's notes from 2/2/25 through 2/5/25 failed to provide documentation Resident #97 or the resident's representative was provided with the Bed Hold Policy at the time of transfer. Review of social work notes during the same period failed to provide documentation Resident #97 or the resident's representative was provided with the bed hold policy.A nurse's note dated 2/5/25 at 6:30 PM identified Resident #97 was re-admitted to the facility. b. Review of the Census Report identified Resident #97 was transferred to the hospital on 6/10/25. A physician's order dated 6/10/25 directed to transfer Resident #97 to the emergency room for evaluation and treatment.The nurse's note dated 6/10/25 at 7:36 PM identified Resident #97 was admitted to the hospital with a diagnosis of pneumonia.Review of the nurse's notes from 6/10/25 through 6/13/25 failed to provide documentation Resident #97 or the resident's representative was provided with the Bed Hold Policy at the time of transfer. Review of social work notes during the same period failed to provide documentation Resident #97 or the resident's representative was provided with the bed hold policy.Interview with RN #1 (supervisor) on 2/26/26 at 10:05 AM identified she does not provide the bed hold notice at the time of transfer to the hospital. RN #1 indicated that the responsibility belonged to the social worker.Interview and clinical record review with the DNS on 2/26/26 at 10:10 AM identified the supervisor is responsible for completing the paperwork and providing the bed hold notice to the resident or resident representative at the time of transfer. The DNS identified on 2/2/25 and 6/10/25 Resident #97 was transferred to the hospital, and the bed hold notices were not provided to the resident or representative. The DNS was unable to explain why the bed hold notices had not been provided. Interview with SW #1 on 2/26/26 at 10:33 AM indicated that nursing was responsible for giving the bed hold notice to the resident at time of discharge to the hospital and then the next day she is in the facility she will reach out to the resident or resident representative to discuss the bed hold policy. SW #1 identified she had not spoken with Resident #27's representative for the hospitalizations on 2/2/25 and 6/10/25. SW #1 indicated she was not aware she was responsible for sending a copy of the hold notice provided at time of discharge or transfer to the Ombudsman's office in addition to the monthly report. 2. Interview with SW #1 on 2/24/26 at 9:00 AM surveyor requested the Ombudsman's monthly notification records and verification of transmissions from 1/1/25 to 2/24/26. Interview with SW #1 on 2/25/26 at 1:00 PM identified she was responsible for sending the monthly report to the ombudsman's office via the portal monthly. SW #1 indicated that she is aware she was not updating the ombudsman's office of resident discharges monthly but was doing it every few months. SW #1 indicated that she is aware she is not in compliance. SW #1 indicated this week she submitted to the ombudsman portal the last few months of resident discharged . SW #1 indicated that she would provide the verification of transmission to the ombudsman's office.Subsequent to surveyor inquiry, SW #1 provided the Ombudsman Monthly Notification Report that identified the following: Residents discharged from 1/1/25 to 3/13/25 were transmitted to the Ombudsman on 4/9/25. Residents discharged from 4/1/25 to 6/30/25 were transmitted on 7/22/25.Resident discharged from 7/1/25 to 1/31/26 were transmitted on 2/24/26. Review of facility Emergency Transfer, Notice of Bed Hold Policy identified when residents are discharged to the hospital for any reason, they will be notified of the right to reserve their bed and return to the same bed at the facility providing their conditions allow. Upon discharge from the unit the charge nurse or the shift supervisor will remove the Notice of Immediate Emergency Transfer Form and the Bed hold Policy notification form. The charge nurse or shift supervisor will complete the necessary blanks and copy the forms. They will place the original in an envelope and give it to the resident upon discharge to the hospital. If a responsible family member is present the forms may be given to them. A copy of the completed forms will be left for the DNS. The DNS will give it to the Director of social services/admissions. Review of the facility Bed Hold Policy identified the resident name and dated will be placed on the form. It is the responsibility of the facility to inform the resident or resident representative at the time of admission and at the time of hospital transfer, that their bed will be held during their absence from the facility due to hospitalization whenever payment is available to reserve the bed. The form explains if a resident is private pay versus Medicaid regarding payment for holding the bed. Then a representative from the facility has to sign the form. Review of facility Notice of Immediate Emergency Transfer Form identified the resident is being transferred to (a blank line to fill in hospital name) hospital date (a blank line to fill in the date). The immediate transfer is being made for your welfare to meet the residents' needs, which requires care at the hospital. The law requires we give the residents this notice. You are also receiving notice about the facility policy to hold your bed while you're at the hospital. Although requested, the ombudsman notification of discharges policy was not provided.

Based on review of the clinical record, facility documentation, facility policy, and interviews for five (5) of fifteen (15) residents ( Resident #4, Resident #47, Resident #58, Resident #68, and Resident #79) reviewed for resident assessment, the facility failed to complete comprehensive assessments within 14 days after admission and at least annually for each resident. The findings include:1.Resident #4 was admitted with diagnoses that included presence of right artificial knee joint, age related cognitive decline, diabetes mellitus, and hypertension.The MDS status report identified the 5-day Minimum Data Set (MDS) assessment for Resident #4, with an Assessment Reference Date (ARD) of 9/9/2025, was completed and submitted on 2/2/2026. The MDS assessment was 185 days late.2. Resident #47 was admitted with diagnoses that included dementia and heart failure.The MDS status report identified the admission the 5-day MDS assessment for Resident #47, with an ARD of 12/8/2025 was documented completed on 2/19/2026 and submitted on 2/20/2026. The MDS assessment was 123 days late.3.Resident #58 was admitted with diagnoses that included cancer of the digestive system and chronic pain.The MDS status report identified the admission MDS assessment for Resident #58, with an ARD of 9/18/2025 was still in process, not yet completed, and as of 2/26/2026 the MDS assessment was 55 days late.4. Resident #68 was admitted with diagnoses that included heart failure, chronic kidney disease, and arthritis.The MDS status report identified an annual MDS assessment for Resident #68, with an ARD of 9/12/2025 was completed and submitted on 11/14/2025 (59 days late).5. Resident #79 was admitted to the facility with diagnoses that included dementia, heart failure, and arthritis.The MDS Status report identified an admission MDS with an ARD of 10/31/2025 for Resident #79 that was identified as finalized. A review of the medical record identified the 10/31/2025 MDS was not signed as completed, and as of 2/26/2026 the MDS assessment was 112 days late.Interview with the LPN #3 (MDS coordinator) on 2/26/2026 at 2:00 PM identified she was responsible for coordinating MDS submissions according to CMS requirements. LPN #3 identified that MDS assessments must be completed no later than three (3) months after the last quarterly assessment, within 14 days of admission, and at least annually and must accurately reflect the resident's status. When asked to provide an MDS submission report LPN #3 identified that most of the identified residents' MDS assessments had not been completed or submitted. LPN #3 indicated a new MDS staff member had recently been hired and she had been doing the best she could.Review of a facility policy titled, Resident assessment dated 2018, directed in part, that a comprehensive, accurate assessment is completed for each resident within 14 days for admission, quarterly and comprehensive assessments. A quarterly update will be completed every 92 days from admission, and an annual update will be completed every 365 days from the comprehensive.

Based on clinical record review, facility documentation review, facility policy review, and interviews for six (6) of fifteen (15) residents (Resident #3, Resident #4, Resident #27, Resident #32, Resident #68, and Resident #75) reviewed for resident assessment, the facility failed to complete quarterly Minimum Data Set (MDS) assessments timely. The findings include: 1.Resident #3 had diagnoses that included stroke and chronic obstructive pulmonary disease (COPD).The Minimum Data Set (MDS) status report identified the quarterly MDS assessment with an Assessment Reference date (ARD) of 12/23/2025 for Resident #3 was still in process and had not yet been completed on 2/26/2026. The last submitted quarterly MDS assessment had an ARD of 9/24/2025. 2. Resident #4 had diagnoses that included presence of right artificial knee joint, age related cognitive decline, diabetes mellitus, and hypertension.The MDS status report identified the quarterly MDS assessment with an ARD of 11/26/2025 for Resident #4 was still in process and had been completed as of 2/26/2026. The last submitted quarterly MDS assessment had an ARD of 9/9/2025. 3. Resident #27 had diagnoses that included displaced fracture of the left femur, dysphagia and stroke.The MDS status report identified the quarterly MDS assessment with an ARD of 11/28/2025 for Resident #27 was still in process and had not been completed as of 2/26/2026. The last submitted quarterly MDS assessment had an ARD of 9/25/2025.4. Resident #32 had diagnoses that included displaced fracture of the left femur and stroke.The MDS status report identified the quarterly MDS assessment with an ARD of 11/03/2025 for Resident #32 was still in process and had not been completed as of 2/26/2026. The last submitted comprehensive 5-day MDS assessment had an ARD of 10/22/2025.5. Resident #68 had diagnoses that included heart failure, chronic kidney disease, and arthritis.The MDS status report identified the quarterly MDS assessment with an ARD of 12/11/2025 for Resident #68 was still in process and had not been completed as of 2/26/2026. The last submitted annual MDS assessment had an ARD of 9/12/2025.6. Resident #75 had diagnoses that included diabetes mellitus, surgical aftercare, following mouth surgery and hypertension.a. The MDS Status report identified a quarterly MDS with an ARD of 8/29/2025 for Resident #75 was completed on 11/14/2025. The last submitted quarterly MDS assessment had an ARD of 6/2/2025. b. The MDS Status report identified a quarterly MDS with an ARD of 11/28/2025 for Resident #75 was still in process and had not been completed as of 2/26/2026. The last submitted quarterly MDS had an ARD of 8/29/2025.Interview with the LPN #3 (MDS coordinator) on 2/26/2026 at 2:00 PM identified she was responsible for coordinating MDS submissions according to CMS requirements. LPN #3 identified that MDS assessments must be completed no later than three (3) months after the last quarterly assessment, within 14 days of admission, and at least annually and must accurately reflect the resident's status. When asked to provide an MDS submission, LPN #3 identified that most of the identified residents' MDS assessments had not been completed or submitted. LPN #3 indicated a new MDS staff member had recently been hired and she had been doing the best she could. Review of a facility policy titled, Resident assessment dated 2018, directed in part, that a comprehensive, accurate assessment is completed for each resident within 14 days for admission, quarterly and comprehensive assessments. A quarterly update will be completed every 92 days from admission, and an annual update will be completed every 365 days from the comprehensive.

Based on a review of the clinical record, facility documentation, facility policy, and interviews for six (6) of fifteen (15) residents (Resident#21, Resident #24, Resident #36, #73, Resident #79, and Resident #87) reviewed for resident assessment, the facility failed to complete and transmit Minimum Data Set (MDS) assessments timely. The findings include:1.Resident #21 was admitted with diagnoses that included heart failure and atrial fibrillation (fast irregular heartbeat).The last submitted MDS assessment for Resident #21 was a 5-day assessment with an ARD of 8/29/2025. Resident #21 had a discharge MDS assessment with an ARD of 9/20/2025 that was still in process and incomplete during the survey on 2/26/2026. Resident #21 was discharged on 9/25/2025 and had not resided in the facility for over five months. 2. Resident #24 was admitted with diagnoses that included rhabdomyolysis (muscle damage releasing toxins into the blood, affecting kidneys) and dysphagia.The last submitted MDS assessment for Resident #24 was a 5-day assessment with an ARD of 8/29/2025. Resident #24 had a discharge MDS assessment with an ARD of 9/20/2025 that was still in process and incomplete during the survey on 2/26/2026. Resident #24 was discharged on 9/20/2025 and had not resided in the facility for over five months.3. Resident #36 was admitted with diagnoses that included endocarditis (heart infection) and heart failure.The last submitted MDS assessment for Resident #36 was a 5-day assessment with an ARD of 9/12/2025. Resident #36 had an MDS with an ARD of 9/16/2025 that was completed on 2/19/2026 and submitted on 2/20/2026 (143 days late).4. Resident #73 was admitted with diagnoses that included joint replacement surgery and bipolar disorder.The last submitted MDS assessment for Resident #73 was a 5-day assessment with an ARD of 10/21/2025. Resident #73 had a discharge MDS with an ARD of 11/23/2025 that was in process and incomplete during the survey on 2/26/2026.5. Resident #79 was admitted to the facility with diagnoses that included dementia, heart failure, and arthritis.The MDS status report identified a death-in-facility MDS assessment for Resident #79 with an ARD of 1/2/2026, marked as finalized. Medical record review on 2/26/2026 identified the MDS assessment had not yet been signed as completed.6. Resident #87 was admitted with diagnoses that included diabetes mellitus, asthma and hypertension.The MDS status report identified Resident #87 had a discharge MDS assessment with an ARD of 9/24/2025 that was in process and not completed as of 2/26/2026.Interview with LPN #3 (MDS coordinator) on 2/26/2026 at 2:00 PM identified she was responsible for coordinating MDS submissions according to CMS requirements. LPN #3 identified that MDS assessments must be completed no later than three (3) months after the last quarterly assessment, within 14 days of admission, and at least annually and must accurately reflect the resident's status. When asked to provide an MDS submission report LPN #3 identified that most of the identified residents' MDS assessments had not been completed or submitted. LPN #3 indicated a new MDS staff member had recently been hired and she had been doing the best she could.Review of a facility policy titled, Resident assessment dated 2018, directed in part, a comprehensive, accurate assessment is completed for each resident within 14 days for admission, quarterly and comprehensive assessments. A quarterly update will be completed every 92 days from admission, and an annual update will be completed every 365 days from the comprehensive.

Based on observation, review of facility documentation, and interview the facility failed to implement a system to consistently and accurately reconcile controlled substances for 2 of 2 medication carts. The findings include:Although requested, the facility was unable to provide the facility monthly or bi-monthly audits of controlled substances for January 2026 or February 2026 and indicated that any previous audits could not be located at time of survey.Interview with the DNS on 2/27/2026 at 10:15 AM identified she has not reconciled any controlled substances or conducted audits since starting 31/2 months ago. The DNS identified she could not locate any bimonthly audits from the past year. The DNS indicated the controlled substance audit process involves counting the controlled substances in the two medication carts and verifying the count matches the controlled substance disposition record (CSDR). The DNS indicated that the pharmacy emailed her audit tools to reconcile and audit controlled substances. The DNS identified that without these audits, the facility cannot verify the accuracy of its controlled substances inventory. The DNS could not explain why the audits had not been completed. Although requested, a facility Controlled Substance Reconciliation and Audit policy was not provided.

Based on a tour of the Dietary Department and Nourishment rooms, review of facility policy, and staff interview, the facility failed to ensure stored food was labeled and dated when opened, expired food was discarded and failed to ensure nourishment refrigerators were maintained in a clean sanitary manner. The findings included:A tour of the Dietary Department on 2/24/26 at 7:40 AM with [NAME] #1 identified:1. Refrigerator #1 was observed to have the following items: a. one hard plastic cup with a lid not labeled but dated 2/20/26 (expired)b. one large pitcher of brown liquid covered with saran wrap not labeled or datedc. one large pitcher with brown liquid not covered, labeled or dated 2. Refrigerator #2 was observed to have the following items:a. 2 cups of yellow liquid not labeled or datedb. one cup of red liquid not labeled or dated 3. Refrigerator #3 was observed to have the following items: a. one large gallon sized plastic clear container covered with saran wrap with what appeared to be peaches dated 2/19/26 (expired)b. one large gallon sized plastic clear container covered with saran wrap with what appeared to be pears dated 2/19/26 (expired)Interview with [NAME] #1 on 2/24/26 at 7:50 AM identified that all food items are required to be labeled and dated. [NAME] #1 identified opened food must be discarded after 3 days. [NAME] #1 indicated she does not know who placed the items into the refrigerators without covering, labeling, or dating them. [NAME] #1 identified because the items were not labeled, or dated, she does not know how long they have been stored. [NAME] #1 identified the dietary staff are responsible for discarding any items found in the refrigerator that have exceeded the 3-day limit.Subsequent to surveyor inquiry, [NAME] #1 discarded the food and drink items that were not labeled and dated. A tour of with the Director of Dietary (DOD) on 2/24/26 at 8:00 AM identified: 4. Nourishment refrigerator #1 was observed to have the following items being stored in the refrigerator and were not labeled, not dated when they were opened, and did not contain an expiration date: a. one yogurt container partially eatenb. Chocolate pudding container (not facility) opened partially eatenc. bottom drawers inside the refrigerator had dried up spilt liquids and food crumbs 5. Nourishment refrigerator #2 was observed to have the following items being stored in the refrigerator and were not labeled, not dated when they were opened, and did not contain an expiration date: a. 3 separate loaves of bread partially usedb. one opened can of soda c. one glass bottle of coconut milk 1/2 full d. one cup of cantaloupe cut up and covered with plastic wrape. a plastic bag with dried cranberries or raisins f. one cup of mixed fruit covered with plastic wrap g. one English muffin h. inside the freezer was a [NAME] candy bar; a paper cup not covered with a frozen yellow liquid frozen. i. the bottom shelf in the freezer had dried brown liquidInterview with DOD on 2/24/26 at 8:10 AM identified she is responsible daily for cleaning and maintaining the nourishment refrigerators and checking that items are labeled and dated. The DOD indicated she had been off for the last 3 days. The DOD identified she would have expected dietary staff to clean the nourishment refrigerators and freezers. The DOD indicated nursing and dietary staff have been educated that all items placed in the nourishment refrigerator must be covered, labeled, dated, and discarded after 3 days. The DOD was unable to explain why the items were not covered, labeled, and dated. Review of the facility Dietary Services Policy identified the dietary aide is responsible to remove all outdated items and rotating items as needed each day when restocking the nourishment refrigerator. Food storage areas shall always be clean. All food must be dated when it is opened and dated when it is stored. The dietary staff for safe food storage will label and date food. The dietary refrigeration inspection log is kept in the kitchen and is completed by the cook. Discarding outdated food will be the responsibility of the cook. Food and beverages brought in from outside sources in the facility will be monitored by the nursing and dietary staff for proper labeling, dating, storage, and discarding of food.Review of the facility Outside Food Policy identified it is the policy of the dietary department to prepare and deliver food safely to our residents, families, and staff. This policy will ensure proper handling, serving and storage of any food items brought into the facility. It is the resident s right to have outside food brought into the facility Food and beverages brought in must be labeled with resident's name, room number, and dated by staff with the current date the item was brought in. All cooked or prepared food brought in for a resident and stored in the facility refrigerators will be dated when accepted for storage and discarded after 72 hours /3 days.

Based on facility documentation review, facility policy review, and interviews for 1 of 3 nurse aides (NA#1), reviewed for In-service training the facility failed to ensure the nurse aide received the required In-service training. The findings include: Review of facility documentation and interview with RN #2, Infection control/staff development nurse, on 2/25/2026 at 2:00 PM identified that all NA's are required to receive a minimum of twelve (12) hours of in-service education annually. RN #2 was unable to locate in-service education for NA #1 for 2024 or 2025 that documented that NA #1 received the minimum 12 hours of Inservice education. RN #2 identified that NA #1's education file lacked documentation of education. RN #2 further stated that she should have ensured all the NAs received the minimum of 12 hours annually and had sent an email to the DNS that NA #1 had not completed the 12-hour requirement each year. She could only locate educational documents for NA #1 from 2016. Interview with the DNS on 2/26/3036 at 10:45 AM identified there was she was unaware that NA #1 had not completed the required education however the expectation was that all NAs should have a minimum of 12 hours of education annually.The facility's policy In-service Education dated 6/16/2021 directed in part that each employee must acquire 12 hours of in-service credit annually. All employees must attend at least one (1) mandatory in-service in the following areas: Infection control, pain, workplace violence, corporate compliance, abuse, neglect prevention, hospice, safety, oral hygiene, choking emergencies, quality improvement, effective communication, dealing with residents with dementia and mental/psychosocial disorders, restraint free environments and cultural diversity. The Facility assessment dated [DATE] directed in part that required in-service ed must be sufficient to ensure the competence of nursing aides but must be no less than twelve (12) hours per year and include dementia training, resident abuse prevention training, cultural competence, identification of changes in condition and providing services to residents with cognitive impairments.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for 2 of 2 sampled residents (Residents #27 and Resident #104) reviewed for Advance Directives, the facility failed to ensure the resident/resident representative were educated and the residents wishes were identified. The findings include1.Resident #27 had diagnoses that included a stroke with memory, speech, and language deficits and dementia. a. A nurse's note dated [DATE] at 4:04 PM identified Resident #27 was admitted to the facility with complaints of weakness to the right side of his/her body. Resident #27 is alert, essentially oriented, but per report he/she has some confusion at night. Review of the nurse's notes and social worker notes dated [DATE] through [DATE] failed to provide documentation that Person #1 (power of attorney) was provided with education on advance directives and that the code status form was signed to identify the resident or resident representative's wishes. Review of the nurse's notes and social worker notes dated [DATE] through [DATE] failed to provide documentation Person #1 was provided with education on advanced directives and that the code status form was signed to identify the resident or resident representative's wishes. b. A physician's note dated [DATE] at 12:15 PM directed Do not Resuscitate (DNR). A nurse's note dated [DATE] at 4:20 PM identified Resident #27 was re-admitted to the facility. Resident #27 was alert, oriented, with confusion. Resident #27's representative was at the bedside.Review of the Advance Directives Consent Form dated [DATE] identified the DNR box was checked off for Resident #27, signed by RN #10, and MD #1. The form further identified MD #1 indicated verbal consent was obtained from Person #1 on [DATE]. The form had not been signed by Resident #27 or Person #1. A physician's order dated [DATE] directed Resident #71's DNR must be renewed annually on the 12th of the month.The APRN note dated [DATE] at 10:28 AM identified Resident #27 is a DNR per chart documentation. The significant change MDS assessment dated [DATE] identified Resident #27 had moderately impaired cognition.Review of the nurse's notes and social worker notes dated [DATE] through [DATE] failed to provide documentation Person #1 was provided with education on advanced directives and that the code status form was signed to identify the resident or resident representative's wishes. The RCP dated [DATE] identified Resident #27 had a stroke with interventions that directed to review code status and advance directives.Interview and clinical record review with DNS on [DATE] at 2:00 PM identified the code status and advance directive form must be signed by the resident or resident's representative within 24 hours of admission or re-admission. The DNS indicated if the resident's representative cannot come to the facility, two (2) nurses may call the representative to verify the resident's wishes, and both nurses must sign the form and document the conversation in a progress note. The DNS stated the APRN or physician is responsible for educating the resident or representative about CPR (cardiopulmonary resuscitation) versus DNR and ensuring they understand the difference. The DNS identified the APRN or physician must then sign the form and document the resident's code status in a progress note. The DNS identified there was no code status documented or signed by Resident # 27 or Person #1 (resident's representative) on the admission dates of [DATE] and [DATE]. The DNS stated that although RN #10 completed the code status form on [DATE]; Resident #27's representative did not sign the form. The DNS identified RN #10 should have presented the form to Person #1 for signature to confirm the DNR code status reflected Resident #27's wishes. 2. Resident #104 was admitted to the facility in [DATE] with diagnoses that included dementia, heart failure, and depression. The RCP dated [DATE] failed to identify a code status or wishes for a code status. Review of the Advance Directives Consent Form dated [DATE] at 12:42 PM indicated verbal consent was obtained from Resident #104's representative. The form was not signed. Review of the physician's and APRN notes dated [DATE] through [DATE] was unable to reflect Resident #104's representative was contacted and provided with education on code status or what Resident #104's wishes were. A physician's order dated [DATE] directed Do not Resuscitate (DNR), Do not intubate (DNI), and RN pronouncement. The quarterly MDS dated [DATE] identified Resident #104 had severely impaired cognition. Interview and clinical record review with RN #1 (day supervisor) on [DATE] at 1:23 PM identified she completes code status only at admission, not on readmission. RN #1 indicated if the resident is confused, she uses the hospital W-10 form to determine code status. RN #1 indicated if the W-10 indicates the resident is a full code or DNR, RN #1 contacts the POA (Power of Attorney) immediately, usually within the same shift, but no later than 24 hours. RN #1 indicated she instructs the resident representative to come in to sign the code status form. RN #1 indicated she recalled a situation where the APRN had to contact multiple resident representatives to obtain signatures on unsigned code status forms. RN #1 identified she signed Resident #104's code status form but did not write the statement regarding code status, as she was not present when the APRN spoke with the resident representative. RN #1 indicated the APRN told RN #1 to sign the form, but RN #1 does not recall the APRN's name, and the APRN's handwriting on the form was not legible. RN #1 indicated she did not recall crossing off CPR multiple times; indicated that the form should have been discarded and a new one completed. RN #1 indicated the APRN wrote the physician order for DNR/DNI, but RN #1 noted there is no progress note from the APRN documenting the change from full code to DNR. RN #1 indicated the APRN just told her to sign it and she did. RN #1 indicated that the APRN wrote on Resident #104's form but she does not recall the APRN's name and it was not legible. RN #1 indicated she does not recall crossing off CPR after it was checked off and then crossed off multiple times with black ink, she indicated that this form should have been discarded and a new form should have been filled out. RN #1 indicated that APRN wrote the physician order for DNR/DNI but does not have progress note written by the APRN who changed Resident #104s code status from a full code (CPR) to a do not resuscitate (DNR). RN #1 indicated that she does not do verbal consent for a code status in person or on the phone, she tells families they have to come in and sign the code status. Interview and clinical record review with DNS on [DATE] at 2:00 PM identified the code status and advance directive form must be signed by the resident or resident's representative within 24 hours of admission or re-admission. The DNS indicated if the resident's representative cannot come to the facility, two (2) nurses may call the representative to verify the resident's wishes, and both nurses must sign the form and document the conversation in a progress note. The DNS stated the APRN or physician is responsible for educating the resident or representative about CPR (cardiopulmonary resuscitation) versus DNR and ensuring they understand the difference. The DNS identified the APRN or physician must then sign the form and document the resident's code status in a progress note. The DNS identified Resident #104's Advance Directives Consent Form was signed by 1 nurse, the APRN crossed off CPR multiple times and did not initial, and form was not signed by the representative. The DNS indicated if the resident is confused, has a representative then 2 nurses will call the resident representative, obtain verbal consent, sign the form, and write a progress note. Review of facility Advanced Directive Policy identified the objective was to comply with the residents' wishes regarding their choice for an advanced directive. When a resident is not competent then a resident representative will be provided with the advanced directive education and form. Upon application to the facility and again upon admission, residents/representatives will be asked if they have or would like to make advanced directives concerning their health care. A DNR and or the RNMP order will be written in the physician's order section of the clinical record and the electronic medical record. CPR will be performed in the absence of a DNR or advanced directives on all levels of care.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident # 71) reviewed for medication administration, the facility failed to ensure the physician and resident representatives were notified of medication omissions. The findings include: Resident #71 had diagnoses that included stoke, Parkinson's disease, depression, and cancer.The Resident Care Plan dated 1/18/25 identified Resident #71 had a diagnosis of Parkinson's disease ( neurological disorder that causes a depletion in circulating dopamine levels in the brain) with interventions that directed to monitor for signs and symptoms of shuffling gait, pill rolling tremors, lip smacking, loss of voluntary movements, blank facial expressions, drooling, difficulty swallowing, feeling weak, easily fatigued, feeling heavy and stiff, and notify physician if any changes.The physician's orders dated 1/19/26 directed to administer Acyclovir (antiviral) 200 milligram (mg) twice a day; Amlodipine (used to lower blood pressure) 5 mg once daily; Calcium Acetate ( used to lower high blood phosphorus) 667 mg 2 tablets three times a day; Eliquis (blood thinner) 5 mg twice a day; Fludrocortisone (used to treat low blood pressure) 0.2 mg once a day; Midodrine (used to treat low blood pressure ) 10 mg three times a day; Potassium Chloride (mineral supplement) 20 milliequivalent (mEq) extended release once a day, Trelegy Ellipta (used to treat chronic obstructive pulmonary disease) inhaler one dose inhaled once daily; Droxidopa ( used to treat orthostatic blood pressure) 200 mg three times a day ; and Sertraline ( used to treat depression) 100 mg daily. The quarterly MDS assessment dated [DATE] identified Resident #71 had intact cognition and required maximum assistance with toileting, dressing, and personal hygiene. Review of the electronic Medication Administration Record dated 2/1/26 to 2/26/26 identified the following medications were omitted:on 2/17/26 Amlodipine (high blood pressure) 5 mg scheduled at 6:00 PM documented as not available and not administeredon 2/18/26 Amlodipine 5 mg scheduled at 6:00 PM documented as not available and supervisor was notifiedon 2/22/26 Droxidopa 200 mg scheduled at 2:00 PM, and 10:00 PM documented as not available and not administeredon 2/23/26 Droxidopa 200 mg scheduled at 8:00 AM, 2:00 PM, and 10:00 PM documented as not available and not administeredon 2/24/26 Droxidopa 200 mg scheduled at 8:00 AM, 2:00 PM, and 10:00 PM documented as not available and not administeredon 2/25/26 Droxidopa 200 mg scheduled at 8:00 AM, 2:00 PM, and 10:00 PM documented as not available and not administeredon 2/26/26 Sertraline 100 mg daily at 8:00 AM identified documented as not available and not administeredon 2/26/26 Droxidopa 200 mg scheduled at 8:00 AM documented as not available and not administeredReview of the nursing progress notes dated 2/1/26 to 2/25/26 were unable to provide documentation to reflect the pharmacy, physician, or resident's representative were notified when Resident #71's medications were not available and were not administered in accordance with physician's orders.Observation of the medication administration with LPN #2 on 2/26/26 at 8:00 AM identified she introduced herself to Resident #71 and asked if he/she was ready for morning medications. LPN #2 went back to the medication cart in the hallway and used hand sanitizer. LPN #2 prepared Resident #71's medications and indicated she did not have available the Sertraline 100 mg daily and did not have the Droxidopa 200 mg available. LPN #2 gave Resident #71 the medications she had prepared. LPN #2 indicated a couple of days ago she notified the supervisor (RN #1) that Resident #71's Droxidopa was not available. Interview with RN #1 on 2/26/26 at 10:40 AM indicated she was not notified by LPN #2 that some of Resident #71's medications were unavailable. RN #1 stated during the medication pass, if a resident's medication is not available, it is the nurse's responsibility to notify her so she can check the emergency medication box to determine whether the medication is available. RN #1 further stated if the medication was still unavailable, she would contact the pharmacy, the physician or APRN, and the resident's representative. RN #1 also stated she would document the issue in the resident's medical record.Subsequent to surveyor inquiry, a nurse's note written by RN #1 dated 2/26/26 at 11:10 AM indicated she contacted the pharmacy and ordered Resident #71's Droxidopa, Potassium, and Sertraline. RN #1 documented MD #1 was notified that Resident #71 had missed 12 doses of Droxidopa 200 mg, 2 doses of Amlodipine 5 mg, and 1 dose of Sertraline 100 mg. RN #1 further documented Resident #71's representative was notified.Interview and review of the clinical record with the Director of Nursing Services (DNS) on 2/26/2026 at 2:00 PM indicated that if a nurse does not have a medication available during the medication pass, the nurse should first check the medication cart and medication room. The DNS stated that if the medication is still not available, the nurse should notify the nursing supervisor so the supervisor can contact the pharmacy to determine when the medication will be available. The DNS further stated the supervisor should then notify the physician to determine whether the medication administration time should be adjusted or if an alternative medication should be ordered. The DNS indicated the supervisor should also notify the resident's representative if a medication is unavailable and inform them of the plan of care. The DNS stated the supervisor must document contact with the pharmacy, the physician, and the resident's representative in the resident's progress notes. Upon review of the clinical record, the DNS stated she was not aware that Resident #71 had not received his/her Parkinson's medication since 2/22/26 and had missed 12 doses. The DNS indicated that on 2/22/26 the nurse or supervisor should have notified the pharmacy, the physician, and the resident's representative and documented these actions in the progress notes. The DNS was unable to explain why on 2/17/26, 2/18/26, 2/22/26, 2/23/26, 2/24/26, 2/25/26, and 2/26/26 she was not aware Resident #71 had omitted medications and was unable to explain why she was not notified the medications were omitted.Interview with MD #1 on 2/26/26 at 2:15 PM identified medications should be administered in accordance with physician/APRN orders. MD identified he was not aware the listed medications were not administered to Resident #71 on 2/17/26, 2/18/26, 2/22/26, 2/23/26, 2/24/26, 2/25/26, and 2/26/26. MD #1 identified he would have expected to be notified, and if he was notified, he would have given additional orders. Review of the facility Notification of Change in Resident Condition Policy identified that the physician and resident's representative will be kept informed of the resident's condition. The person notified, the time, and date of notification will be documented in the clinical record. Review of the facility Medication Administration Policy identified all medications are properly administered and documented on the electronic medication administration record. All medications will be properly administered per the physician/APRN orders. If a medication is unavailable per pharmacy the nursing supervisor or designee will call the physician/APRN and the resident/resident's representative to update them.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents (Resident #10) reviewed for accidents, the facility failed to report an injury of unknown origin. The findings include:Resident #10 was admitted with diagnoses that included dementia, chronic obstructive pulmonary disease (COPD), systemic lupus erythematosus (lupus- a chronic autoimmune disease where healthy tissue was inflamed and damaged) and peripheral vascular disease (arteries in leg and arms become blocked).The RCP dated 9/20/3035 identified Resident #10 was at risk for impaired skin due to fragile skin secondary to long term steroid use with interventions that included to monitor skin with transfers and during care reporting any changes.The significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/6/2025 identified Resident # 10 had a Brief Interview for Mental Status (BIMS) score of 11 indicative of moderately impaired cognition, required substantial assistance for transfer and was dependent on staff for mobility in the wheelchair. The facility incident report dated 12/15/2025 at 5:00 AM identified during care, staff observed a bruise on the right side of Resident #10's face. The bruise measured three (3) centimeters (cm) by 3 cm near the chin line. Resident #10 reported that she/he did not know how it happened. Resident #10 was alert with confusion and oriented to name per baseline. An investigation form completed by RN #4 identified Resident #10 was on Eliquis (blood thinner) as a causative factor, but the actual cause was unknown. The APRN was notified. No additional investigative documents were included in t incident file.A nurse's note dated 12/15/25 at 6:30 AM indicated Resident #10's family was notified of the bruise.A nursing note dated 12/18/25 at 2:23 PM written by RN #1 identified the bruise on Resident #10's right lower face was stable, and the resident reported no pain.A nursing note dated 12/19/25 at 2:39 PM written by RN #1 indicated that an ecchymotic area on Resident #10's right lower face was stable, the skin was intact, and no swelling was noted.Interview with APRN #1 on 2/26/2026 at 2:30 PM identified Resident #10 had fragile skin due to long term steroid use and had experienced multiple skin tears on her/his extremities despite use of protective interventions. APRN #1 indicated she could not recall being informed of any facial bruising on Resident #10. APRN #1 stated nursing may not have reported bruises separately when documenting frequent skin tears. APRN #1 identified a bruise on the face, torso, or one measuring 3 cm in length by 3 cm in width, would be unusual, potentially suspicious, and require further medical evaluation, as it may not be related to long-term steroid use for Resident #10's Lupus diagnosis.Interview and review of the clinical record with RN #1 on 2/27/2026 at 8:00 AM identified she recalled evaluating Resident #10's facial bruise on 12/18/2025 and 12/19/2025. RN #1 indicated Resident #10's bruise was resolving and she had documented daily per protocol for any identified skin issue. RN #1 identified if a staff member identifies a change in a resident's skin integrity such as a bruise or skin tear; the supervisor is notified. RN #1 indicated the supervisor completes a facility incident report and investigation to determine possible causes, updates the care plan, completes the necessary notifications, and initiates every shift evaluation in the electronic medical record. RN #1 indicated Resident #10 was self-propelling in the wheelchair and had fragile skin prone to tearing but could not recall observing any facial bruises on Resident #10. RN #1 indicated she was unaware that a bruise of unknown origin was defined in the facility abuse policy and the facility abuse policy should have been followed. Interview, review of the clinical record, and facility incident report with the DNS on 2/27/2026 at 11:00 AM identified that she was not aware on 12/15/2025, Resident #10 had a facial bruise. The DNS identified based on the incident report Resident #10 did not know how the bruise occurred, so the cause of the facial bruise was of unknown origin. The DNS identified the investigation lacked staff interviews, and the facial bruise was determined to be of unknown origin. The DNS indicated she was unaware that a bruise of unknown origin is considered an injury of unknown origin, but that the facility Abuse Policy should be followed. The DNS identified there was insufficient information to determine the cause of the bruise and that the facility Abuse Policy should have been followed for reporting.Interview and review of the clinical record with RN #4 on 2/27/2026 at 12:00 PM identified she was the supervisor on 12/15/2025 at 5:00 AM when Resident #10's facial bruise was identified by the charge nurse on the unit during care. RN #4 identified she was called to the unit to evaluate the area and Resident #10 was unable to explain how the bruise occurred. RN #4 indicated she asked staff if they had observed anything that could have caused the bruise or if any incidents happened during care. RN #4 indicated staff reported they had not witnessed anything unusual during the shift. RN #4 indicated the APRN and the family were notified and she left the incident report in the nursing office. RN #4 could not recall notifying anyone else. The facility's Abuse policy dated 6/6/2024 directed in part, reports of alleged abuse by a resident or family member will be immediately reported to the DON, ADON, Administrator and/or supervisor. Signs of abuse included but were not limited to suspicious or unexplained bruising. Definitions of abuse and neglect included an injury of unknown origin when the source of the injury was not observed and could not be explained by the resident. For injuries of unknown origin or suspicious injuries, a state report was initiated as determined by the results of the investigation. Classification and categories of abuse are determined upon investigation. An investigation is used to determine what happened and include who was involved, interviews and written statements from staff and residents as applicable and completed applicable observations.

Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents (Resident #10) reviewed for accidents, the facility failed to complete a thorough investigation for an injury of unknown origin. The findings include: Resident #10 was admitted with diagnoses that included dementia, chronic obstructive pulmonary disease (COPD), systemic lupus erythematosus (lupus- a chronic autoimmune disease where healthy tissue was inflamed and damaged) and peripheral vascular disease (arteries in leg and arms become blocked).The RCP dated 9/20/3035 identified Resident #10 was at risk for impaired skin due to fragile skin secondary to long term steroid use with interventions that included to monitor skin with transfers and during care reporting any changes.The significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/6/2025 identified Resident # 10 had a Brief Interview for Mental Status (BIMS) score of 11 indicative of moderately impaired cognition, required substantial assistance for transfer and was dependent on staff for mobility in the wheelchair. The facility incident report dated 12/15/2025 at 5:00 AM identified during care, staff observed a bruise on the right side of Resident #10's face. The bruise measured three (3) centimeters (cm) by 3 cm near the chin line. Resident #10 reported that she/he did not know how it happened. Resident #10 was alert with confusion and oriented to name per baseline. An investigation form completed by RN #4 identified Resident #10 was on Eliquis (blood thinner) as a causative factor, but the actual cause was unknown. The APRN was notified. No additional investigative documents were included in t incident file.A nurse's note dated 12/15/25 at 6:30 AM indicated Resident #10's family was notified of the bruise.Interview with APRN #1 on 2/26/2026 at 2:30 PM identified Resident #10 had fragile skin due to long term steroid use and had experienced multiple skin tears on her/his extremities despite use of protective interventions. APRN #1 indicated she could not recall being informed of any facial bruising on Resident #10. APRN #1 stated nursing may not have reported bruises separately when documenting frequent skin tears. APRN #1 identified a bruise on the face, torso, or one measuring 3 cm in length by 3 cm in width, would be unusual, potentially suspicious, and require further medical evaluation, as it may not be related to long-term steroid use for Resident #10's Lupus diagnosis.Interview and review of the clinical record with RN #1 on 2/27/2026 at 8:00 AM identified she recalled evaluating Resident #10's facial bruise on 12/18/2025 and 12/19/2025. RN #1 indicated Resident #10's bruise was resolving and she had documented daily per protocol for any identified skin issue. RN #1 identified if a staff member identifies a change in a resident's skin integrity such as a bruise or skin tear; the supervisor is notified. RN #1 indicated the supervisor completes a facility incident report and investigation to determine possible causes, updates the care plan, completes the necessary notifications, and initiates every shift evaluation in the electronic medical record. RN #1 indicated she was unaware that a bruise of unknown origin was defined in the facility abuse policy and the facility abuse policy should have been followed. RN #1 identified had she been aware, she would have completed a thorough investigation. Interview, review of the clinical record, and facility incident report with the DNS on 2/27/2026 at 11:00 AM identified that she was not aware on 12/15/2025, Resident #10 had a facial bruise. The DNS identified based on the incident report Resident #10 did not know how the bruise occurred, so the cause of the facial bruise was of unknown origin. The DNS identified the investigation lacked staff interviews, and the facial bruise was determined to be of unknown origin. The DNS identified that had she been aware, she would have expected a complete and thorough investigation of Resident #10's injury of unknown origin. Interview and review of the clinical record with RN #4 on 2/27/2026 at 12:00 PM identified she was the supervisor on 12/15/2025 at 5:00 AM when Resident #10's facial bruise was identified by the charge nurse on the unit during care. RN #4 identified she was called to the unit to evaluate the area and Resident #10 was unable to explain how the bruise occurred. RN #4 indicated she asked staff if they had observed anything that could have caused the bruise or if any incidents happened during care. RN #4 indicated staff reported they had not witnessed anything unusual during the shift. RN #4 indicated the APRN and the family were notified and she left the incident report in the nursing office. RN #4 could not recall notifying anyone else. Review of facility Abuse policy dated 6/6/2024, directed in part, that signs of abuse include but were not limited to suspicious or unexplained bruising. Definitions of abuse and neglect include an injury of unknown origin when the source of the injury was not observed and could not be explained by the resident. For injuries of unknown origin or suspicious injuries, a state report was initiated as determined by the results of the investigation. An investigation is used to determine what happened and include who was involved, interviews and written statements from staff and residents as applicable and completed applicable observations.

Based on review of the clinical record, facility documentation, facility policies, and interviews for one (1) of five (5) residents (Resident #4) reviewed for unnecessary medications, the facility failed to develop and implement a comprehensive care plan to address the resident's diagnosis of dementia. The findings include:Resident #4 was admitted with diagnoses that included dementia, presence of right artificial knee joint, age related cognitive decline, diabetes mellitus, and hypertension.The admission orders dated 8/21/25 identified Resident #10 had a diagnosis of dementia.The nursing admission note dated 8/21/2025 at 4:14 PM identified Resident #10 had diagnoses that included weakness, diabetes, chronic kidney disease, and dementia. The note further identified Resident #10's family provided consent for psychiatric evaluation.The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/28/25 identified that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition, and an active diagnosis of non-Alzheimer's dementia.The RCP dated 9/3/25 identified that Resident #10 was newly admitted to the facility with a diagnosis of depression. Interventions directed staff to orient the resident to the facility and provide psychiatric services as needed. The RCP did not include the resident's diagnosis of dementia or any interventions to address dementia-related needs.Interview and review of the medical record with APRN #2 (psychiatric) on 2/26/2026 at 10:41 AM identified she evaluated Resident #4 on 10/15/2025 due to depression and cognitive decline. APRN #2 stated on 10/15/2025 her evaluation revealed significant cognitive problems consistent with Resident #4's diagnoses of unspecified dementia without behavioral disturbances.Interview with the Director of Nursing (DNS) on 2/26/26 at 2:00 PM identified that if a resident has a diagnosis of dementia, she expects the care plan to include specific interventions to address the resident's needs related to that diagnosis. The DNS was unable to explain why a comprehensive care plan was not implemented to address Resident #4's diagnosis of dementia.Review of the facility Resident Care Plan policy dated 5/17/2024, directed in part, that the RCP shall ensure maintenance of high quality, individualized care plan that utilized standard assessments and MDS to complete. The care plan will be reviewed and revised based on the changing needs of the resident. The care plan includes goals for resident care, approached to accomplish the goals consistent with resident's rehabilitation potential to ensure the highest level of function possible.

Based on clinical record review, facility documentation review, facility policy review and interviews for 1 of 4 residents (Residents #71) reviewed for medication administration, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: Resident #71 had diagnoses that included stoke, Parkinson's disease, depression, and cancer. The Resident Care Plan dated 1/18/25 identified Resident #71 had a diagnosis of Parkinson's disease ( neurological disorder that causes a depletion in circulating dopamine levels in the brain) with interventions that directed to monitor for signs and symptoms of shuffling gait, pill rolling tremors, lip smacking, loss of voluntary movements, blank facial expressions, drooling, difficulty swallowing, feeling weak, easily fatigued, feeling heavy and stiff, and notify physician if any changes.The physician's orders dated 1/19/26 directed to administer Acyclovir (antiviral) 200 milligram (mg) twice a day; Amlodipine (used to lower blood pressure) 5 mg once daily; Calcium Acetate ( used to lower high blood phosphorus) 667 mg 2 tablets three times a day; Eliquis (blood thinner) 5 mg twice a day; Fludrocortisone (used to treat low blood pressure) 0.2 mg once a day; Midodrine (used to treat low blood pressure ) 10 mg three times a day; Potassium Chloride (mineral supplement) 20 milliequivalent (mEq) extended release once a day, Trelegy Ellipta (used to treat chronic obstructive pulmonary disease) inhaler one dose inhaled once daily; Droxidopa ( used to treat orthostatic blood pressure) 200 mg three times a day ; and Sertraline ( used to treat depression) 100 mg daily. The quarterly MDS assessment dated [DATE] identified Resident #71 had intact cognition and required maximum assistance with toileting, dressing, and personal hygiene. Review of the electronic Medication Administration Record dated 2/1/26 to 2/26/26 identified the following medications were omitted:on 2/17/26 Amlodipine (high blood pressure) 5 mg scheduled at 6:00 PM documented as not available and not administered on 2/18/26 Amlodipine 5 mg scheduled at 6:00 PM documented as not available and supervisor was notifiedon 2/22/26 Droxidopa 200 mg scheduled at 2:00 PM, and 10:00 PM documented as not available and not administered on 2/23/26 Droxidopa 200 mg scheduled at 8:00 AM, 2:00 PM, and 10:00 PM documented as not available and not administeredon 2/24/26 Droxidopa 200 mg scheduled at 8:00 AM, 2:00 PM, and 10:00 PM documented as not available and not administeredon 2/25/26 Droxidopa 200 mg scheduled at 8:00 AM, 2:00 PM, and 10:00 PM documented as not available and not administeredon 2/26/26 Sertraline 100 mg daily at 8:00 AM identified documented as not available and not administeredon 2/26/26 Droxidopa 200 mg scheduled at 8:00 AM documented as not available and not administered Review of the nursing progress notes dated 2/1/26 to 2/25/26 were unable to provide documentation to reflect the pharmacy, physician, or resident's representative were notified when Resident #71's medications were not available and were not administered in accordance with physician's orders. Observation of the medication administration with LPN #2 on 2/26/26 at 8:00 AM identified she introduced herself to Resident #71 and asked if he/she was ready for morning medications. LPN #2 went back to the medication cart in the hallway and used hand sanitizer. LPN #2 prepared Resident #71's medications and indicated she did not have available the Sertraline 100 mg daily and did not have the Droxidopa 200 mg available. LPN #2 indicated a couple of days ago she notified the supervisor that Resident #71's Droxidopa was not available. LPN #2 gave Resident #71's the medications she had prepared. Interview with RN #1 on 2/26/26 at 10:40 AM indicated she was not notified by LPN #2 that some of Resident #71's medications were unavailable. RN #1 stated during the medication pass, if a resident's medication is not available, it is the nurse's responsibility to notify her so she can check the emergency medication box to determine whether the medication is available. RN #1 further stated if the medication was still unavailable, she would contact the pharmacy, the physician or APRN, and the resident's representative. RN #1 also stated she would document the issue in the resident's medical record. Subsequent to surveyor inquiry, a nurse's note written by RN #1 dated 2/26/26 at 11:10 AM indicated she contacted the pharmacy and ordered Resident #71's Droxidopa, Potassium, and Sertraline. RN #1 documented MD #1 was notified that Resident #71 had missed 12 doses of Droxidopa 200 mg, 2 doses of Amlodipine 5 mg, and 1 dose of Sertraline 100 mg. RN #1 further documented Resident #71's representative was notified.Interview and review of the clinical record with the Director of Nursing Services (DNS) on 2/26/2026 at 2:00 PM indicated that if a nurse does not have a medication available during the medication pass, the nurse should first check the medication cart and medication room. The DNS stated that if the medication is still not available, the nurse should notify the nursing supervisor so the supervisor can contact the pharmacy to determine when the medication will be available. The DNS further stated the supervisor should then notify the physician to determine whether the medication administration time should be adjusted or if an alternative medication should be ordered. The DNS indicated the supervisor should also notify the resident's representative if a medication is unavailable and inform them of the plan of care. The DNS stated the supervisor must document contact with the pharmacy, the physician, and the resident's representative in the resident's progress notes. Upon review of the clinical record, the DNS stated she was not aware that Resident #71 had not received his/her Parkinson's medication since 2/22/26 and had missed 12 doses or that Resident #71 had not received the additional listed medications. The DNS indicated that on 2/17/26 and 2/22/26 the nurse or supervisor should have notified the pharmacy, the physician, and the resident's representative and documented these actions in the progress notes. The DNS identified the omission of a medication is a medication error.Interview with Pharmacist #1 on 2/26/26 at 1:53 PM indicated the pharmacy does not contact the facility when medications require refilling. Pharmacist #1 identified it is the responsibility of the facility nurses to contact the pharmacy to request medication refills when a resident's supply is running low or has been depleted. Interview with MD #1 on 2/26/26 at 2:15 PM identified medications should be administered in accordance with physician/APRN orders. MD identified he was not aware the listed medications were not administered to Resident #71 on 2/17/26, 2/18/26, 2/22/26, 2/23/26, 2/24/26, and 2/26/26. MD #1 identified that if Resident #71 was not administered Droxidopa, it could result in an increase in Parkinson's disease symptoms; but had not at this time. MD #1 indicated that the medication had been ordered and would be delivered to the facility today. MD #1 further indicated that once the medication arrives at the facility, a dose will be administered to the resident. Review of the facility Medication Error Policy identified is to provide the appropriate identification, documentation, and assessment of medication errors, as well as for the education and systems improvement necessary to minimize and respond effectively to medication errors that occur. All medication errors are to be reported to the supervisor upon finding. The supervisor will notify the DNS and the attending physician or APRN. Examples of medication errors include wrong medication, wrong dose, omission of ordered dose, unordered medication, extra dose, wrong time of administration, and the wrong route of administration. When a medication error is made, the following will occur notify the physician or APRN, notify the residents representative, notify the DNS, supervisor will complete the medication error report, and resident will be placed on vital signs and charting every shift. Review of the facility Medication Administration Policy identified all medications are properly administered and documented on the electronic medication administration record. All medications will be properly administered per the physician/APRN orders. If a medication is unavailable per pharmacy the nursing supervisor or designee will call the physician/APRN and the resident/resident's representative to update them.

Based on review of facility documentation, facility policy and interviews for three (3) of three (3) nurse aides (NA #1, NA #2 and NA #3), the facility failed to complete performance reviews at least once every 12 months as required. The findings include: Review of NA #1's personnel file identified a hire date of 11/14/2008. NA#1 was listed on the current nursing staff contact list.Review of NA #2's personnel file identified a hire date of 7/6/1992. NA# was listed on the current nursing staff contact list. Review of NA #3's personnel file identified a hire date of 7/17/2001. NA# was listed on the current nursing staff contact list. Interview with the Administrator on 2/25/26 at 10:00 AM identified that the Director of Nursing (DNS) is responsible for ensuring annual performance reviews are completed. The Administrator stated he was not surprised that NA #1, NA #2, and NA #3 had not received recent performance reviews because there had been recent transition in the DNS position. due to a recent transition in the DNS position. Interview and review of the employee files with the Human Resources Director on 2/25/2026 at 11:00AM identified that NA #1, NA#2 and NA #3 lacked documentation of an annual evaluation for 2024 and 2025. The facility Performance Appraisals policy directed in part, that the employee's supervisor was required to formally evaluate the employee's job performance before the end of sixty working days and then at least annually.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure the resident used an assistive device while ambulating in accordance with the plan of care resulting in a fall with injury. The finding includes: Resident #1 had diagnoses that included unilateral osteoarthritis of right knee, and was status post right knee arthroplasty. Review of Resident #1's fall risk assessment dated [DATE] identified Resident #1 was at a high risk for falls. Review of a nurse's note dated 6/11/24 identified that the resident was admitted with a wound vacuum to the right knee, the wound vacuum dressing should stay in place for seven (7) days and then the wound can be dressed with a clean dry dressing. Review of Resident #1's caregiver training record dated 6/12/2024 identified Resident #1 required the assistance of one (1) staff with use of a two (2) wheeled walker with transfers. The 5-day Minimum Data Set assessment dated [DATE] identified Resident #1 had intact cognition, required substantial assistance with transfers and was non-ambulatory. The care plan dated 6/13/2024 identified Resident #1 requires assistance with Activities of Daily Living related to total knee replacement with interventions that directed to provide one (1) assist with a two (2) wheeled walker for transfers. Review of the Facility's Accident and Incident Form dated 6/13/2024 at 7:00 PM identified Resident #1 required the assistance of one (1) staff with utilization of a two (2) wheeled rolling walker for transfers. On 6/13/2024, Nurse Aide (NA) #1 had transferred Resident #1 from a raised recliner (the recliner raises up to assist a resident to standing position) to an adjacent wheelchair without using the two (2) wheeled rolling walker for the transfer and the resident fell. Review of Registered Nurse (RN) #1's nurse's note dated 6/13/2024 at 7:06 P.M. identified she was called to Resident #1's room and observed Resident #1 on the floor leaning on h/her left shoulder, with the right knee bent up and with bleeding coming from the dressing. RN #1 identified Resident #1 continued to cry out and complain of a pain level of ten (10) out of ten (10), (a zero (0) being no pain and a ten (10) being the worst pain) in h/her left shoulder and right knee. Emergency Medical Services were activated, and Resident #1 was transferred to the hospital. Review of a hospital progress note dated 6/15/2024 identified Resident #1 had a fall at the skilled nursing facility and sustained a left humeral head fracture. Further, Resident #1 had a recent Right knee replacement, the wound had a dehisced (a wound rupture) and required irrigation (wash out) and debridement (a procedure to remove damaged tissue) with wound closure on 6/14/2024. The nurse's note dated 6/16/2024 at 3:00 P.M. identified Resident #1 returned to the facility with a sling in place to h/her left upper extremity and a wound vacuum to the right knee. Interview with NA #1 on 7/9/2024 at 1:30 P.M. identified she did receive care giver training pertaining to the care needs of Resident #1 on 6/13/2024. The training directed Resident #1 required the assistance of one (1) staff with use of a two (2) wheeled walker with transfers, however, on 6/13/2024 she transferred Resident #1 from the recliner to the wheelchair without using the two (2) wheeled walker. NA #1 identified that although she knew the resident required the use of the two (2) wheeled walker she wanted to save time and while transferring the resident she (NA#1) was holding on to Resident #1 with her hands when Resident #1 lost his/her balance and fell forward onto the floor. Interview with the Director of Nursing Services (DNS) on 7/9/2024 at 11:00 A.M. identified on 6/13/2024 NA #1 did not follow Resident #1's plan of care for transfers, the resident fell and sustained a left humeral head fracture and right knee wound dehiscence. NA #1 should have had used the two (2) wheeled rolling walker with the transfer in accordance with the plan of care. The DNS further identified that all nurse aides are required to review a resident's plan of care prior to providing care. Review of the fall prevention policy identified each resident will receive adequate supervision and assistance to prevent accidents.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to ensure that staff provided the resident with the required assistance while ambulating and failed to use a safety device resulting in a fall with injury. The finding includes: Resident #1 had diagnoses that included cerebral infarction (stroke), muscle weakness, abnormalities of gait and mobility. Review of Resident #1's caregiver training record dated 3/25/2024 identified Resident #1 required the assistance of two (2) staff with use of a walker and gait belt while ambulating and the use of a gait belt and walker with transfers. Review of Resident #1's fall risk assessment dated [DATE] identified Resident #1 was at a high risk for falls. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had moderately impaired cognition, required extensive assistance with bed mobility, transfers, and toileting, and the resident had one fall since admission to the facility. The care plan dated 4/1/2024 identified Resident #1 was at risk for falls related to a cerebral vascular accident, poor safety awareness, and non-compliance with calling for help with interventions that directed to provide the assistance of two (2) staff and to utilize gait belt for transfers and when ambulating the resident. Review of Resident #1's undated care card (directs the care the resident required) identified Resident #1 required the assistance of 2 staff with use of a gait belt for transfers and with ambulation. Review of RN #2's nurse's note dated 4/7/2024 at 4:02 P.M. identified he was called to Resident #1's room and observed Resident #1 lying on his/her right side on the floor. RN #2 documented that Nurse Aide (NA) #1 reported Resident #1 lost his/her balance and fell to the ground onto h/her right side. RN #2 documented that Resident #1's right leg appeared shortened in comparison to the left leg, was externally rotated, and the resident complained of severe pain. Emergency Medical Services was activated, and Resident #1 was transferred to the hospital. Review of the Facility's Accident and Incident Form dated 4/7/2024 at 4:00 PM identified Resident #1 required the assistance of 2 staff and the utilization of a gait belt for transfers and ambulation. On 4/7/24, NA #1 had ambulated Resident #1 to the commode without the assistance of another staff member and without the use of a gait belt. Resident #1 subsequently fell . Review of Resident #1's hospital x-ray report dated 4/7/2024 identified Resident #1 had a comminuted intertrochanteric fracture (a fracture that breaks the bone into more than two (2) pieces) of the right femur with avulsion of the lesser trochanter (tearing of the tendon from the bone). The nurse's note dated 4/13/2024 at 2:29 P.M. identified Resident #1 returned to the facility from the hospital following surgery for repair of a right hip fracture sustained from the fall on 4/7/24. Interview with NA #1 on 4/24/2024 at 10:55 A.M. identified that she did receive care giver training pertaining to the care needs of Resident #1 on 3/25/2024. The training identified Resident #1 required assistance with 2 staff and a gait belt with ambulation, however, on 4/7/2024 she ambulated Resident #1 to the commode without the assistance of another staff member, and without the benefit of a gait belt. NA #1 identified that although she knew the resident required 2 assist and a gait belt, she just wasn't thinking. NA #1 stated that while ambulating Resident #1 to the commode, Resident #1 lost his/her balance, and fell to the floor. NA #1 further identified that gait belts are part of the nurse aide uniform and are to be used when transferring or ambulating any resident. Interview with the Director of Nursing Services (DNS) on 4/24/2024 at 12:00 P.M. identified on 4/7/2024 NA #1 did not follow Resident #1's plan of care for transferring and ambulation, the resident fell and sustained a hip fracture. NA #1 should have had another staff member assist with the transfer and ambulation, and a gait belt should have been utilized in accordance with the plan of care. The DNS further identified that she expects that all nurse aides review a resident's plan of care prior to providing care. Review of the fall prevention policy identified each resident will receive adequate supervision and assistance to prevent accidents. NA assignment sheets are updated on the master sheet at the time of change and weekly to reflect residents' methods of transfer, ambulation, and safety devices needed.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who required a mechanical lift (Hoyer) for transfers in and out of bed, the facility failed to ensure environmental hazards were eliminated prior to transferring the resident back to bed to prevent a fall with an injury. The findings include: Resident #1's diagnoses included cerebral vascular disease, morbid obesity, and osteoarthritis of the left knee. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life and required extensive two (2) person assistance with turning and repositioning when in bed and getting in and out of the bed and chair. The Resident Care Plan dated 4/26/23 identified Resident #1 was at risk for falls related to a history of cerebral vascular accident and required assistance with Activities of Daily Living. Interventions directed to maintain a clutter free environment, keep the floor free of debris and complete transfers with a mechanical lift. The Facility Reported Incident form dated 5/18/23 at 8:00 PM identified Resident #1 was being transferred via the Hoyer lift from the recliner to bed when the Hoyer lift tipped resulting with the resident falling to the ground onto his/her buttock. The report identified the Advanced Practice Registered Nurse was notified and ordered to transfer Resident #1 to the Emergency Department for further evaluation. The Emergency Department report dated 5/19/23 identified Resident #1 had sustained an acute displaced fracture of the left iliac bone, the injury was identified as inoperable with recommendations for physical therapy, and to follow up with the primary care physician upon return to the facility. The Reportable Event Summary dated 5/23/23 identified Resident #1 sustained a fall while being transferred using a Hoyer lift on 5/18/23 around 8:00 PM. Upon further review of the incident, it was found that Resident #1's bed was not high enough to support clearance of the Hoyer lift legs and the call bell wire was on the floor in the direct path of the Hoyer lift. The summary identified there were two (2) nurse aides present in the room, one (1) nurse aide, Nurse Aide, (NA) #1, was supporting the lower extremities while the other nurse aide, NA #2, was maneuvering the lift. The summary indicated Resident #1 was near the bed when NA #1 went to move the bed higher via the controller which was located on the other side of the bed at and at that time NA #2 pushed the Hoyer legs under the bed striking the call bell wire and bed frame causing Resident #1 to swing in the lift, the lift to tip over and Resident #1 then fell landing onto the back and buttock region. An interview with Resident #1 on 6/5/23 at 10:40 AM identified he/she was being transferred from the recliner chair to the bed on the evening of 5/18/23 by two (2) nurse aides, NA #1 and NA #2. Resident #1 indicated NA #2 was maneuvering the lift while NA #1 was holding his/her legs. Resident #1 stated he/she was beside the bed and could see the call light wire on the floor beneath the bed and the bed was in a low position. Resident #1 identified he/she suddenly fell striking his/her head and buttock region causing pain and was subsequently transferred to the hospital. In an interview with NA #1 on 6/5/23 at 11:22 AM identified on 5/18/23 she assisted with transferring Resident #1 to bed and that during the transfer, the wheels of Hoyer hit the call bell wire that was on the floor causing the lift to tip over resulting in Resident #1 hitting the floor beside the bed. Interview with NA #2 on 6/5/23 at 11:30 AM identified she was operating the Hoyer lift. NA #2 indicated she was looking at the floor, saw the call bell wire and then the Hoyer tipped over. NA #2 identified she had received training on Hoyer lifts. An interview with the Medical Director on 6/5/23 at 12:01 PM identified he would expect that accident hazards be removed prior to a resident transfer with a mechanical lift. Review of the Mechanical Lift (Hoyer) policy failed to direct staff to ensure the environment is free of obstacles. A review of the facility policy for Accident Prevention directed that interventions be in place to minimize environmental hazards to ensure the facility remains free from accident hazards.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure the resident was properly positioned while in a showerchair to prevent a fall resulting in an injury. The finding includes: Resident #1's diagnoses included Alzheimer's disease, dementia with behavioral disturbances, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required two staff assistance for transfers, and was dependent with assist of one for bathing. The Resident Care Plan (RCP) dated 1/27/2023 identified Resident #1 was at risk for falls due to dementia, poor safety awareness, and required assistance with ADLs. Interventions directed to anticipate needs, use of a modified custom wheelchair, and to be sure Resident #1 was positioned with hips fully back and aligned in seat with leg rests in place at all times while seated in chair, and two (2) staff for bathing. Review of Resident #1's care card signed by Certified Occupational Therapy Assistant (COTA) #1 (the card detailed the care the resident required) dated 12/1/2022 identified Resident #1 required the assist of two staff for transfers, bed mobility, toileting, and ADLs. A facility reportable event form and investigation dated 2/9/2023 at 6:00 PM identified NA #1 was drying Resident #1 after his/her shower. NA #1 leaned Resident #1 forward to remove the towels from Resident #1's back, and he/she slid out of the shower chair onto his/her right knee and buttocks. Resident #1 was assessed by the charge nurse and supervisor immediately, and Resident #1 had immediate complaints of right leg pain. MD #1 was updated of the incident, an order was obtained to send Resident #1 to the emergency room for evaluation, and it was identified that Resident #1 had sustained a fracture of the right distal femur. The report further identified the causative factor in the fall was the resident was still wet and slipped easily from the (shower) chair. The report indicated the corrective action plan was to ensure the resident was dried prior to any movement. Facility investigation dated 2/10/2023 indicated NA #1 had positioned Resident #1 near the grab bar and Resident #1 refused to use the grab bar to hold on. NA #1 asked Resident #1 to lean forward, and after the removal of the towel, Resident #1 proceeded to lean forward, slid of the shower chair, and landed on his/her right knee. NA #1 failed to ensure the resident remained properly positioned in the showerchair, resulting in a fall. Review of the nursing note dated 2/9/2023 at 6:22 PM identified RN #1 was alerted at 6:10 PM that Resident #1 had slid out of the shower chair in the shower room, after his/her shower. RN #1 observed Resident #1 sitting on the floor of the shower room with his/her back against the shower chair. An abrasion was noted to Resident #1's right knee and left toes with a scant amount of serosanguineous (thin, watery pink fluid) drainage present. Resident #1 was assisted back to the shower chair with assist of two and back to his/her room. The RN Supervisor was updated and went to Resident #1's room for an assessment. Resident #1 was yelling in pain and stating that his/her right thigh and knee hurt, and Tylenol 650 milligrams (mg) was administered for pain. Review of the nursing note dated 2/9/2023 at 7:07 PM identified RN #2 was notified at 6:15 PM that Resident #1 had slipped out of the shower chair following a shower. Resident #1 was alert and oriented to person, place and had complaints of right leg pain on assessment. A right knee abrasion and swelling were noted, and Resident #1 yelled, Ow, that hurts, that hurts! when he/she mobilized Resident #1's right leg. A pillow was placed to support Resident #1's leg in bent position chosen by Resident #1 after the femur and patella (kneecap) were observed out of alignment. Pedal pulses were present, and the skin on the right lower leg was warm and pink. The MD #1 was notified and ordered to call EMS for transfer to the hospital for evaluation. Resident #1 remained in staff attendance until transferred via ambulance by stretcher and two attendants to hospital at 6:54 PM. Nursing note dated 2/9/2023 at 10:11 PM indicated Resident #1's x-ray confirmed a right distal femur fracture and Resident #1 was admitted to the hospital. Review of the hospital summary dated 2/9/2023 at 10:00 PM identified Resident #1 presented to the emergency department from skilled nursing facility after slipping out of a shower chair and falling on his/her right knee. While in the emergency department, resident was noted to have a right distal femur fracture on Xray. Resident #1 was discharged back to the facility on [DATE] status post a surgical open reduction and internal fixation (ORIF) for right distal femur fracture on 2/13/2023. Review of the clinical record identified Resident #1 was readmitted to the facility on [DATE]. Interview with NA #1 on 3/2/2023 at 12:50 PM identified Resident #1 required assist of two with transfers, but once in the wheelchair, bed or shower chair, Resident was an assist of one. NA #1 identified Resident #1 as a leaner and indicated Resident #1 would slouch when he/she sat in a chair and the resident would require reminding or repositioning (by one staff); NA #1 indicated Resident #1 would normally position his/her back on the back of the chair but will position his/her buttocks in the middle or closer forward to the front edge of the chair, even after repositioning Resident #1 would move his/her buttocks back to the middle or front edge of the chair. NA #1 indicated when she attempted to remove the towel, Resident #1 was not positioned all the way back in the shower chair; his/her back was against the back of the shower chair, and Resident #1's buttocks were in the middle part of the shower chair. After NA #1 completed the shower for Resident #1 on 2/9/2023, she placed a towel on Resident #1's back, and then using another towel, began drying Resident #1. When NA #1 attempted to remove the towel from Resident #1's back, she noticed Resident #1 was slightly sitting on the corner edge of the towel. NA #1 requested Resident #1 to hold onto the railing (grab bar) in the shower to help assist with removing the towel, but Resident #1 refused. NA #1 identified she then stood on Resident #1's left side and placed one arm underneath Resident #1's arm to lean Resident #1 forward in the shower chair to attempt to remove the towel under Resident #1's buttocks. NA #1 was able to remove the towel, and she removed her arm from under Resident #1's arm. At that moment when NA #1 let go of Resident #1, Resident #1 began sliding forward off the wet shower chair, feet first and NA #1 was unable to stop the continuation of Resident #1 sliding forward to the ground. NA #1 identified the floor was still wet and Resident #1 didn't have any footwear in place. When Resident #1 refused to use the grab bar and was not seated fully back in the shower chair, NA #1 failed to call for assistance to remove the towel from Resident #1's back and failed to ensure Resident #1 was seated fully back in the shower chair prior to moving Resident #1 to attempt to remove the towel. Interview with the DON (Director of Nursing) on 3/2/2023 at 2:45 PM identified subsequent to the fall, the facility changed Resident #1's plan of care to be an assist of two for showers. Although the DON verbalized she did not think NA #1 needed to call for assistance when Resident #1 refused to use the grab bar, the DON was unable to explain why NA #1 attempted to remove the towel when Resident #1 was not seated fully back in the shower chair. Review of the facility Falls Prevention Policy dated 6/2019 directed in part, each resident will receive adequate supervision and assistance to prevent accidents.

Based on clinical record review, facility documentation review, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to provide adequate supervision and assistance to prevent an injury. The findings include: Resident #1's diagnoses included diabetes, neuropathy, atherosclerosis bilateral legs, heart failure, hypertension, cerebral infarction, chronic kidney disease, respiratory failure, chronic pain, dementia, Alzheimer ' s disease, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4 out of fifteen, indicative of severe cognitive impairment, had no behavioral symptoms and required extensive assistance with transfer and locomotion on unit. The Resident Care Plan (RCP) dated 10/17/22 identified Resident #1 had significant visual impairment with visual hallucinations related to diagnosis of [NAME] Bonnet (a disorder that occurs when sight is lost can cause hallucinations). Interventions directed to assist the resident when needed to prevent injury, announce your arrival in resident ' s presence and provide adequate lighting. A nurse's note dated 11/8/22 at 6:30 PM was recorded as late entry identified that Resident #1's left foot/lower extremity struck on the doorway to the room. During assessment lower extremity was warm with positive pedal pulses, no redness noted with painless ROM. The resident offered no complaints of pain. A nurse's note dated 11/8/22 at 9:54 PM identified Resident #1 was in wheelchair being assisted out of dining room and while passing through bedroom doorway his/her left foot was jolted against the door jamb. The resident initially complained of my foot hurts. Left foot and ankle were not swollen, red, warm to touch and skin was intact. Tylenol was administered at 7:00 PM and the resident had no further complaints. A Reportable Even Form dated 11/8/22 at 5:30 PM identified Resident #1's left foot hit doorway and was bent backward. A nurse's note dated 11/9/22 at 12:31 PM identified that APRN was notified regarding the resident ' s left foot hitting door jamb while entering his/her room last evening on 11/8/22. Order for X-ray of left ankle and foot was obtained. A nurse's note dated 11/10/22 at 6:39 AM identified the resident's left lower extremity had discoloration and skin was intact. The resident flinched his/her foot upon movement. A nurse's note dated 11/10/22 at 10:58 AM identified Resident #1 continued with left foot pain and was shouting in pain ouch during care and with transfer, the X-ray ordered had not been taken at that time. Scheduled Tylenol was not effective. Blood pressure was elevated, MD #1 was notified and new order for Lisinopril 10 mg and blood work was obtained. X-ray of left foot and ankle was obtained on 11/10/22 (no time identified) and results interpreted by a physician at 4:55 PM. Conclusion identified nondisplaced fracture of the distal third of the tibia and no other bony abnormality identified. A nurse's note dated 11/10/22 at 5:45 PM identified Resident #1 had fracture of left distal tibia. APRN was notified, new order for pain medication was obtained. Pillow splint was applied to left lower extremity; the resident was calling out in pain with any movement of left lower extremity. Review of Doctor's order sheet dated 11/10/22 identified orders for Oxycodone 5 mg for left lower leg pain, pillow splint to left lower leg and STAT orthopedic appointment on 11/11/22. A nurse's note dated 11/10/22 at 8:00 PM Resident #1 was with increased complaints of pain during care despite Oxycodone administration. RN #2 called APRN to discuss possibility of having left lower extremity fracture splinted in the emergency room instead of waiting until 11/11/22, 911 was called and the resident was transferred to the hospital. Review of the emergency room documentation dated 11/10/22 identified Resident #1 had posterior splint applied to his/her left leg extending from the posterior mid-thigh to the foot and the resident returned to the facility on [DATE]. Review of orthopedic note dated 11/14/22 identified Resident #1 reportedly was in wheelchair and his/her leg was struck going through a door sustaining fracture, this occurred several days ago. Unable to obtain X-ray of his/her leg in the office, the resident required a Hoyer lift and was in a wheelchair, unable to be put on the exam table and was sent to the hospital emergency room for repeated X-ray of his/her left leg. Further review identified X-ray obtained on 11/14/22 noted distal tibial shaft with butterfly fragment fracture with no significant displacement nor angulation and noted proximal fibula fracture. Plan included to continue the use of long-leg posterior splint and add U-splint involving the lower leg for further stabilization. Interview with Rehabilitation Manager on 11/29/22 at 11:08 AM identified Resident #1 was unable to propel himself/herself in the adaptive wheelchair provided by the facility, therefore the resident was dependent on staff for wheelchair mobility. Interview with RN #1 on 11/29/22 at 2:57 PM identified he observed NA #2 pushing Resident #1 in his/her adaptive wheelchair into his/her room on 11/8/22. Further interview identified that he observed the resident's left leg slightly bump the door frame. RN #1 stated the resident had chronic pain, received Tylenol and he did not hear the resident yell out in pain. During an assessment the resident denied pain and had good range of motion in the left foot/ankle, therefore he did not notify the MD or APRN about the incident. Interview with NA #2 on 11/29/22 at 4:10 PM identified she was pushing Resident #1 in his/her adaptive wheelchair to his/her room, but when she was turning in the hallway at the entrance to the resident's room, the resident's left foot slipped to the side and off the elevated foot pedal. The left foot became caught up on a door jamb and bent backward. NA #2 kept pushing the resident in his/her adaptive wheelchair and lifted it to go over the threshold. NA #2 identified that Resident #1's legs were spread out like a letter V, and although she was aware to be careful while pushing the wheelchair through the door, she was not looking at the resident's feet, as she should have been. NA #2 stated that when Resident #1 yelled out, she realized that something was wrong, she stopped and looked, that is when she noted that the resident's left foot knock on the door jamb and bent backward. NA #2 pulled the resident in his/her customized wheelchair back, straightened out and pushed the resident back into his/her room, and notified charge nurse LPN #1 of the incident immediately. Interview and written statement review with NA #1 on 11/30/22 at 11:20 AM identified she observed on 10/8/22 Resident #1's left foot got caught on the door jamb and the wheelchair kept going forward. Interview with Orthopedics PAC #1 on 12/2/22/ at 5:30 PM identified this type of fracture that Resident #1 sustained on 11/8/22 may happen due to twisting. When Resident #1 left leg got stuck on the door jamb, it could have been twisted and fractured. The resident would have fair amount of pain with this type of fracture. Interview with DNS on 11/29/22 at 3:30 PM identified NA's responsibility was to keep the resident safe and comfortable when assisting the resident with w/c mobility. Review of facility Providing Quality Care dementia training directed safety is a major concern. Dementia puts people at risk of accidents and injuries. Memory impaired people may not be able to protect themselves from everyday hazards because they have forgotten how. Staff should take every precaution to prevent accidents.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #45) reviewed for accidents, the facility failed to provide appropriate safety measures to prevent a fall with injury. The findings include: Resident #45's diagnoses included fracture of the right femur, fracture of 6th vertebrae, difficulty in walking, muscle weakness, lack of coordination, kyphosis, and [CONDITION(S)]. A fall risk assessment dated [DATE] indicated Resident #45 was at risk for falls. The annual MDS assessment dated [DATE] identified Resident #45 had moderately impaired cognition, was always continent of bowel and bladder and required extensive assistance of one staff member for bed mobility, transfers, ambulation, dressing, toileting and personal hygiene. Additionally, the MDS identified that Resident #45 had no falls since admission (8/23/18). The Resident Care Plan (RCP) dated 8/26/21 identified Resident #45 had a problem with impaired activities of daily living. Interventions included to provide extensive assistance with a wheeled walker, gait belt and wheelchair to follow for ambulation. Additionally, the RCP identified a problem with being at risk for falls. Interventions included to independently use a recliner to reposition for comfort, staff will need to check on the resident so the resident does not slide out, safety checks per policy, close supervision with transfers and ambulation, do not leave the resident alone on the toilet, and as passing by resident's room, arrange room so that necessary articles are kept accessible. A nurse's note dated 9/22/21 at 4:30 AM identified Resident #45 was lifted back to bed after a fall, and Resident #45's may have sustained a fracture to the right hip from the fall. Additionally, the nurse's note indicated that the family member was notified, the APRN was informed and an order was received to send Resident #45 to the emergency room for evaluation, 911 was initiated and Resident #45 left the facility via ambulance. A nurse's note dated 9/22/21 at 7:05 AM indicated Resident #45 was ambulating with the rolling walker with NA #1 from the bathroom to bed when Resident #45's legs gave out and fell . NA #1 notified the nurse and upon entering the room, Resident #45 was laying on his/her buttocks on the floor with his/her legs in front and head resting on a pillow. Additionally, the nurse's note indicated Resident #45 was assisted to the recliner where the nurse noticed Resident #45 would not put pressure on the right leg and the Nursing Supervisor and APRN were made aware. A nurse's note dated 9/22/21 at 7:17 AM identified Resident #45 was admitted to hospital with a fractured right hip. A Reportable Event form dated 9/22/21 identified NA #1 was ambulating with Resident #45 without the benefit of a gait belt. A facility statement from NA #1 dated 9/22/21 identified she was exiting Resident #45's bathroom with Resident #45 and a 2 wheeled walker with her left hand supporting the resident's back (without the use of a gaitbelt). Additionally, NA #1 indicated Resident #45 fell backwards and NA #1 stated holding her night shirt did not prevent the fall entirely. An interview with the DNS on 10/18/21 at 10:00 AM identified that NA #1 did not give a reason she did not utilize a gait belt to ambulate Resident #45. Additionally, the DNS indicated that due to the contact guard status as well as the care plan, the NA should have utilized the gait belt. An interview with RN #1 on 10/18/21 at 11:55 AM indicated that when a resident is on contact guard precautions, it is the expectation that NA's utilize a gait belt. The DNS further indicated that immediately after the fall, NA #1 was re-educated regarding gait belt use. An interview with NA #1 on 10/19/21 at 12:22 PM indicated that she had been ambulating Resident #45 for a long time and there was no documentation in the care plan book to utilize a gait belt for transfers. NA #1 further identified at the time of the fall, she was ambulating Resident #45 without the benefit of a gait belt. Additionally, NA #1 indicated that her interpretation of contact guard precautions meant to keep contact with the resident with her hands on the resident at all times. An interview with the DNS on 10/20/21 at 8:55 AM indicated that Resident #45's care plan book was updated after the fall to include using a gait belt. Additionally, the DNS identified that the policy for contact guard supervision was in place prior to Resident #45's fall, it is reviewed with all staff at hire and at least annually, and this policy does include the use of the gait belt for any resident that is on contact guard precautions. The facility policy regarding Fall Prevention identified nursing and therapy staff should utilize gait belts with residents who require contact guard or if mobility is unsteady.

Based on clinical record reviews, review of facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who had food allergies, the facility failed to ensure that the resident received the appropriate diet which resulted in an allergic reaction. As a result of the facility's failure, a finding of Immediate Jeopardy was identified. The findings include: Resident #1's diagnoses included diabetes, asthma, [CONDITION(S)] and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had moderately impaired cognition, required supervision with eating and was on a therapeutic diet. The Resident Care Plan dated 5/26/21 identified Resident #1 was allergic to nuts, peanuts, bananas and aspartame. Interventions directed no nuts, peanuts, and NutraSweet (aspartame) as Resident #1 was allergic to theses foods. Further Resident #1 required assistance with activities of daily living related to a fall. Interventions directed carbohydrate controlled regular diet, Resident #1 was independent with eating. The Facility Reported Incident form dated 7/27/21 at 7:28 PM identified that Resident #1 had a severe peanut allergy, took a bite of a peanut butter cookie, and developed shortness of breath and tongue swelling. The nurse's note dated 7/27/21 at 10:38 PM identified approximately at 7:15 PM Resident #1 reported that he/she had unknowingly eaten a cookie that contained peanuts that was on his/her supper tray. Resident #1 accepted medications without difficulty. Incident was reported to the supervisor. Shortly before 7:30 PM Resident #1 rang the call bell and reported that he/she could not breath. Resident #1 was noted with dyspnea, tachypnea, watery red eyes with mild periorbital swelling, moderated swelling to tongue and upper lip. Resident #1 was grabbing at chest and throat. Order for [MEDICATION(S)] obtained, and [MEDICATION(S)] was administered intramuscular (IM) to left thigh for apparent signs and symptoms of anaphylactic reaction of peanut ingestion. Resident #1 was brought to common area for safety. Oxygen saturation level was 74% on room air (normal levels 95-100%), Resident #1 was placed on oxygen at 4 liters per minute and oxygen level increased to 95% and oxygen was decreased to 2 liters per minute. Resident #1 become diaphoretic and began vomiting, cold compress was applied to head, back and neck. Staff remained with Resident #1 for safety until EMT's arrived. Review of the Medication Administration Record for July 2021 identified Resident #1 received [MEDICATION(S)] auto-injector 0.3mg/0.3 ml IM STAT on 7/27/21. Review of the supper regular diet menu dated 7/27/21 identified a Reese's peanut butter cup cookie for supper. Review of the hospital history and physical report dated 7/28/21 at 9:43 AM identified Resident #1 had a known nut allergy but was exposed to peanut butter. Upon arrival Resident #1 was found to be experiencing [MEDICATION(S)] with severe respiratory distress, using accessory muscles, and required steroids, [MEDICATION(S)], and Nebulizer treatments. Interview with Resident #1 on 8/2/21 at 10:20 AM identified Resident #1 smelled the cookie first and the cookie did not smell or look like a peanut butter cookie. Resident #1 indicated he/she ate a little bit of the cookie, immediately realized it was a peanut butter cookie and immediately called the nurse. Resident #1 identified the cookie was not labeled and there was no meal ticket on the tray indicating a Reese's peanut butter cup cookie was served for desert that evening. Resident #1 indicated the cookie looked like a chocolate chips cookie. Resident #1 identified he/she received [MEDICATION(S)] injection that evening and was send out to the hospital, however Resident #1 could not recall the ride in the ambulance to the hospital. Interview with 7:00 AM-3:00 PM Charge Nurse, Licensed Practical Nurse (LPN) #1 on 8/2/21 at 11:47 AM identified Resident #1 usually went down to the dining room for dinner, however that evening Resident #1 requested a room tray. LPN #1 indicated around 7:15 PM she was about to administer Resident #1's medications when Resident #1 stated to LPN #1 that he/she had a cookie on his/her dinner tray that had peanuts in it. LPN #1 identified Resident #1 stated he/she had a bite of the cookie and swallowed it. LPN #1 indicated she asked Resident #1 if he/she felt well, if Resident #1 could take his/her medications and Resident #1 replied yes. LPN #1 identified Resident #1 was able to take the medications fine. LPN #1 indicated she reported the incident to the Nursing Supervisor, the supervisor contacted Resident #1's physician and obtained an order for [MEDICATION(S)] and [MEDICATION(S)]. LPN #1 identified as the Supervisor and her were sitting at the nurse's station, Resident #1 rang his/her call bell and reported he/she could not breath. LPN #1 indicated she ran to Resident #1's room and Resident #1 was short of breath, his/her eyes were puffy, tongue, top lip were swollen. LPN #1 identified she checked Resident #1's oxygen saturation level and it was 74 % on room air. LPN #1 indicated oxygen was applied and [MEDICATION(S)] was injected into the left thigh. LPN #1 indicated the supervisor called 911 and she put Resident #1 into a wheelchair and brought him/her into common area by the nurse's station. LPN #1 identified Resident #1 then became diaphoretic and vomited. LPN #1 indicated she stayed with Resident #1 until EMT's arrived. LPN #1 identified Resident #1 did not know it was a peanut butter cookie on the tray and the cookie almost looked like a brownie. LPN #1 indicated she knew Resident #1 was allergic to peanuts, however she was unaware that Reese's peanut butter cup cookie was served for supper that day. LPN #1 also identified that meal trays did not have meal tickets on them and the NA's would not know what is on the menu. Interview with 3:00 PM-11:00 PM nurse aide, Nurse Aide (NA) #1 on 8/2/21 at 12:33 PM identified she delivered Resident #1's dinner tray to him/her. NA #1 indicated she was unaware Resident #1 was allergic to peanuts and that there were peanuts in his/her cookie. NA #1 identified the cookie looked like a chocolate chips cookie. NA #1 indicated Resident #1 was independent with eating and usually ate his/her meals in the dining room. NA#1 identified that night Resident #1 did not feel well and decided to have supper in his/her room. Interview with Food Service Director on 8/2/21 at 1:02 PM identified she interviewed Dietary Aide #1 after the incident and he stated, he was the one who prepared Resident #1's dinner tray. The Food Service Director indicated Dietary Aide #1 stated he was busy that night, he did not check Resident #1's allergies and placed a Reese's peanut butter cup cookie on Resident #1's dinner tray. Food Service Director identified the dietary aide was responsible to check Resident #1's allergy list which was posted on the refrigerator and offer Resident #1 an alternative dessert for dinner. The Food Service Director identified that the facility was in the process of implementing a meal ticket system that would identify diet and allergy information and be placed on the meal tray. Interview with Dietary Aide #1 on 8/3/21 at 10:45 AM (obtained after conclusion of survey) identified Resident #1 usually ate dinner in the dinning room and it was unusual for Resident #1 to request a tray. Dietary Aide #1 indicated nursing staff called the kitchen to prepare a tray for Resident #1. Dietary Aide #1 identified he was the one who prepared the dinner tray for Resident #1. Dietary Aide #1 indicated he was trying to help and normally he did not set up the meal trays for residents. Dietary Aide #1 identified his responsibility was to serve meals in one section of the dining room and wash the dishes afterwards. Dietary Aide #1 identified he was stressed, he did not check the allergy list for Resident #1 and made a mistake by serving Resident #1 a Reese's peanut butter cup cookie for dinner. The Dietary Service Policy directed the cook to serve meals according to the Dietitian, resident and care plan specifications. All diets being distributed or leaving the kitchen were on a tray will be to mutual responsibility of the Diet Aide and the Cook. Subsequent to the incident the facility implemented an immediate plan of correction that included immediate and on-going education on food allergies for all dietary and nursing staff, diet and allergy policy and procedure review and revision, implementation of a new meal ticket system to alert staff of allergies, nurse aide care sheets updated to include resident allergies, food to be served in clear containers in to help staff recognize and identify potential allergens, review of the list resident allergies, food allergy list to be kept where food is cooked at buffet stations, and where trays were prepared. Audits were initiated.

Based on clinical record review, review of facility documentation and interviews for one sampled resident reviewed for Accidents (Resident #1), the facility failed to implement interventions for a resident who was an elopement risk and failed to reassess the resident when the resident had behavioral changes, including exit seeking behaviors. The findings include: Resident #1's diagnoses included Alzheimer's disease, dysthymic disorder. An Elopement Risk assessment dated [DATE] identified contributing factors of wandering with no rational purpose and attempting to open doors. The assessment further identified the preventive action taken directed placement on a secured unit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident had severe cognitive impairment and required extensive assistance of one staff for bed mobility, and supervision of one staff for transfers, walking in corridor and for locomotion on the unit. The assessment also noted the resident had no wandering behaviors. A care plan dated 9/24/20 for at risk for wandering related to cognitive loss and admitted to facility with a history of wandering. Interventions included: Elopement Assessment to be completed upon admission, quarterly and as needed and if resident refuses or removes wander guard bracelet, attach bracelet to walker, wheelchair or piece of their clothing, otherwise initiate 15-minute safety checks with safety alarm outside resident's room until wander guard is in place. A review of the clinical record identified the resident utilized a wander guard from 3/2019 through 11/2/20 until discontinued. Physician's order sheet identified a nursing order dated 11/2/20 directing to discontinue wander guard. The nurse's note dated 11/2/20, 10:33 A.M., identified: Resident #1 is no longer an elopement risk. He/she no longer ambulates/wanders on his/her own. Wander guard discontinued. Elopement risk assessment dated [DATE] identified the assessment was written by RN #4 but otherwise was a blank assessment form (indicating the assessment had not been completed). A communication sent via text message by RN#3 on 12/10/20 to the Assistant Director of Nursing Services (ADNS) and to the unit secretary identified Resident #1 had walked through secure doors into an unsecure unit. The resident was observed by staff and returned to the unit without incident. RN #3 could not locate a wander guard to place on the resident and requested assistance from the ADNS. The ADNS via text message identified wander guards would need to be ordered and directed RN # 3 to look further for one. An invoice dated 12/14/20 identified wander guards were ordered. The quarterly MDS assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required limited assistance of one staff for ambulation on the unit and had no wandering behavior. A social service quarterly review note dated 12/23/20 identified the resident with BIMS of 5, consistent with advancing cognitive loss. The social service notes noted Resident#1 had a medication change in the beginning of December 2020 when his/her [MEDICATION(S)] was added to the resident's daily medication regimen. Staff began noticing adverse reaction as evidenced by this previously calm and loving resident becoming agitated, attempting to slap staff, decline in appetite with increased restlessness. [MEDICATION(S)] was discontinued on 12/18/20, with improvement and indicated return towards baseline. The social service notes further identified that [MEDICATION(S)] was discontinued on 12/15/20, and identified the resident generally ambulates ad lib throughout the facility but does not exit seek. A care plan dated 12/24/20 identified a focus of [CONDITION(S)] drug use of the antidepressant [MEDICATION(S)], interventions included: to monitor the resident's mood and response to medication, and update physician of any changes noted. The care plan dated 12/24/20 did not identify risk for elopement. The nurse's note dated 12/28/20 identified the resident was observed trying to open sliding door in dining room (which led to an enclosed area) and yelling. The nurse's note dated 1/6/21 identified RN #3 was notified of the resident missing by LPN #1 and at approximately 9:00 P.M. all units were directed to conduct a search for the resident. The ADNS was notified and begin notifying the DNS and Administrator, 911 was called. The nurse's notes dated 1/6/21 identified the resident was located on the facility grounds by police canine unit at 10:20 P.M (1hour and 20 minutes after the resident was identified as missing). The Emergency Medical Services (EMS) run sheet dated 1/6/21 identified a dispatch time of 10:17 P.M, assessment time of 10:52 P.M., and identified the resident's temperature reading was low (unable to record). The resident was transferred to the emergency room for an evaluation. A review of the Emergency Department discharge summary dated 1/7/21 identified a discharge diagnoses of accidental hypothermia, dementia, low back pain, dysphagia and Urinary Tract Infection (UTI). Minimum temperature (rectal) was 93.6 degrees (Normal Range 97.9) Fahrenheit. The nurse's noted 1/7/21 identified Resident #1 was transferred back to the facility at 6:45 P.M. Documentation identified the resident was found by state troopers wandering outside in his/her nightclothes. Temperature reports identified temperature range for the location on 1/6/21 was a high of 29 degrees and a low of 25 degrees. A review of the clinical record on 1/9/21 failed to identify that Resident #1 was reassessed and interventions were implemented for a resident with a history of exit seeking behaviors: when the resident's wander guard was discontinued on 11/2/20 without the benefit of an assessment , on 12/10/20 when the resident attempted to exit from a secure unit to an unsecure area , on 12/28/20 attempted to open an enclosed sliding door and when the resident exhibited behavior changes. Interviews and observations with the Administrator on 1/9/21 at 10:40 AM identified: The unit lobby door Resident #1 exited by was able to be exited at any time by residents without wander guards. This was the ongoing practice for the unit as family came in and out of that door to visit residents. Since COVID-19 restrictions, the entrance had been locked from the outside, but the door remained open for exiting by any person without a wander guard. The Administrator identified the door should have required keypad code to open the door. Interview with LPN # 1 on 1/9/21 at 4:50 P.M. Identified Resident #1 was missing at 8:50 P.M., when LPN #1 went to the resident's room to obtain a bladder scan, LPN #1 immediately notified the unit staff to search for Resident#1 and notified RN #3. Interview with RN #3 on 1/10/21 at 2:55 P.M. identified RN #3 did not document the 12/10/20 incident of Resident #1 walking through an unlatched door because he/she forgot. RN # 3 also indicated that the unlatched door had signage alerting staff to make sure the door latches. RN #3identified he/she was present on 12/28/20 and had observed the documented behavior of the resident attempting to open the dining room sliding door. RN #3 further indicted on 12/28/20 the resident was monitored until calm and no further action had been taken because she/he believed there were no available wander guards. Interview with the ADNS on 1/10/21 at 3:25 PM identified the ADNS did not recall a text message regarding Resident #1 being found in [NAME] Unit on 12/10/20, but did recall telling RN #3 to look in the nursing office for a wander guard. The ADNS identified wander guards were ordered but does not recall the date they were ordered. Interview with RN #3 on 1/10/21 at 4:35 PM identified RN #3 had now just checked with the unit administrative staff who identified the wander guards had been ordered and delivered. RN #3 identified one of the wander guard was not used for Resident #1 and indicated a wander guard should have been given to Resident #1. RN #3 could not identify why Resident #1 had not received the wander guard. Interview with NA #1 on 1/10/21 at 4:39 P.M. identified the resident prior to elopement was last seen in bed at 8:00 PM. Interview with the ADNS on 1/10/21 at 4:45 P.M. identified nursing is responsible for assessing the resident's behavior, review and revise the care plan, implement interventions, obtain wander guard and document all incidents.

Based on a review of clinical records, facility documentation, policies, and interviews, for two of five residents who were at risk for wandering and utilized a wander guard device, (Resident #1 and Resident #2), the facility failed to ensure a system was in place for the monitoring of wander guard devices for proper function and as a result, R #1 eloped from the facility. This resulted in immediate jeopardy which was determined to be corrected during documentation review. On 9/24/18, the facility revised the elopement policy that directed the wander guard would be checked weekly for function, staff were educated, and audits were implemented to monitor compliance. In addition, the facility failed to ensure that the wander guard system, twenty (20) throughout the facility was monitored for functionality on a weekly basis and/or elopement drills were conducted in accordance with facility policy. The findings include: 1. Resident #1 was admitted to the facilities secured dementia unit on 8/17/18 with [DIAGNOSES REDACTED]. Review of the admission nurses note dated 8/17/18 identified that the resident was alert and confused and noted with four (4) sutures to the left occipital area from a recent fall. An elopement assessment dated [DATE] identified that the resident was at risk for elopement and a wander guard device was applied. A care plan dated 8/17/18 identified that the resident had a history of [REDACTED]. Review of the 14 day Minimum Data Set (MDS) assessment dated [DATE] identified that the resident had severe cognitive impairment, inattention, disorganized thinking, required extensive assistance with activities of daily living, and required a wheelchair and/or a walker with assistance for mobility. A social service note dated 8/29/18 identified that a care plan meeting was held and twenty-four hour care was recommended due to the resident being a significant wander risk. Review of a facility reportable event and investigation dated 9/23/18 at 2:50 PM identified that as Registered Nurse (RN) #1 was pulling into the facility driveway, she noticed a pick-up truck with Resident #1 in the passenger seat, a passerby had realized that this was a resident of the facility that seemed to be lost, so he had picked the resident up. RN#1 placed the resident in her vehicle and drove him/her back to the facility. The wander guard was noted to be on the resident's left wrist but apparently had malfunctioned. The resident was given a new wander guard and placed on every fifteen minute monitoring checks. A body audit was conducted and although the resident denied falling, a three centimeter (cm) by three cm bruise was noted to the left flank area. Review of the clinical record failed to identify that the wander guard device was monitored for function prior to application of the device upon admission on 8/17/18, and/or that the resident's risk for elopement was re-assessed subsequent to the elopement on 9/23/18. Interview with RN#2 on 10/3/18 at 10:30 AM identified that she had completed the resident's elopement assessment upon admission on 8/17/18 and had placed the wander guard on the resident. RN #2 was unable to recall if the wander guard was new from a package or had been utilized previously, was unaware wander guards had expiration dates and stated she did not check the wander guard for function prior to placing it on the resident. Interview with Nurse Aide #1 on 10/3/18 at 11:30 AM identified that she was taking care of Resident #1 on 9/23/18, the resident expressed a desire to go home during the shift, however, had no exit seeking behaviors, and this was the resident's baseline behavior. NA#1 further identified that the resident had finished lunch around 1:00 PM, she walked the resident back to his/her room to allow for toileting, then brought the resident back to the lounge around 1:30 PM, seated him/her in a recliner, turned the chair pad alarm on and went to assist other residents. NA#1 stated that she did not see the resident again until 2:40 PM, when RN #1 brought him/her back to the unit, nor did she hear any alarms go off. Interview with RN #1 on 10/3/18 at 2:00 PM identified that on 10/3/18 she was pulling in to the facility driveway at about 2:40 PM when she witnessed a pick-up truck blocking the driveway, she exited her car to see if assistance was needed. The driver of the pick-up truck stated that he saw Resident #1 walking down the driveway and stopped him/her about 100 feet from the main road, because the resident seemed lost. RN#1 assisted Resident #1 into her vehicle and brought him/her back to the nursing unit, and identified that there was a wander guard located on his/her wrist, completed a body check and identified a three by three cm bruise to the left flank area. Interview with LPN#1 on 10/3/18 at 2:00 PM identified that RN#1 had directed her to test Resident #1's wander guard upon re-entry to the facility. LPN #1 brought the resident to the exit door located by the dining room to test the wander guard, and the door did not lock. LPN#1 stated that she obtained a new wander guard from the manager's office, and ensured proper functioning before applying it to the resident. Interview and observation of the exit door located adjacent to the Whitridge dining room on 10/3/18 at 9:00 AM with RN#3 (the unit manager), identified that it was suspected that this was the door that the resident exited through on 9/23/18. RN#3 stated that the door is unsecured during the hours of 8:00 AM to 8:00 PM, but is wander guard equipped. The exit door will auto lock when a resident with a wander guard approaches the door within 5 feet of the door and the door will remained locked until a staff member enters a code into the keypad to disengage the lock. Further interview and review of the clinical record with RN#3 identified that it was her understanding that the facility should be checking the wander guard function every 30 days and documenting on the Treatment Administration Record (TAR). The function should be checked by bringing the resident to the wander guarded equipped door to ensure the door locks when the resident is present. RN#3 further identified that although the staff were monitoring the placement of the resident's wander guard every shift, the clinical record failed to identify that the function of the wander guard was checked prior to the elopement on 9/23/18 (36 days after the wander guard was placed on the resident). Interview with the Director of Nurses (DON) on 10/3/18 at 1:30 PM identified that the resident should be re-assessed for elopement risk after an elopement of 9/23/18 but the clinical record failed to reflect it had been done. The DON stated that when RN #2 placed the wander guard on the resident, she should have checked the expiration date, ensured function. Further interview with the DNS identified that the elopement policy and/or wander guard policy failed to direct any monitoring of wander guard devices to ensure function. Review of the manufacturer's specifications for use, with the DNS, identified that the device should be tested for function every 30 days to ensure proper functioning. The DNS further identified that immediately upon return to the facility on [DATE], the resident was given a functional wander guard device, placed on every fifteen minute checks, and the elopement policy was revised to include the checking wander guard function weekly. The facility also placed a wander guard tracking tool in the supervisor's office to track the wander guard function and tracking of expiration dates. Audits of these processes were ongoing. 2. Resident #2 had a [DIAGNOSES REDACTED]. A resident care plan dated 3/2/18 identified that the resident was at risk for elopement and had a wander guard. An elopement assessment dated [DATE] identified that the resident was at risk for elopement and a wander guard device was in place. Review of the clinical record and/or facility documentation from 4/1/18 - 9/30/18 (a total of five months) failed to identify that the wander guard device was monitored for placement and/or function. Interview with RN #4 on 10/3/18 at 12:45 PM identified that Resident #2 frequently will leave the unit and wheel himself throughout the facility in his/her wheelchair. RN#4 further identified that although she was unable to find the documentation in the clinical record in regards to checking for the placement and/or function of the wander guard, the nursing assistants are aware of the wander guard because it is on the nurse aid assignment. Interview with the DON on 10/3/18 at 1:45 PM stated subsequent to Resident #1's elopement on 9/23/18, the function and placement for Resident #2's wander guard was completed. 3. Review of the elopement policy dated 3/15/18 identified that entrances and exits equipped with wander/roam alert devices such as audible alarms, magnetic locks, or both, will be checked weekly by the evening maintenance staff to ensure proper function. Interview with the Administrator on 10/3/18 identified that the Director of Environmental Services (DEM) who was responsible to complete the weekly checks was no longer employed at the facility since 9/11/18 and that he was in the process of hiring a new Director. Interview with the previous DEM on 10/3/18 at 2:45 PM identified that he could not remember the last time he checked the wander/roam alert doors for function but it had been quite some time, but couldn't recall why he had stopped checking the function. Interview with the interim DEM and Administrator on 10/3/18 at 2:00 PM identified that they were not aware of how many wander/roam alert doors were located within the facility, but subsequent to surveyor inquiry, an audit was conducted and the facility was equipped with twenty (20) wander/roam equipped doors. The Administrator identified that all doors would be checked immediately for function and then checked weekly per the facility policy. 4. Review of the elopement policy identified that the Director of Environmental Services (DES) and the Director of Nurse (DON) will conduct elopement drills twice per year. Interview with the administrator on 10/3/18 at 2:00 PM identified that the previous DES had been terminated on 9/11/18, and he was unable to find any documentation on elopement drills. Interview with the previous DEM on 10/3/18 at 2:45 PM identified that he had not conducted elopement drills because he was unaware that it was his responsibility.

Based on a review of clinical records, facility documentation, staff interviews and a review of the facility policies, for one of two sampled residents reviewed for allegations of mistreatment (Resident #1), the facility failed to ensure the resident was free from abuse. The finding included: Review of the clinical record identified Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified moderate cognitive impairment, extensive assistance with transfers, bed mobility, personal hygiene and toilet use with a one person assist. The Nursing Care Plan dated 6/22/16 identified psychosocial well-being as a potential problem with an intervention that included the residents quality of life would be maintained with dignity and respect in accordance with the resident's rights. Interview and review of the facility documentation dated 7/7/16 with NA #3 on 7/21/16 indicated Resident #1 disclosed to NA #2 and NA #3 on 7/7/16 that during incontinent care on 7/6/16 at approximately 5:30 AM, NA #1 pushed hard on the resident's hip and abdomen and it caused pain. Resident #1 indicated he/she told NA #1 to stop and she did not. In addition Resident #1 alleged NA #1 slapped him/her on the face prior to leaving the room. Further interview with NA #3 on 7/21/16 indicated Resident #1 identified he/she was relieved to receive care from NA #2 and #3 on 7/7/16 as he/she was fearful of NA #1. Interview with Resident #1 on 7/21/16 at 11: 00 AM identified he/she was fearful of NA #1 following the incident and was relieved that NA #2 and #3 were assigned to him/her the following day. Interview and review of the clinical record with Nursing Supervisor #1 on 7/21/16 identified she was notified on 7/7/16 by LPN #1 after the resident disclosed the allegation and examined him/her. Two round purple bruises on the left flank hip area were noted that measured 2 by 2 centimeters (cm) and 1 by 1 cm. Interview with the facility Medical Director on 7/21/16 at 3:15 PM indicated he also examined Resident #1 on 7/7/16 and identified the two bruises noted on the residents hip and abdomen were consistent with hand placement and tender to the touch. Review of the police statement and interview with State Trooper #1 on 7/21/16 indicated on 7/6/16 at 5:30 AM NA #1 identified she provided incontinent care to Resident #1. NA #1 had grabbed the resident's left hip as he/she rolled the resident onto his/her right side. Resident #1 was resistive to care and asked NA #1 to stop however, NA #1 indicated I was squeezing hard with my left hand on his/her hip and rib area. I held onto him/her because I was frustrated with the resident as I had twelve other residents to care for and figured I could quickly finish his/her incontinent care. Further interview with State Trooper #1 indicated the bruises noted on the Resident's left side were approximately 6 inches apart and consistent with a hand print. Interview with the Assistant Director of Nursing (ADNS) on 7/21/16 indicated that NA #1 had received education on 3/22/16 regarding preventing, recognizing and reporting abuse. The ADNS further stated the resident's story remained consistent throughout the investigation and NA #1 was subsequently terminated as the facility substantiated abuse. An attempt to interview NA #1 on 7/21/16 was unsuccessful. The facility policy entitled abuse identified that residents would be free from verbal, sexual, physical or mental abuse and involuntary seclusion. Residents would be protected from abuse from, but not limited to the following, facility staff.

Based on clinical record reviews, observations, review of facility policies, and staff interviews for four of six sampled residents reviewed for pressure ulcers (R # 14, 17,21, 49), the facility failed to assess a pressure ulcer when identified, and at least every 7 days thereafter until healed, and/or failed to review and revise the care plan to treat a pressure ulcer when identified, and/or failed to initiate interventions to prevent pressure sores to the heels/feet, and/or failed to treat wounds in accordance with industry standards. The findings include: 1. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Braden scale dated 2/5/16 identified that the resident was at risk for pressure sore development. Interventions included pressure reducing device for the bed. The admission skin integrity assessment dated [DATE] identified two stasis ulcers located on the left lower extremity; one on the dorsal side and one on the ventral side with granulation tissue and a moderate amount of serosanguinous drainage, surrounding tissue was intact with two plus [MEDICAL CONDITION]. No pressure ulcers were identified. Physician orders dated 2/5/16 directed to apply [MEDICATION NAME] to the left lower extremity wound, wrap with a six inch ace from toes to knee, and to change daily. physician progress notes [REDACTED].#17 developed an ulcer over the Achilles tendon area on the left lower leg, probably from the ace bandage being attached to tightly. Recommendations included to discontinue ace wrap. The physician orders failed to reflect treatment orders were obtained and/or initiated when the resident was identified with a pressure ulcer. The skin integrity wound record dated 2/9/16 identified a pressure ulcer on the posterior ankle measuring 1.8 CM x 1.2 CM with yellow slough present in the wound bed, scant amount of sero-sanguineous exudate, surrounding tissue with [DIAGNOSES REDACTED], and two plus [MEDICAL CONDITION], with a moderate amount of pain present. Interventions included to off load heels. The admission MDS assessment dated [DATE] identified the resident had severely impaired cognition, required extensive assistance with bed mobility, was frequently incontinent of bowel and bladder, was at risk for developing pressure ulcers, and no pressure ulcers currently. Nurse's notes dated 2/10/16 by RN # 3 noted that the MD dictation in the record stated pressure area on the Achilles tendon from ace wrap being too tight. This writer disagrees. The most likely scenario was the resident was sitting in the recliner chair with his/her feet hanging over the foot rest. The resident sits with a pillow behind her back which moves him/her forward in the chair so that the back of the ankles is on the edge of the chair. The feet were offloaded yesterday and now will be done daily when his/her feet are in the up in the reclined position. The skin integrity wound record dated 2/19/16 (ten days later) noted the pressure ulcer located on the posterior ankle measured 3 CM x 1.8 CM with yellow slough present in the wound bed, scant amount of serosanguinous exudate, surrounding tissue with [DIAGNOSES REDACTED], and two plus [MEDICAL CONDITION] to the lower extremities. The plan of care failed to reflect any new interventions had been developed and/or implemented when the pressure ulcer had declined. Facility policy and procedure for wound and skin care direct upon admission, all residents will undergo a skin assessment performed by the licensed nurse, and documented on the skin assessment form. The pressure ulcer risk assessment/prevention intervention protocol is to be completed upon admission, and appropriate interventions implemented, followed by weekly assessments. Nurse managers monitor the wounds on their units, respectively. The interdisciplinary plan of care will address problems, goals and interventions directed toward the prevention and/or treatment of [REDACTED]. All residents admitted to this facility with pressure ulcers or other skin breakdown will be comprehensively assessed, inclusive of photo, by a licensed nurse, and a treatment plan will be initiated by physician order. For venous stasis ulcers apply compression stockings as ordered, monitor resident every shift for changes in skin integrity, and document changes. Ensure the resident is turned every two hours while in bed, and document. Elevate lower extremities while in bed or chair and document. Interview and review of the clinical record with RN #3 on 6/29/16 at 9:30 AM identified he/she is responsible for completing weekly wound assessments and documenting his/her findings on the skin integrity wound record. The clinical record identified a weekly wound assessment was completed on 2/9/16 with the next wound assessment not completed until 2/19/16 (ten days later) when the pressure ulcer was noted as larger in size. RN #3 identified he/she was unable to provide documentation a weekly wound assessment was completed. RN #3 indicated that he/she was probably busy and was not able to complete the weekly assessment on time, and felt there was no difference in assessing the pressure ulcer in seven days or ten days. RN #3 indicated although there were no physician orders for the treatment of [REDACTED]. Additionally, RN #3 indicated [MEDICATION NAME] was an appropriate treatment for [REDACTED]. RN #3 identified he/she knew [MEDICATION NAME] ointment had [MEDICATION NAME] properties because when he/she removed residents old dressings he/she could visualize slough on the soiled dressings. RN #3 was unable to provide evidenced based information related to the [MEDICATION NAME] properties with the use of [MEDICATION NAME] or literature indicating that [MEDICATION NAME] was an appropriate treatment for [REDACTED]. Interview with ADON on 6/29/16 at 9:45 AM identified residents with pressure ulcers have weekly wound assessments completed by the unit manager and documented on the skin integrity form. When a resident is identified at risk for developing pressure ulcers, interventions are implemented for pressure relief/off-loading of the area, and documented on the treatment administration record (TAR), or in the nurse aide flow record. When a resident is identified with a pressure ulcer, the physician is notified, treatment orders are obtained for each area, and documented on the (TAR). Every wound will have specific treatment orders related to that particular wound. The clinical record failed to reflect weekly wound assessments were completed, and/or interventions were implemented when the resident was identified at risk for skin breakdown and/or failed to obtain physician orders for the treatment of [REDACTED]. Interview with MD #1 on 6/30/16 at 11:15 AM indicated when he/she assessed R #17's wounds, he/she determined the open area on the Achilles tendon was due to pressure from the ace wrap being applied to tightly on the left lower extremity. The clinical record failed to reflect interventions were implemented for pressure relief/off-loading of the lower extremities. 2. Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment dated [DATE] indicated the resident had no memory problems, required assist of 1 for ADL ' s and had no pressure ulcers. An admission care plan dated 1/5/16 identified a risk for altered skin condition related to a fractured ankle and cast. Interventions included elevate left lower leg at all times and monitor the left lower leg for color, moisture, sensation, temperature, pain, and pressure. A Physician referral form dated 2/17/16 indicated the cast to the left leg was removed and an ankle brace was applied. A Physician's order dated 2/17/16 directed weight bearing as tolerated with walker and ankle brace. Review of nurse ' s notes noted the following: On 2/18/16 11:00 PM - 7:00 AM, it was noted scabs to the left ankle were clean, dry and intact. On 2/19/16 7:00 AM - 3:00 PM, a bruise was noted on the left ankle. On 2/20/16 11:00 PM - 7:00 AM, the scabs on the left ankle were intact. On 2/24/16 11:00 PM - 7:00 AM, a scab on the left inner ankle with pink near the scabs only. The resident complained of pain 2 inches from the scab. On 2/25/16 11:00 PM - 7:00 AM, a scab was noted on the left outer ankle. On 3/3/16 11:00 PM - 7:00 AM, a bruise/scab was noted on the left outer lateral foot. On 3/11/16 11:00 PM -7:00 AM, a scab was noted on the outer left lower leg Review of a pressure ulcer observation note dated 3/21/16 indicated R #14 had a 1.3 cm x 1.5 cm unstageable area on the left foot. A nursing progress note dated 3/21/16 indicated a 1.3 cm x 1.5 cm black area was noted on the resident's left foot. The resident indicated the orthopedist was aware of the area and indicated it was from the cast he/she had on and the scab would fall off in time. A review of the clinical record and staff interview on 6/30/16 at 7:30 AM with the DNS indicated although there were periodic entries in the nurse ' s notes regarding a scab on the resident's left foot, there were no initial assessments and/or ongoing assessments of the wound until 3/21/16 (31 days later). He/she would have expected weekly assessments. Further review with the DNS failed to provide documentation that the care plan had been updated to reflect the presence of a pressure sore and/or develop interventions to aide in healing it from 2/18/16 when the area was identified through 3/21/16. 3. Resident #21's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE] identified that R#21 had moderate cognitive impairment, required extensive assistance with bed mobility and was at risk for developing pressure ulcers. The care plan dated 2/7/16 identified a risk for impaired skin integrity related to incontinence. A skin integrity document dated 2/16/16 noted a slit to coccyx that measured 1.5 CM. Nurse ' s notes dated 3/22/16 identified that R#21's buttock was reddened but intact and that the previous stage two pressure sore was healed. Interview and review of R#21's clinical record with the ADNS on 06/30/2016 at 9:48:40 AM indicated that although it was the facility policy to monitor and document pressure areas weekly, s/he was unable to provide (four weeks) of documentation that ongoing weekly wound assessments were conducted. 4. Resident #49's [DIAGNOSES REDACTED]. The 60 day MDS assessment dated [DATE] identified that the resident was cognitively impaired and required extensive assistance with bed mobility and transfers. The care plan dated 3/21/16 identified a risk for impaired skin integrity related to impaired mobility, incontinence, poor nutrition, and altered mental status. Interventions included to monitor skin integrity with AM and PM care, report changes in skin condition, turn and reposition every two to three hours per protocol and per request and provide an air mattress. Interview and review of facility documentation with RN#4 on 6/29/16 at 12:13 PM identified that on 3/14/16, according to a nurse ' s note, a red blanchable area was identified to the right outer foot bony prominence. Further, RN#4 identified that a Nurse ' s note dated 3/21/16 identified that a purplish area to the right outer foot was reported to him/her and that he/she had assessed the area to find a blister approximately 1.3 x 1.3 cm on the right outer foot bony prominence that was previously red and blanchable. RN#4 identified that he/she did not measure the area following the measurement on 3/24/16 because the blister was intact. Additionally, RN#4 was not aware that a blister over a bony prominence was, according to the National Pressure Ulcer Advisory Panel, a stage 2 pressure ulcer. RN#4 identified that an order for [REDACTED].#4 identified that he/she felt that the blister was healed by 5/18/16 when a nurse ' s note identified that the right outer foot skin was intact, no signs of redness noted and the order for skin prep was discontinued, but that no other tracking or on-going assessments were identified. According to the facility policy, a stage 2 pressure ulcer may present as an intact or open/ruptured serum-filled blister and that there should be on-going documentation by the charge nurse in the medical record to describe the effectiveness of interventions and resident's response to therapy

Based on clinical record reviews, reviews of facility documentation and interviews for the only sampled resident with a medication overdose (R#68), the facility failed to ensure that medications were swallowed prior to leaving the resident, and/or for two of six sampled residents reviewed for an injury of unknown origin, (Resident #36, #75) the facility failed to complete a thorough initial assessment of the injury and/or conduct on-going assessments. The findings include: 1. Resident # 68 ' s [DIAGNOSES REDACTED]. A physician order [REDACTED]. The care plan dated 7/27/14 identified mood/behavior problems requiring the use of psychoactive medications. Interventions directed the staff to monitor for side effects of the medications. A quarterly MDS dated [DATE] identified the resident was without cognitive impairment and independent with ADL ' s. Nurse ' s notes dated 10/13/14 identified that when the charge nurse entered the resident ' s room to administer morning medications, a change in the resident ' s metal status was noted. The resident was lethargic, not easily aroused, but able to answer questions with one word responses. An APRN assessment and progress note dated 10/13/14 identified an acute mental status change and questioned a [MEDICAL CONDITION]. The resident was transferred to the ED for evaluation. Nurse ' s notes dated 10/15/14 identified that the facility was notified that although the resident was transferred to the ED for a possible [MEDICAL CONDITION], the resident showed improvement and confessed to hospital staff that she/he ingested [MEDICATION NAME] which the resident had been hoarding in an attempt to end her/his life. The resident reported spitting the medication into a jar and hoarding enough over a period of time. Prior to the event, the resident showed no signs of worsening depression or routines outside her/his norm. A Laboratory report dated 10/13/14 identified a [MEDICATION NAME] level greater than 6250 ng/ml. (normal reporting limits 50 ng/ml). Interview, review of the clinical and review of the facility ' s investigation of the incident on 5/7/15 with the DNS identified that from 9/13/14 to 10/13/14, the resident had received 62 tablets of [MEDICATION NAME] for anxiety. All nurses who administered the medications were interviewed. It was discovered that two nurses had left the resident unattended with her/his medications on at least 11 occasions in the 30 days. The resident admitted to pocketing additional [MEDICATION NAME]. The resident did not have an order to self-administer medications. The facility medication administration policy directs nurses to remain with the resident while they take medications to ensure appropriate administration. 2. Resident #36's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified Resident #36 had long and short term memory impairment and was independent with bed mobility, transfers, locomotion on and off the unit, toileting and personal hygiene. The ADL care plan dated 8/6/14 identified the resident was independent with transfers, non-ambulatory, and utilized an electric scooter. Review of the facility documentation dated 9/15/14 at 2:30 PM identified the resident complained of a sore wrist and the APRN examined the resident on 9/12/14 and determined that the resident had no loss in range of motion. Review of the nurse's and APRN notes from 9/12/14 until 9/15/14 lacked any documentation of the resident's complaints regarding his/her wrist and/or assessment of the area until 9/13/14 at 4:27 PM when a partial assessment was conducted that identified Resident #36 complained of left wrist pain. No further assessments were conducted until 9/15/14 at 8:24 AM when it was identified that Resident #36's wrist remained swollen and painful to touch and it was noted that the resident exhibited difficulty with range of motion and was guarding the extremity. The Medication Administration Record [REDACTED]. Review of the x-ray report dated 9/15/14 identified that Resident #36 had a possible non -displaced [MEDICAL CONDITION] radius, no dislocation and bone demineralization was present. Interview with the ADNS on 5/7/15 at 12 PM identified that when Resident #36 ' s wrist condition changed, he/she would have expected the nursing staff to assess for pain, range of motion and to document the findings. Additionally, the ADNS identified that when pain medications were administered on 9/13/14 and 9/14/14 an assessment of the wrist should have been conducted and correspondingly documented in the clinical record. 3. Resident #75's [DIAGNOSES REDACTED]. The care plan dated 4/9/15 identified the resident required assistance with ADL's. Interventions included two person transfer with a weight bearing mechanical lift. The Medication Administration Record [REDACTED]. The clinical record failed to reflect a physical assessment was completed when the resident was noted with a change in condition with new onset left arm pain. Nurse's notes dated 4/28/15 at 10:19 PM noted the left arm was evaluated by the nurse, resident is wincing upon gentle ROM which is limited. [MEDICAL CONDITION] noted left hand, left shoulder has a divot and is protruding slightly. No bruising, redness or warmth noted. Arm elevated and turn and reposition with draw sheet only. The MD was notified and directed to obtain an x-ray in the AM. X-ray report dated 4/29/15 identified an anterior left shoulder dislocation. The facility event documentation dated 4/29/15 at 1:00 PM identified that the resident had a left shoulder dislocation, no fall or any other reason for this injury to have occurred. No investigation was initiated and/or completed when the resident was identified with an injury of unknown origin with a dislocated left shoulder. The facility policy directs that staff will initiate an investigation within 24 hours of discovery of a resident with an injury of suspicion or of unknown origin. Interview and review of the clinical record with RN #1 on 5/6/15 at 12:15 PM noted during evening care on 4/28/15, NA #1 noted the resident was in pain when moving the left arm. Interview with NA #2 on 5/7/15 at 10:10 AM noted he/she had provided am care to R #75 on 4/28/15. He/she noted that he/she transferred R #75 with RN #1 utilizing the Sarita stand up lift to his/her customized wheelchair. Once in the wheelchair R #75 was noted to have left arm pain. NA #2 reported it RN #1. Additionally NA #2 indicated when returning R #75 back to bed after lunch on 4/28/15, he/she utilized a Hoyer transfer instead of the Sarita lift due to R #75's complaints of left arm pain. Subsequent interview with RN #1 on 5/7/15 at 10:20 AM identified when R #75 had complaints of left arm pain after being transferred out of bed on 4/28/15 he/she did look at the left arm and felt that it was a minor issue that did not need a documented assessment.