Every finding on record at North Bay Post Acute

Based on interview and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents was free from physical abuse when Resident 2 struck the back of Resident 1's head and forcefully shook Resident 1's wheelchair.This failure placed Resident 1 at risk for actual and potential physical and psychosocial harm.A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of Wernicke's Encephalopathy (a medical condition caused by a severe deficiency of thiamine (Vitamin B1) which is liked with alcohol abuse. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke) and Hemiplegia (paralysis on one side of the body) affecting the left side. A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 1/17/26, indicated Resident 1's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 14 of 15 which indicated intact cognition.A review of Resident 2's Situation, Background, Assessment and Recommendation (SBAR- a structured, standardized format for concise communication in healthcare which is designed to enhance patient safety and team communication) documentation, described Resident 2's previous physical altercations with other residents as follows:On 6/10/25 at 6:51 p.m., indicated, resident to resident physical incident where one resident's hand made contact with another resident's face after getting upset after hearing the resident cussing.On 10/2/25 at 9:34 p.m., indicated staff heard yelling coming from Resident 2 's room. Resident 2's roommate reported incident of resident-to-resident altercation with physical contact.On 3/21/26 at 7:10 a.m., indicated Resident 1 informed his nurse that he was hit by [Resident 2] on the right side of his head.A review of Resident 2's care plan, dated 6/10/25 and updated on 3/21/26, indicated Resident 2 was involved in a resident physical incident. A goal was for Resident 2 to have no further episodes of verbal or physical altercation with another resident. To meet this goal, the staff would administer Resident 2's medications, keep other residents away from Resident 2 until aggressive behavior resolved, monitor target behaviors and redirect, and intervene before agitation escalated.A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 1/17/26, indicated Resident 1's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 14 of 15 which indicated intact cognition.A review of Resident 2's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/19/26, indicated Resident 2's BIMS score of 13 of 15 which indicated intact cognition. During an interview in Resident 1's room on 4/14/26 at 11 a.m., Resident 1 stated Resident 2 was in the bed closest to the room's entrance/exit door of the three bedroom room. Resident 1 reported that as he was passing by Resident 2's bed, Resident 2 attempted to punch him but missed. Resident 1 continued toward his bed which was the farthest from Resident 2's bed. Resident 2 then got out of bed, pushed Resident 1-who was in his wheelchair-across the room toward the window by Resident 2's bed, and whacked him on the back of the head. Resident 1 stated he then wheeled himself into the hallway, followed by Resident 2. Resident 2 began forcefully shaking Resident 1's wheelchair, prompting Resident 1 to call for help from Certified Nursing Assistant 1 (CNA 1).During an interview in the MDS office, on 4/14/26, at 11:43 a.m., CNA 1 stated he was in the hallway of the facility when he heard someone calling his name urgently. CNA 1 looked over and witnessed Resident 2 forcefully shaking the back of Resident 1's wheelchair. CNA 1 stated Resident 1 appeared scared while Resident 2 appeared angry about something. CNA 1 stated he was familiar with both residents, and that Resident 2 had been known to be aggressive on occasion.A review of facility policy titled Abuse, Neglect and Exploitation, dated 12/2022, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.The facility will implement policies and procedures to prevent and prohibit all types of abuse.that achieves.the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict.

Based on interview and record review, the licensed nurses did not revise a care plan for one resident (Resident 2) of two sampled residents after Resident 2 was involved in a physical altercation with another resident.This failure decreased the facility's potential to implement interventions to prevent further physical harm among residents.Findings:A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of Wernicke's Encephalopathy (a medical condition caused by a severe deficiency of thiamine (Vitamin B1) which is liked with alcohol abuse. A review of Resident 2's Situation, Background, Assessment and Recommendation (SBAR- a structured, standardized format for concise communication in healthcare which is designed to enhance patient safety and team communication) documentation, described Resident 2's previous physical altercations with other residents as follows:On 6/10/25 at 6:51 p.m., indicated, resident to resident physical incident where one resident's hand made contact with another resident's face after getting upset after hearing the resident cussing.On 10/2/25 at 9:34 p.m., indicated staff heard yelling coming from Resident 2 's room. Resident 2's roommate reported incident of resident-to-resident altercation with physical contact.On 3/21/26 at 7:10 a.m., indicated Resident 1 informed his nurse that he was hit by [Resident 2] on the right side of his head.A review of Resident 2's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/19/26, indicated Resident 2's BIMS score of 13 of 15 which indicated intact cognition.In an interview on 4/14/26 at 1:16pm, the Director of Nursing (DON) acknowledged Resident 2 had a history of physical and verbal abuse. The DON also acknowledged Resident 2's care plan did not include Resident 2's involvement in a physical altercation which occurred on 10/2/25. The DON stated the resident's care plan is supposed to reflect new interventions with every additional incident in hopes of preventing future incidents.A review of the facility's policy and procedure titled Abuse, Neglect and Exploitation dated December 2022 indicated, The facility will make efforts to ensure all residents are protected from physical and psychological harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to.Revision of the resident's care plan if the resident's [NAME], nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on observation, interview, and record review, the facility failed to protect resident health information for a census of 92 when meal tickets were disposed of in the facility's regular trash.This failure decreased the facility's potential to protect and safeguard resident confidentiality and personal privacy.Findings:During a concurrent observation and interview on 1/8/26 at 8:28 a.m. with the Dietary Aide (DA), in the kitchen dishwashing area, the DA was observed removing trays from the soiled tray carts to prepare them to be washed. The DA sorted the tray contents and threw residents' meal tickets into the garbage can along with scraps of food. The DA stated residents' meal tickets were thrown into the garbage with food scraps. An observation of the contents of the garbage can included 4 meal tickets.During an interview on 1/8/26 at 8:47 a.m. with the Dietary Manager (DM), the DM stated the meal tickets were thrown into the regular trash. The DM agreed the residents' name, room number, diet order, allergies, and likes and dislikes were visibly clear to read on the meal tickets.During an interview on 1/9/26 at 10:00 a.m. with the Director of Nursing (DON), the DON stated any information with residents' identifiers was not to be disposed of in the regular trash. The DON confirmed residents' meal tickets contained the resident's name, room number, diet order and texture, food likes and dislikes, and food allergies which were part of the residents' health information; therefore, it should have been disposed of in a locked confidential information bin for shredding.During a review of the facility's policy and procedure (P&P) titled, Confidentiality of Information and Personal Privacy, revised 2/21, the P&P indicated, Our facility will protect and safeguard resident confidentiality and personal privacy .The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.

Based on observation, interview, and record review, the facility failed to store and prepare, food under sanitary conditions and in accordance with professional standards for a census of 92 when shelf surfaces in the walk-in refrigerator were observed to be discolored with rust-colored markings, indicating deterioration and potential contamination risk.This failure had the potential to contribute to the spread of foodborne illnesses among a vulnerable resident population.Findings:During the initial kitchen tour on 1/6/26 at 8:48 a.m. multiple shelves inside the walk-in refrigerator were observed with dark brown and/or rust colored markings.During a concurrent observation and interview on 1/8/26 at 8:35 a.m., with the Dietary Manager (DM), the DM observed these same walk-in refrigerator shelves and described the shelves as, Very rusty and need to be replaced. The DM also acknowledged the rusted surfaces could not be sanitized.During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P stipulated, all shelves shall be free from corrosions.

Based on interviews and record reviews, the facility failed to ensure the accuracy of assessments for four out of four sampled residents for Preadmission Screening and Resident Review level 1 (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care), when Residents: 5, 58,72 and 55's PASARR did not indicate their diagnosed serious mental illness (MI, disorders that affect your mood, thinking and behavior).This failure could result in residents not being accurately identified with MI, missing further evaluation, and not receiving care/services in setting most appropriate to their needs.Findings:A review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of 1/31/25 with a diagnosis of major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health condition characterized by persistent, excessive worry or fear in situations that aren't threatening, interfering with daily life) and Post Traumatic disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) .A review of Resident 58's PASARR dated 10/23/2024 did not indicate Resident 58 had a diagnosis of major depression, anxiety disorder or PTSD.A review of Resident 5's face sheet indicated an admission date of 3/2025 a diagnosis of major depression, anxiety disorder and PTSD.A review of Resident 5's PASARR dated 12/19/25 did not indicate Resident 5 had had a diagnosis of major depression, anxiety disorder or PTSD.A review of Resident 72's face sheet indicated an admission date of 9/2024 with a diagnosis of Depression and Schizophrenia (a mental illness that is characterized by disturbances in thought).A review of Resident 72's PASARR dated 9/20/24 did not indicate Resident 72 had a diagnosis of Depression or Schizophrenia.A review of Resident 55's admission record indicated he was last admitted in 9/25 with the diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought).A review of Resident 55's PASARR, dated 9/17/25, indicated he did not have a serious mental illness and was not referred for a PASARR Level II.During an interview on 1/8/26 at 1:15 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC reviewed the PASARR for Resident 55, agreed it was incorrect, and stated Resident 55 should have been flagged to have a PASARR II (an in-depth, mandatory evaluation for nursing facility applicants suspected of having serious mental illness) completed.During a concurrent interview and record review with the MDSC on 01/09/2026, Residents 58, 5 and 72's face sheet and PASARR were reviewed. The MDSC verified Resident 58's face sheet indicated a diagnosis of major depression, anxiety disorder and PTSD however, Resident 58's PASARR dated 10/23/2024 did not indicate these diagnoses. The MDSC verified Resident 5's face sheet indicated diagnosis of major depression, anxiety disorder and PTSD however, Resident 5's PASARR dated 12/19/25 did not indicate these diagnoses. The MDSC verified Resident 72's face sheet indicated a diagnosis of Schizophrenia and Depression however, Resident 72's PASARR dated 9/20/24 did not indicate these diagnoses. MDSC verified Residents 58, 5 and 72's level 1 PASARR 1 was inaccurate as it did not accurately capture Residents 58, 5 and 72's diagnosis of serious mental illness. The MDSC stated it was important to ensure the information on the PASARR accurately reflects the residents' mental and psychological status to ensure appropriate placement and receive the appropriate care/ treatment they need. During an interview on 01/09/2026 at 09:40 p.m., the Director of Nursing (DON) stated it was important that the PASARR was accurate to ensure residents with MI get the necessary support they need and to prevent inappropriate placement. The DON stated he recognized their deficient practice and will ensure that PASARR will contain accurate information moving forward. During an interview on 1/9/26 at 10:00 a.m. with the Director of Nursing (DON), the DON stated PASARR screenings should be reviewed for accuracy, corrected if an error is found, and a referral for a PASARR Level II screening if necessary.A review of the facility's policy and procedure (P&P) titled, PASARR, dated 2/25, the P&P stipulated, the facility coordinates assessments with the PASARR program under Medicaid to ensure the most suitable setting for individuals with qualifying conditions.

Based on interviews and record reviews, the facility failed to ensure the baseline care plan (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents safety and well-being, focusing on basic needs and resident-specific information) for four out of four sampled residents (Residents 5, 58, 72 and 106) were completed within 48 hours of admission.This failure could result in residents' delayed or inconsistent care and increased vulnerability to immediate harm.Findings:A review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of 1/31/25 with a diagnosis of major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental health condition characterized by persistent, excessive worry or fear in situations that aren't threatening, interfering with daily life) and Post Traumatic disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) .A review of Resident 58's BCP with an admission date of 1/31/25 did not indicate it was completed within 48 hours of admission. A review of Resident 5's face sheet indicated an admission date of 3/2025 with a diagnosis of major depression, anxiety disorder and PTSD.A review of Resident 5's BCP with an admission date of 3/25/25 did not indicate it was completed within 48 hours of admission.A review of Resident 72's face sheet indicated an admission date of 9/2024 with a diagnosis of Depression and Schizophrenia (a mental illness that is characterized by disturbances in thought).A review of Resident 72's BCP with an admission date of 9/20/24 did not indicate it was completed within 48 hours of admission.A review of Resident 106's face sheet indicated an admission date in 12/2025 with a diagnosis of Hypertension (HTN, high blood pressure) and Acute Kidney Injury (AKI, a sudden decrease in kidney function that develops within seven days)A review of Resident 106's BCP with an admission date of 12/19/25 indicated it was completed on 12/22/25.During a concurrent interview and record review on 01/09/2026 at 08:37 a.m., the Minimum Data Set coordinator (MDSC) verified the BCP for Resident 106 with an admission date of 12/19/25 was late when it was completed on 12/22/25. The MDSC verified the BCP for Residents 5, 58 and 72 did not indicate it was completed within 48 hours of admission. The MDSC stated the facility policy was to complete the BCP within 48 hours of admission. The MDSC stated not completing the BCP within 48 hours of admission meant the facility policy was not followed and could put the residents at risk for receiving unsafe care.During an interview on 01/09/2026 at 10:31 a.m., the Director of Nursing (DON) stated BCP were expected to be completed within 48 hours of admission per facility policy. The DON stated if a BCP was not completed within 48 hours of admission, it meant the facility policy was not followed and it could compromise residents' safety and quality of life. The DON stated he recognized the deficient practice and will strive to complete the BCP within 48 hours upon admission moving forward.A review of the facility's policy and procedure (P&P) titled Care Plan-Baseline, undated, the P&P indicated a baseline plan of care should be developed for each resident within 48 hours of admission.

Based on observations, interviews and record review, the facility failed to maintain accurate records of controlled medications (medications that the use and possession of are controlled by the federal government) for one out of 92 residents of the facility (Resident 24), when a dose of Resident 24's Oxycodone Hydrochloride (Oxycodone, a controlled medication that treats pain) was not documented as administered in the Medication Administration Record (MAR a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).This failure had the potential for a medication error to occur, which could cause Resident 24 to experience increased sedation (increased sleepiness), respiratory depression (condition where breathing becomes dangerously slow and shallow) and/or hospitalization. Findings:A review of Resident 24's Order Summary Report, an order dated 11/7/25, indicated Oxycodone 5 milligrams (mg, a unit of measure) to be given one tablet by mouth every six hours as needed (PRN) for severe pain (pain level 7-10 on a number pain scale [ A number pain scale, usually a 0 to 10 scale, helps people rate their pain intensity, with 0 meaning no pain and 10 representing the worst pain imaginable]).During a concurrent interview and record review on 1/6/26 at 4 p.m. with Licensed Nurse 1 (LN 1), Resident 24's document titled, Antibiotic or Controlled Drug Record, dated 12/19/25 at 9:30 p.m., indicated Resident 24's Oxycodone 5 mg was signed out by a nurse but Resident 24's MAR, dated 12//19/25, revealed the nurse did not document Oxycodone 5 mg was administered to Resident 24 at 9:30 p.m. LN 1 verified Resident 24's Oxycodone 5 mg was signed out in his narcotic log (another term used for the Antibiotic or Controlled Drug Record) by a nurse, but not inputted into Resident 24's MAR to show the nurse had administered the Oxycodone.During an interview on 1/6/26 at 4:26 p.m., LN 1 stated that she was expected to document the administration of controlled medication in the resident's MAR, including the date and time it was given, after administering the medication.During an interview on 1/6/26 at 4:50 p.m., the Director of Nursing (DON) stated a narcotic (controlled medications used to treat pain) given to a resident should be documented in the resident's narcotic log to show the narcotic count was accurate as well as the resident's MAR to indicate the controlled medication was administered to the resident. The DON stated if the narcotic logged out was not documented in the resident's MAR, there could be a potential issue with narcotic diversion (when a medication is taken for use by someone other than whom it is ordered for). The DON stated the resident's physician would review the resident's MAR to see if the resident was still needing the narcotic, so accurate documentation was essential.A review of the facility policy/procedure titled, Medication Administration-General Guidelines, dated 10/2017, indicated: . C. Documentation: 1) The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. 4) The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are verified with a full signature in the space provided on MAR. 5) When PRN medications are administered, the following documentation is provided: a. Date and time of administration, medication, dose.

Based on interview and record review, the facility failed to notify the physician within 24 hours of a significant change in condition for one of one sampled resident with a change in condition (Resident 33), when nursing staff identified ongoing confusion, urinary frequency, and symptoms consistent with a urinary tract infection (UTI- an infection in the bladder/urinary tract).This failure resulted in delayed medical evaluation and treatment of Resident 33's UTI.Findings:A review of Resident 33's admission record indicated she was admitted in 6/2021 with the diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). A review of Resident 33's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare professionals when there is a change of condition among the residents), dated 12/19/25, indicated, .[Patient 33] experienced confusion for past 2 days, [Patient 33] has been urinating more frequently[Patient 33] increased confusion.Needs more assistance with ADLs [Activities of Daily Living].Reported to Primary Care Clinician.12/19/2025 10:55A review of Resident 33's progress note, dated 12/19/25 at 10:07 p.m., indicated Nursing staff was monitoring resident's increased confusion, frequent urination, and painful urination. There was no documentation that the physician was notified. A review of Resident 33's care plan focused .at risk for impaired cognitive function., initiated 6/8/21 and revised 3/4/22, indicated interventions staff to implement included, .monitor/document/report [as needed] any chances in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.During an interview on 1/7/26 at 3:19 p.m. with licensed nurse (LN C), LN C stated she was aware of the residents' confusion and urinary symptoms and recalled monitoring the resident. LN C stated she notified Resident 33' primary physician via text message, which she identified as the normal method of physician communication at the facility. However, LN 3 was unable to show documentation on the electronic tablet verifying that the physician was notified prior to 12/19/25.During an interview on 1/7/26 at 11:44 a.m. with Residents 33's responsible party (RP - healthcare decision maker). The RP stated on 12/22/25, she found Resident 33 not dressed appropriately for the day, wearing shorts without underwear, and with a wet bed. The RP stated that due to the Resident 33's past history of UTI's, she took the resident to the hospital. The RP reported Resident 33 was admitted with a diagnosis of a UTI.During an interview on 01/09/26 at 11:00 a.m., with the Director of Nursing (DON), the DON stated he expected nursing staff to notify the physician when a change of condition occurred and for the physician to respond in a timely manner. The DON further stated that if the physician did not respond, nursing staff were expected to follow up and document the communication in the electronic health record. The DON acknowledged there was no documentation that the physician was notified or that a physician response occurred for Resident 33. The DON stated this situation did not meet his expectations for managing and communicating a change in condition.During a review of the facility policy titled Change in a Resident's Condition or Status, revised 2/21, indicated, Our facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition.notifications will be made within twenty-four (24) hours of a change occurring.

Based on interviews and record reviews, the facility failed to ensure an abuse allegation of misappropriation of property (when someone in a position of trust steals, misuses, or benefits personally from assets belonging to another) for one out of two sampled resident (Resident 106) when the allegation was not reported to the state licensing agency and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within 2 hours.This failure could put Resident 106 at risk for continued financial and emotional distress.Findings:A review of Resident 106's face sheet (frontpage of the chart that contains a summary of basic information about the resident) indicated an admission date in 12/2025.A review of Resident 106's inventory of personal effects, dated 12/19/25, indicated Resident 106 had a black wallet.A review of a promissory note dated 12/23/25, signed by both Resident 106 and the Social Services Director (SSD), indicated Resident 106 had 3 bank cards.A review of Social Services Note dated 1/7/26 12:51 p.m. indicated Resident 106 reported that someone has taken his money, and his wallet was missing. During an interview on 01/07/2026 at 3:36 p.m., Resident 106 stated he had his wallet in his room. Resident 106 stated his wallet and bank cards were missing when his bank alerted him that his card was used for about $6000 of unauthorized purchases since 1/4/26. Resident 106 stated he reported this incident to the Social Services Director (SSD) before lunch time on 1/7/26.During an interview on 01/08/2026 at 1:55 p.m., the administrator (admin) verified the facility was aware of Resident 106 allegation of misappropriation of funds but did not report the allegation to the state licensing agency or the ombudsman.During an interview on 01/08/2026 at 2:06 p.m., the Minimum Data Set coordinator (MDSC), stated if a resident was missing his wallet and there was unauthorized use of his bank card, these would be considered an allegation of financial abuse or misappropriation of property. The MDSC stated if a resident reported that his wallet was missing and his card had unauthorized charges while he was at the facility, this should have been reported to the ombudsman and the state licensing agency within 2 hours. The MDSC stated if this allegation was not reported to these agencies within the 2 hours' time frame per the facility policy, it could lead to potentially escalating abuse and might leave the residents vulnerable to further exploitation.During an interview on 01/08/2026 at 2:26 p.m., the Director of Nursing (DON) stated being aware of Resident 106's allegation of missing wallet and unauthorized charges on his bank card. The DON acknowledged the facility did not report this incident to the state or the ombudsman.During an interview on 01/08/2026 at 4:06 p.m., the Social Services Director (SSD) stated that on 1/7/26, before lunch, Resident 106 reported his wallet and money was missing. The SSD verified she had this conversation documented on 1/7/26.During an interview on 01/09/2026 at 09:15 a.m., Licensed Nurse (LN) E stated if a resident reported that his wallet was missing and there were unauthorized charges on his cards then this could be an allegation of abuse and should be reported to the state and the ombudsman per facility policy. LN E stated not reporting this allegation to the state and the ombudsman could result in continued abuse.A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 9/2022, the policy indicated .if a resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the admin and to the other officials according to the state law.the admin or the individual making the allegation immediately reports his or her suspicion to the following person or agency: the state licensing/certification agency responsible for surveying/licensing the facility, the state ombudsman.immediately is defined as within 2 hours of any allegation involving abuse or serious bodily injury.

Based on observation, interviews and record reviews the facility failed to deliver professional standards of quality for one of 22 sampled residents (Resident 7), when a physician order was not obtained prior to the application of bordered dressing (a multi-layered wound care product with a central absorbent pad and an adhesive border that secures it to the skin ) on Resident 7's Deep Tissue Injuries (DTI, purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear)This failure could put the patient at risks for physical harm and worsening wound conditions.Findings:1.A review of Residents 7's Minimum Data Set assessment (MDS, a federally mandated resident assessment tool), dated 11/26/25, indicated Resident 7 had two deep tissue injuries (DTI, purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear).A review of Resident 7's physician order summary (POS, a healthcare professional's written instruction specifying the care, services, treatment and medications a patient should receive) of active orders, as of 1/9/26, indicated an order of may self-apply bordered dressing as needed (PRN) per patients' request for preventative treatment for wound care management with the start date of 1/7/26.A review of Resident 7's electronic treatment administration record (ETAR, a digital system used to track and document the administration of treatments), for 1/2026, did not indicate an order to apply bordered dressing for treatment.During a concurrent observation and interview on 01/07/2026 at 11:00 AM, Licensed Nurse (LN) B verified Resident 7 had two DTI's, one on each posterior (back) leg. LN B was seen with two bordered dressings. LN B stated she had used the bordered dressings to treat Resident 7's DTIs both in the past and on this date. LN B confirmed an order from the physician was required to use the border dressing on Resident 7's DTIs and acknowledged there was no such order.During an interview on 01/08/2026 at 10:42 AM, Resident 7 stated staff had been placing the bordered dressing on the DTIs on her legs and buttocks for a while now. Resident 7 stated that 1/7/26 was not the first time staff had used bordered dressing to cover her DTI's. During a concurrent interview and record review on 01/08/2026 at 10:57 AM, with the Minimum Data Set coordinator (MDSC) 2, Resident 7's POS was reviewed. The MDSC 2 verified the order for the bordered dressing was provided on 1/7/26 and there were no previous orders to apply the bordered dressing on Resident 7's DTI's in the past. MDSC 2 stated the application of bordered dressing need to have a physician order. The MDSC 2 stated physician's order must be followed by the nurses and deviations were not allowed. She stated applying a dressing without a physician's order was beyond a nurse's scope of practice and could result in harm to the resident.During an interview on 01/08/2026 at 11:52 AM, MDSC stated a physician's order was needed prior to using a bordered dressing on a resident. MDSC clarified it was important that a physician order was requested prior to using any type of dressing to ensure the correct type of dressing was being used for the correct type of wound, as the physician would know best which type of dressing was appropriate to use on certain type of wound. The MDSC stated if an incorrect dressing was used for a certain type of wound, the wound might worsen and could be a safety risk for the resident.During an interview on 01/09/2026 at 10:31 AM, the Director of Nursing (DON) stated a physician's order was needed prior to using bordered dressing to treat a resident wound. A review of the facility's policy and procedure (P&P) titled Medication Administration-General Guidelines, dated 10/2017, the P&P indicated .medications are administered as prescribed in accordance with good nursing principles and practice. medications are administered in accordance with written orders of the attending physician.

Based on observations, interviews and record reviews, the facility failed to ensure two out of two sampled residents (Residents 37 and 80's) received care to maintain grooming when fingernails were long with brownish material underneath.This failure could negatively affect the resident's sense of dignity and be an infection control concern.Findings:A review of Resident 37's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 4/2025 with a diagnosis of Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and muscle weakness.A review of Resident 37's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/29/25, section GG Functional Abilities and Goals, indicated Resident 37 needed moderate assistance from staff for personal hygiene tasks.A review of Resident 80's face sheet indicated an admission date in 1/2019 with a diagnosis of Traumatic Brain Injury (TBI, a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head).A review of Resident 80's MDS, dated 11/30 25, section GG Functional Abilities and Goals, indicated Resident 80 needed maximum assistance from staff for personal hygiene tasks.During a concurrent observation and interview on 01/06/26 at 12:19 p.m., Resident 80 was noted with long fingernails that had brownish material underneath while he was eating his lunch. Resident 80 stated he had dirt under his fingernails and his fingernails were long because no one will cut them.During an observation on 01/06/2026 at 12:20 p.m., Resident 37 was noted with long fingernails that had brownish material underneath while he was eating his lunch.During an interview on 01/09/2026 at 10:57 a.m., when shown photos of Residents 37 and 80's fingernails, the Director of Staff Development (DSD) verified these residents' fingernails were long and had brownish materials underneath. The DSD stated this was not acceptable since Residents 37 and 80 were dependent on staff to keep their nail short and clean. The DSD stated it was not acceptable to see residents' fingernails long with brownish/blackish materials underneath as it was for their dignity and for infection control concerns. During an interview on 01/09/2026 at 12:05 p.m., the Director of Nursing (DON) stated it was not acceptable for Residents 37 and 80 to have long fingernails with brownish materials underneath. The DON stated the expectation was that resident's fingernails will be kept short and clean. The DON stated he recognized the deficient practice and will strive to be better moving forward. A review of the facility's policy and procedure (P&P) titled Nail Care, undated, the P&P indicated .to provide residents with safe hygienic and thorough nail care assistance .clean nails and under nails .A review of the facility's P&P titled Activities of Daily Living, revised 3/2018, the P&P indicated .residents who were unable to carry out activity of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene.

Based on observations, interviews, and record review, the facility failed to ensure the bed cane (a type of bed rail that is a bar that attaches to the side of a bed, to help a person get in and out of bed) for one of 24 sampled residents (Resident 8), was in proper use when:it was installed without completed assessment of risk of entrapment;Informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was not obtained prior to installation; andIt was installed incorrectly.These failures increased the risk of resident injury, including falls or entrapment, which could result in serious harm or death.Findings:A review of Resident 8's admission record indicated she was last admitted to the facility in 8/2018 with the diagnosis of unspecified dementia (a progressive state of decline in mental abilities).A review of Resident 8's physician order, dated 9/21/24, indicated, Bed cane x 1as an enabler to assist with bed mobility. (non-restraint)1. A review of Resident 8's bed rail (bars attached to the sides of a bed, serving as safety and mobility aids) evaluations, dated 10/7/24, 4/7/25, 7/8/25, and 10/16/25, indicated entrapment evaluations had not been completed during any of the bed rail evaluations and that a bed cane was in use. During an interview on 1/9/26 at 8:47 a.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated entrapment assessments were completed by the maintenance department prior to installation of bed canes and bed rails. MDSC also reviewed Resident 8's bed rail evaluations dated 10/7/24, 4/7/25, 7/8/25, and 10/16/25 and confirmed the entrapment evaluations were not completed and should have been. During an interview on 1/9/26 at 10 a.m. with the Director of Nursing (DON), the DON stated the maintenance department kept records of entrapment evaluations completed prior to installation of bed canes and bed rails.A copy of Resident 8's entrapment evaluation completed by the maintenance department was not provided as requested.2. During an interview on 1/9/26 at 8:47 a.m. with the MDSC, the MDSC stated informed consent should be obtained prior to installation of bed canes and bed rails. MDSC also stated the initial consent for Resident 8's bed cane was not in the electronic health record (EHR).During an interview on 1/9/26 at 10 a.m. with the DON, the DON stated informed consent was obtained prior to the installation of a bed rail due to the risk of entrapment. The DON stated it had not been obtained prior to installation of the bed cane because it was different from a bed rail and there was not risk for entrapment. After viewing a photograph of the bed cane with three, Risk for Entrapment, warnings on it the DON acknowledged3. During an observation on 1/7/26 at 10:21 a.m., Resident 8's bed cane was observed to be installed on the left side of the bed, with three clearly visible warning signs for possible entrapment. The bed cane was secured to the bed frame with the safety strap looped over and around the central frame bar repeatedly, creating a bundled wrap at the midpoint of the frame.During an interview on 1/7/26 at 12:46 p.m. with the Maintenance Supervisor (MS), the MS stated he could not provide installation instructions for Resident 8's bed cane. The MS also stated straps which secured the bed cane should go across to the other side of the bed frame.During an interview on 1/7/26 at 2:55 p.m. with the MS, the MS provided an installation video for bed canes which showed safety straps used to secure the bed cane were supposed to go under and across the whole bed frame.During a concurrent observation and interview on 1/7/26 at 3:23 p.m. of Resident 8's bed with the MS, the MS agreed Resident 8's bed cane was not installed properly and stated it needed to be corrected. During an interview on 1/9/26 at 10 a.m. with the DON, the DON stated bed canes were expected to be installed properly, per manufacturer's instructions. The DON viewed the photo of how Resident 8's bed cane was installed and agreed it was not installed properly. During a review of the facility's policy and procedure (P&P) titled, Bed Rails, revised 8/22, the P&P stipulated, For the purpose of this policy bed rails include.grab assist bars. The P&P also stipulated, Bed rails are properly installed and used according to the manufacturer's instructions. and The use of bed rails.is prohibited unless the criteria for use of bed rails have been met including.resident assessment and informed consent.

Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident for dental services (Resident 6) received timely and appropriate dental evaluation and treatment, when the resident had broken teeth, and a history of uncompleted dental referrals with no follow-up or treatment plan.This failure resulted in Resident 6 not being able to eat effectively, placing the resident at risk for decreased nutritional intake and potential further decline.Findings:A review of Resident 6's admission record indicated she was admitted in 5/2021 with the diagnosis of dementia (a progressive state of decline in mental abilities).A review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/26/25, indicated she had no memory impairment.A review of Resident 6's progress notes, dated 12/8/25 to 12/9/25, indicatged Resident 6 was being monitored for unplanned weight loss. A review of Resident 6's weights summary, dated 8/4/25, indicated Resident 6's weight was 109 lbs. (pounds, an unit of measurement) and on 12/8/25 Resident 6's weight was 101 lbs., a loss of 8 lbs. in 4 months. A review of Resident 6's physicians' orders, dated 12/5/25, indicated an order for Health shakes to be given 3 times a day and for staff to monitor percentage meal consumed. During an interview on 1/8/26 at 10:30 a.m. with Resident 6, Resident 6 stated she had mouth pain and the discomfort affected her ability to eat. Resident 6 expressed that she did not like her mechanical soft diet (foods that are easy to chew by being pureed, mashed, or chopped to change the food's texture) and wanted food with more normal texture. Resident 6 stated her mouth pain was 5 of 10 on a number pain scale (A number pain scale, usually a 0 to 10 scale, helps people rate their pain intensity, with 0 meaning no pain and 10 representing the worst pain imaginable). During a concurrent observation and interview on 1/8/26 at 10:45 a.m. with Resident 6 and the SSD, Resident 6 again reported mouth pain and pointed to her right lower jaw. Observation revealed the resident had only five remaining teeth in the front lower jaw. During an interview on 1/8/26 at 10:47 a.m. with the SSD, the SSD acknowledged the resident needed to see a dentist. The SSD stated that if the resident received dental treatment, Resident 6 would likely enjoy eating more, potentially gain weight, and have more energy.During a concurrent interview and record review on 1/8/26 at 9:20 a.m. with the SSD, the SSD confirmed she had reviewed resident 6's dental notes and acknowledged the documentation was not informative regarding any plan for improving oral health. The SSD confirmed that although a referral to a local dentist was made on 2/13/25, there was no documentation an appointment had been made.During a concurrent interview and record review on 1/9/26 at 12:30 p.m. with the Director of Nursing (DON), the DON stated he expected residents to receive timely follow-up for outside services. After reviewing Resident 6's dental notes, the DON confirmed there had not been timely follow-up and that treatment appointments had not been made as he would expect.During a review of the facility's policy titled, Dental Services Policy, implemented 2/2025, the policy indicated Social Services would assist residents in making dental appointments.

Based on observations, interview, and record review the facility failed to properly maintain the residents' food refrigerator for a census of 92 when a food item was not properly labeled and another food item was past the expiration date.These failures had the potential to result in residents consuming spoiled or contaminated food, increasing the risk of foodborne illness and adverse health outcomes.Findings:During an observation on 1/7/26 at 1:06 p.m., the resident refrigerator contained an open pack of string cheese with five pieces remaining, labeled with the resident's room and bed number, and, Date in 9/30/25. The five pieces of string cheese were marked with an expiration date of 12/26/25. The freezer unit of the resident refrigerator also contained one quart of cookie butter ice cream only labeled with, Date in 11/25.During an interview on 1/9/26 at 10:30 a.m. with the Director of Nursing (DON), the DON stated he expected items placed in the resident refrigerator were labeled properly with dates and who the items belonged to, otherwise resident food could be shared with another resident if not properly labeled. The DON also stated he would expect foods to be removed when they are expired.During a review of the facility's policy and procedure (P&P) titled, Food Brought by Family/Visitors, revised 3/22, the P&P stipulated, items left for the resident to consume later will be labeled and stored in a distinguishable manner and the nursing staff will discard foods on or before the use by date.

Based on observations, interviews and record reviews, the facility failed to ensure smoking safety was practiced for one out of four sampled residents who smoke when:1.a smoking evaluation was not completed upon Resident 72's admission,2. quarterly smoking assessments were not completed for Resident 72, and3.Resident 72 kept a pack of cigarettes at his bedside.These failures increased safety risks for Resident 72 and other residents who could have gained access to Resident 72's cigarettes.Findings:A review of Resident 72's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 9/2024 with a diagnosis of Schizophrenia (a mental illness that is characterized by disturbances in thought) and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that could interfere with daily activities).A review of Resident 72's care plan (a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed) titled [Resident 72] is a smoker, dated 2/14/25, indicated the resident smoking supplies are stored at activity departmentA review of Resident 72's Smoking-Safety Screen assessment, dated 1/6/25, indicated safety, the facility was to store Resident 72's lighter and cigarettes.During an observation on 01/07/2026 at 10:13 a.m., in Resident 72's room, Resident 72 had a pack of cigarettes tucked underneath the right side of his bed.During a concurrent observation and interview on 01/07/2026 at 10:20 a.m., the Director of Staff Development (DSD) verified Resident 72 had a pack of cigarettes tucked underneath the right side of his bed. The DSD stated Resident 72 was not supposed to keep cigarettes in their room for safety purposes.During a concurrent interview and record review on 01/07/2026 at 10:27 a.m. with the Director of Nursing (DON), Resident 72's care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed) titled Resident 72 .is a smoker was reviewed with. The DON verified Resident 72 was not supposed to keep cigarettes in his room and verified Resident 72's care plan indicated the activity department would keep his cigarettes.During a concurrent interview and record review on 01/07/2026 at 11:18 a.m. with the Minimum Data Set coordinator (MDSC), Resident 72's care plan titled Resident 72 .is a smoker, dated 2/14/25, and Resident 72's Smoking-Safety Screen assessment, dated 1/6/25, was reviewed. The MDSC verified that the Smoking-Safety Screen assessment should have been completed upon Resident 72's admission, however, Resident 72's Smoking-Safety Screen assessment was not completed until 1/6/25 and no other smoking assessments were completed after that one. The MDSC stated that at a minimum, there should be a quarterly smoking assessment to determine if there were changes so the facility could adjust Resident 72's care plan accordingly. The MDSC verified Resident 72's cigarettes should have been kept by the activity department as the care plan indicated. The MDSC stated it was not safe for residents to keep cigarettes in their room as the facility has confused residents who could get a hold of the cigarettes, ingesting them, and cause poisoning and endangering their safety.A review of the facility's policy and procedure (P&P) titled Smoking Policy-Residents, undated, it indicated .the resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. a residents ability to smoke safely will be evaluated quarterly.residents without any independent smoking privileges may not have or keep any smoking articles including cigarettes except when they are under direct supervision.

Based on observation, interview and record review, the facility failed to ensure three of 22 sampled residents (Resident 21, Resident 31, and Resident 54) were provided a comfortable and homelike environment when: 1. Resident 21's ceiling had an area in mid-repair state; and2. Resident 31 and Resident 54's walls showed significant surface deterioration, cracking, and extensive paint peeling.These failures had the potential to negatively impact the residents' comfort and create an environment that was not homelike.Findings:1. During a concurrent observation and interview on 1/6/26 at 9:28 a.m. in Resident 21's room, the ceiling was observed to have an unfinished repair characterized by a large, rectangular beige patch, approximately 2 feet by 3 feet in size, surrounded by several areas of fresh, un-sanded white plaster. Resident 21 stated the repair was due to a leak in the ceiling.During an interview on 1/7/26 at 12:46 p.m., with the Maintenance Supervisor (MS), the MS stated he did not know when staff completed the repair. The MS added that the issue had been present since he started working at the facility approximately one year ago.2. During an observation on 1/6/26 at 10:21 a.m., in Resident 31's room, the wall next to Resident 31's bed was observed to be dirty with food debris and with the top layer of yellow paint curling and falling off in large flakes and a deep, straight vertical crack approximately 3 feet long extended down the corner where the two walls meet, exposing peeling paint and plaster.During an observation on 1/6/26 at 12:29 p.m. in Resident 54's room, the wall next to Resident 54's bed was observed with the top layer of yellow paint curling and falling off in large flakes and a deep, straight vertical crack approximately 2 feet long extended down the corner where the two walls meet, exposing peeling paint and plaster.During an interview on 1/6/26 at 12:48 p.m. with Licensed Nurse (LN) 4, LN 4 stated the walls in Resident 31's room and Resident 54's room were in need of repair due to the paint chipping. LN 4 stated the condition of the walls did not present a homelike environment.During an interview on 1/9/26 at 10:00 a.m. with the Director of Nursing, the DON agreed peeling paint, dirt and gashes on the walls, and unfinished repairs do not present a homelike environment. The DON also stated repairs should not take as long as a year to be completed.During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, undated, the P&P stipulated, residents are provided with a clean and homelike environment.

Based on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident 1) when licensed nurses did not remove a transdermal medicated patch (an adhesive patch that delivers a specific dose of medication through the skin and directly in to the bloodstream over a controlled period of time) before a new one had been applied.This failure had the potential to cause unwanted side effects due to a higher than prescribed dose of the medication being absorbed through the skin.Findings:During an observation on 12/30/25 at 11:52 a.m., Resident 1 was noted to have a transdermal medication patch on the skin near his right ear and an identical second transdermal medication patch on the skin near his left ear. The patch near his right ear had the date 12/28 written on it and the patch near his left ear had writing which was smudged and unreadable.A record review of Resident 1's physician (MD) orders indicated, Scopolamine [a medication used to control excess secretions] Transdermal Patch 72 Hour, 1MG [milligram, a unit of measurement] / [every] 3DAYS (Scopolamine). Apply 1 patch transdermally one time a day every 3 day(s) for secretion and remove per schedule. The scopolamine patch had an order date of 9/25/25.A record review of the manufacturer's instructions for use, dated August 2023, indicated, Wear only one scopolamine transdermal system [patch] at any time. The instructions also indicated, If the system is needed for longer than 3 days, remove scopolamine transdermal system.get a new scopolamine transdermal system and place it.During a concurrent observation and interview on 12/30/25 at 12:45 p.m., Licensed Nurse 1 (LN 1) verified Resident 1 had a transdermal medication patch in place near his left ear and an identical transdermal medication patch in place near his right ear.During an interview on 12/30/25 at 1:42 p.m., Licensed Nurse 2 (LN 2) reviewed Resident 1's MD orders and stated Resident 1 had an order for a scopolamine transdermal patch every 3 days. LN 2 stated we took off the old one and put on the new one every three days. LN 2 also stated Resident 1 was not supposed to have two scopolamine transdermal patches on at one time.During an interview on 12/30/25 at 1:58 p.m., the Director of Nursing (DON) stated licensed nurses should have followed doctor's orders. The DON stated if the MD order indicated a transdermal medicated patch was removed before a new medicated transdermal patch was applied, and there were two medicated transdermal patches on Resident 1, then the order was not followed. The DON also stated it was important to follow MD orders so there were no adverse effects from medications.A review of a facility policy and procedure titled, Medication Administration - General Guidelines dated October 2017, indicated, Medications are administered in accordance with written orders of the attending physician.

Based on observation, interview, and record review the facility failed to ensure one resident (Resident 1) of two sampled residents was free from physical abuse when Resident 2 punched Resident 1 in the eye.This failure resulted in Resident 1 sustaining a bruise on the left eye.Findings:A review of Resident 2's admission record indicated admission to the facility on [DATE] with diagnosis which included Wernicke's Encephalopathy (a severe neurological disorder caused by a deficiency of Vitamin B1) and anxiety disorder (a mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life).A review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated 8/19/25 indicated Resident 2 had a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (the person thought and remembered well at the time of the assessment).A review of Resident 2's Psychotherapeutic Drug Summary dated 9/1/25 at 12:35 a.m. indicated Resident 2 was on four orders for psychotropic medications (medication that affect a person's mental state, emotions, and behavior) due to behaviors of angry outbursts and physical aggression.A review of Resident 1's admission record indicated admission to the facility on 8/29/25 with a diagnosis which included Alcoholic Cirrhosis of Liver without Ascites (a chronic liver disease caused by excessive alcohol consumption, leading to scarring and damage to the liver) and Type 2 Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).A review of Resident 1's MDS dated [DATE] indicated Resident 1 had a BIMS score of 10 (which indicated the person had mild impairment in their thought and memory process at the time of the assessment).A review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form and progress note, dated 10/2/25 at 9:34 p.m., indicated, [Resident 2] had physical altercation with [Resident 1].A review of Resident 1's SBAR Communication Form and progress note, dated 10/2/25 at 9:35 p.m. indicated, Situation.resident-to-resident altercation .During rounds at approx. 8pm resident heard yelling from room., then [Resident 1] reported incident.of resident-to-resident altercation with physical contact.A review of Resident 1's Skin Observation Tool dated 10/2/25 at 11:45 p.m. indicated, .Bruise noted under [Resident 1's] Left eye. This tool did not indicate Resident 1 had any other bruising to the body prior to 10/2/25.A review of Resident 2's nursing progress note dated 10/3/25 at 12:49 a.m. indicated, Resident on monitoring for Physical and Verbal aggression d/t [due to] resident to resident altercation.Resident left facility, taken by police at approx. [11:30 p.m.].A review of Resident 1's nursing progress note dated 10/6/25 at 2:19 p.m. indicated, .Resident on monitoring for emotional distress related to altercation (physical) with another resident resulting in violent behavior. Patient complains of tolerable pain over his left eye. Bluish discoloration around the eyes still noted.A review of Resident 1's nursing home visit by the physician dated 10/10/25 at 9:58 p.m. indicated, Chief complaint.Altercation.[Resident 1] had an altercation with [Resident 2], [Resident 2] end up punching patient in the face, leaving a left eye ecchymosis [bruise], [Resident 2] now in jail.Objective [Assessment].Left eyelid and periphery with ecchymosis.During an interview on 10/10/25 at 11:50 p.m., Case Manager B (CM B) stated she saw Resident 1 on 10/3/25 and Resident 1 told CM B that he asked Resident 2 to turn off the light and the conversation turned into a verbal argument then Resident 2 became physical.During a concurrent observation in Resident 1's room and interview on 10/10/25 at 12:49 p.m., Resident 1 was sitting up in bed with the blankets up around his face. Resident 1 refused to be interviewed and stated he wanted to be left alone.During a telephone interview on 10/13/25 at 1:56 p.m., Licensed Staff A (LS A) stated on 10/2/25 she heard yelling from Resident 1 and Resident 2's room and went to see what happened. When she entered the room, she saw Resident 1's meal tray on the floor. LS A stated she saw Resident 1 had bruising under his left eye and asked if he wanted to go to the emergency room. Resident 1 refused so LS A offered Resident 1 an ice pack for his left eye. LS A stated when the police arrived Resident 1 wanted to press charges and Resident 2 was arrested and taken by the police. LS A stated she asked Resident 1 what happened, and he stated, he asked Resident 2 to turn out the light and the conversation turned into an argument resulting in Resident 2 punching Resident 1 in the left eye. LS A stated Resident 2 had not returned to the facility and was waiting for a court hearing.A review of the facility's policy titled, Alleged or Suspected Abuse and Crime Reporting, dated 2/21/25, indicated, Each Resident has the right to be free from abuse.

Based on observation, interviews and record review, the facility failed to ensure a call light (a communication tool used in healthcare settings to allow patients/residents to request assistance from staff) was provided to one out of three sampled residents (Resident 2) when the call light was not within Resident 2's reach.This failure could result in late provision of care, unmet needs and increases the risk of accidents.Findings:During a concurrent observation and interview on 7/15/25 at 1:38 p.m., Resident 2's call light was tangled with a red string by the wall and near the foot of his bed. Resident 2 stated when he needed help he would use his call light but added, it was not where he could reach as it was too far [away].During a concurrent observation and interview on 7/15/25 at 1:44 p.m., in Resident 2's room, Unlicensed Staff A verified Resident 2's call light was tangled with red string by the wall, near the foot of his bed, and was not within Resident 2's reach. Unlicensed Staff A stated Resident 2's call light should be within his reach so he could ask for assistance when he needed it. Unlicensed Staff A verified Resident 2's call light had a clip to ensure it could be clipped on his clothes or pillowcase to ensure the call light was within his reach. During an interview on 7/15/25 at 1:58 p.m. Licensed Nurse (LN) B stated residents' call light should be clipped to their clothing and be within residents' reach at all times. LN B stated residents used the call light to alert staff when they need assistance. LN B stated if a resident could not reach his call light easily, then it was a safety issue, as it could lead to unmet needs, and accidents. During an interview on 7/15/25 at 2:30 p.m., the Director of Nursing (DON) stated residents' call light should be within residents' reach at all times. The DON verified it was the facility's policy to place the call light within reach of the resident. A review of the facility's policy and procedure (P&P), titled Call light, revised 6/26/2024, the P&P indicated, .place the call light within reach of the resident .

Based on observations, interviews and record reviews, the facility failed to ensure the provision of a sanitary environment that would prevent the development and transmission of infections for one out of four residents (Resident 2) when:1. Resident 2's foley catheter (FC, a hollow tube inserted into the bladder to drain or collect urine also known as a urinary catheter) bag (a drainage bag connected to the FC) was touching the floor.2. Staff did not wear a gown, in accordance with enhanced barrier precautions (EBP, an infection control intervention, that involves the use of gowns and gloves during high-contact care activities to reduce the transmission of Multidrug-Resistant Organisms [MDRO, microorganisms (germs), that are resistant to one or more antibiotics]) while handling Resident 2's FC.These failures had the potential to cause and spread infections among residents and staff. Findings:1. During a concurrent observation and interview on 7/15/25 at 1:44 p.m. Unlicensed Staff A verified Resident 2's FC drainage bag was touching the floor. Unlicensed Staff A stated the FC drainage bag should not be touching the floor, for infection control purposes, as Resident 2 could get sick with an infection.During an interview on 7/15/25 at 1:58 p.m., Licensed Nurse (LN) B stated FC drainage bags should not touch the floor because the floor was dirty. LN B further explained, bacteria (germs) could contaminate the FC drainage bag and Resident 2 could end up with an infection.During an interview on 7/15/25 at 2:30 p.m., the Director of Nursing (DON) stated the FC drainage bag should not touch the floor, for infection control, as it increases the risk of a resident acquiring an infection.A review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised 8/2022, the P&P indicated, . be sure the catheter tubing and drainage bag are kept off the floor.2. During a concurrent observation and interview on 7/15/25 at 1:53 p.m., outside Resident 2's door a poster indicated Resident 2 was on EBP. Unlicensed Staff A was observed handling Resident 2's FC drainage bag while not wearing a gown. Unlicensed Staff A verified Resident 2 was on EBP and that she had not followed the EBP when she had not worn a gown when she handled Resident 2's FC drainage bag. Unlicensed Staff A acknowledged EBP was expected to be followed to prevent spreading infections to other residents.During an interview on 7/15/25 at 1:58 p.m., LN B stated residents who had a FC were placed on EBP, and all staff were expected to follow the EBP when caring for these residents. LN B stated anytime a staff touched a residents' FC, staff must wear gloves and a gown to prevent cross contamination (transfer of germs from one place to another with harmful effect) and infection. During a concurrent interview and record review on 7/15/25 at 2:45 p.m., with the DON, the Centers for Disease Control (CDC, the national public health agency of the United States) EBP poster was reviewed, the DON verified Resident 2 had a foley catheter and was on EBP. The DON verified the facility followed the CDC's EBP guidelines which indicated when staff handled a resident's FC, they should wear gloves and gown. The DON stated it was important to follow EBP to prevent or reduce the spread of infections.A review of the CDC document titled Enhanced Barrier Precaution, undated, indicated, . everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and gowns for the following high contact resident care activities.device care or use:.urinary catheter.

Based on interview and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 1), who had a history of COPD (chronic obstructive pulmonary disease; a chronic lung disease causing difficulty in breathing) and cancer in her lungs received care consistent with nursing professional standards of quality and the resident's individualized nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes). Resident 1 experienced a medical emergency (a serious and sudden situation that requires immediate medical attention to prevent serious injury, disability, or death) on the morning of 3/23/25 that included respiratory distress (difficulty breathing associated with inadequate oxygenation) and critical hypoxia (low level of oxygen in the blood), but licensed nursing staff: 1) Did not physically assess Resident 1 by listening to her lung sounds (using a stethoscope [medical instrument used to detect sounds produced in the body] to assess airflow through the respiratory tract/lungs) or by assessing her use of accessory muscles (use of neck or intercostal [between the ribs] muscles when breathing is an indication of respiratory distress); 2) Did not administer oxygen (medical treatment that provides extra oxygen to the body when the lungs cannot oxygenate the blood sufficiently) to meet her needs; licensed staff attempted to titrate (adjust) the oxygen down while she had critical hypoxia; 3) Did not administer Albuterol (a rescue medication that opens the airways and can ease breathing) as ordered by her physician; 4) Did not document Resident 1's oxygen saturation levels (percent of oxygen in a person's blood; normal range is approximately 95% - 100%) throughout her medical emergency; 5) Did not ensure Resident 1 was promptly transferred to the hospital when her emergent condition was discovered on 3/23/25 at approximately 10:30 a.m.; the ambulance company was contacted at 11:20 a.m. (reflecting a timespan of approximately 50 minutes); 6) Did not document contacting Resident 1's physician immediately upon discovery of her critical condition; nursing staff documented they contacted Physician F at 11:20 a.m., approximately 50 minutes after her hypoxia was discovered; and, 7) Did not document nursing interventions implemented to treat Resident 1's emergency. These failures: 1) Impaired Physician F from knowing the extent of Resident 1's condition and ordering medication to treat her declining respiratory status; 2) Potentially exacerbated (to make worse or more severe) Resident 1's critical hypoxia by decreasing her oxygen administration, when she required additional oxygen administration; 3) Potentially contributed to Resident 1's respiratory distress by failing to administer medication (Albuterol) designed to treat COPD and the resulting hypoxia; and, 4) Delayed Resident 1's transportation to the Emergency Department, thereby delaying life-saving respiratory treatments (Resident 1's was ultimately admitted to the Intensive Care Unit - specialty unit providing round-the-clock monitoring and treatment for critically ill patients). Findings: During a telephone interview on 4/1/25 at 12:46 p.m., Registered Nurse C (RN C), who worked at Hospital E, stated a nurse from the facility called report (nurse to nurse communication regarding important patient health status details) to her on the morning of 3/23/25, prior to Resident 1's hospital transfer. RN C stated the facility nurse told her Resident 1's oxygen saturation was 78% and she was struggling (to breathe), but the facility nurse was weaning (decreasing) Resident 1 off her oxygen. RN C stated she instructed the facility nurse to go back to the patient and increase her oxygen, because she needed the oxygen. RN C stated she was concerned because the facility nurse lacked knowledge of how to treat hypoxia. RN C stated if a patient had hypoxia, you give them oxygen; if 5 liters (of oxygen) is not working, she stated you put on a mask (oxygen is measured in liters [L] per minute and delivered via mask or nasal cannula [small plastic tube, which fits into the person ' s nostrils for providing supplemental oxygen]). During the same telephone interview on 4/1/25 at 12:46 p.m., RN C stated Emergency Responders (ER's) determined Resident 1's physical status required Code 3 transport (driving using lights and sirens) and they administered an Albuterol treatment in route to the hospital. RN C stated Code 3 transportation was utilized with someone who was dying. RN C stated Resident 1 was critical upon arrival to the Emergency Department (ED) and she was classified as an ESI 2 (Emergency Severity Index; high risk of deterioration; ESI 1 is the most urgent/ESI 5 is the least urgent) and she was close to coding (code blue; an emergent situation when a patient's breathing or heart has stopped). RN C stated Resident 1 was also struggling (to breathe), unable to speak, and weak as a noodle when she arrived and was subsequently transferred to the Intensive Care Unit. RN C stated Resident 1's hypoxia (at the facility) contributed to her respiratory distress and bumped her into a more critical presentation in the ED and came close to killing her. Online review of the Cleveland Clinic's website indicated, .Hypoxia is when the tissues of your body don't have enough oxygen .Hypoxia can be life-threatening .prolonged hypoxia can cause organ damage. Brain and heart damage are particularly dangerous and can lead to death . (https://my.clevelandclinic.org/health/diseases/23063-hypoxia) Review of the Ambulance Trip Sheet (ER's documentation of Resident 1's care), dated 3/23/2025 at 11:21 a.m., indicated on 3/23/25, the facility called for an ambulance at 11:20 a.m. and the emergency responders arrived at approximately 11:27 a.m. (seven minutes later). The ER's documented upon their arrival at the facility, Resident 1's respiratory rate was increased (a sign of respiratory distress), her breathing was labored (abnormal breathing; increased effort to breathe; may include use of accessory muscles), and her oxygen saturation was 74%. The ER's also documented Resident 1 had decreased tidal volume (the amount of air inhaled or exhaled during a normal breath ), had retractions (indicating use of accessory muscles) around her neck area, her lung sounds were diminished in the bases (reduced air flow in the lower part of the lungs) and she had mild wheezing (high-pitched sound caused by narrowed airways). Continued review of the Ambulance Trip Sheet, dated 3/23/2025 at 11:21 a.m., indicated on 3/23/2025 at approximately 11:29 a.m., the ER's gave Resident 1 a respiratory treatment with Albuterol and placed her on 6 liters of oxygen; they documented Resident 1's response to their interventions was improved. At approximately 11:42 a.m., prior to arrival at Hospital 3, the ER's documented Resident 1's breathing was still labored but her oxygen saturation had increased to 92%. Oxygen saturation is measured by a pulse oximetry devise at the bedside. According to the National Library of Medicine, pulse oximetry is a quick, non-invasive technique to measure/monitor oxygen saturation in the blood. Normal pulse oximeter readings (oxygen saturation) range from 95% to 100%. Hypoxemia (hypoxia) is an oxygen saturation of less than 90%. Critical findings prompting intervention for most patients would be oxygen saturation in the mid to high 80%. [https://www.ncbi.nlm.nih.gov/books/NBK470348/] During an interview on 4/3/2025 at 1:58 p.m., RN A stated she worked on 3/23/25 but did not remember Resident 1 being sent out to Hospital 3. RN A described the process she would follow if a resident had SOB (shortness of breath): RN A stated she would check the resident's vital signs (temperature, heart rate, blood pressure and respirations/breathing), check the oxygen saturation, listen to the lungs, look at medication (for possible administration), and call the physician. She stated the physician may order labs (laboratory blood work; draw the resident's blood to run tests) and order a chest X-ray (medical imaging of the lungs and heart). RN A stated if a resident's oxygen saturation was below 90%, she would increase the oxygen up to the maximum (ordered by the physician) and would call the physician. She stated if the saturation was in the 80's or 70's (percentile), she would send the resident out (to the hospital) by calling 911 (request for emergency assistance; emergency responders). RN A stated if a resident's saturation was 68%, that would be a very critical situation and she would send the resident to the hospital ASAP (as soon as possible). During an interview on 4/3/2025 at 3:13 p.m., Licensed Nurse B (LN B) stated she would follow the following process if her resident had SOB: check the oxygen saturation, if it was below 90% she would start oxygen and notify the physician; she would elevate the head of the bed, give medication via the nebulizer (medical equipment that administers medication directly and quickly to the lungs via mist) and check the saturation level again; if there was no improvement, she would call 911. LN B stated normal oxygen saturation levels were between 92% - 96%. LN B stated if a residents oxygen saturation was in the 60's or 70's (percentile), they were at risk of dying and she would call 911. During an interview on 4/7/2025 at 1:58 p.m., RN D stated on the morning of 3/23/25 at approximately 10:30 a.m., Resident 1's daughter came out of the room and told her something was wrong with her mother. RN D stated she checked Resident 1's vital signs, her oxygen saturation was 68%, and she was short of breath. RN D stated she turned Resident 1's oxygen up to 5 L (via nasal cannula) and her oxygen saturation increased to 88%. RN D stated she instructed a nursing assistant to stay with the resident while she called Physician F. When questioned if these interventions were documented in Resident 1's medical record, RN D confirmed that she had not documented them. RN D stated she had not listened to Resident lungs during the morning of 3/23/25. When asked why she had not assessed her lung sounds, RN D stated she did not think of it. Review of facility policy titled, Oxygen Administration subtitled, Assessment (revised 10/2010) indicated, . while the resident is receiving oxygen therapy, assess for the following: .5. Lung sounds . Under subtitle, Documentation, the policy indicated, After completing the oxygen . adjustment (dose change), the following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed . 3. The rate of the oxygen flow, route (delivery method, nasal tubing or mask), and rationale. 4. The frequency and duration of the treatment . 6. All assessment data obtained before, during, and after the procedure . Review of facility Registered Nurse job description (dated 08/2015) indicated, . A. Safety discussions: . 17. Reports change of condition to physician . in timely manner . Under subtitle, A. Provision of Nursing Care, the document indicated, 1. Performs nursing care consistent with resident needs . Under subtitle, B. Demonstrates Knowledge and Understanding of Physical Evaluations, the document indicated, 1. Respiratory a. Breath Sounds . During the same interview on 4/7/2025 at 1:58 p.m. RN D reviewed Resident 1's MAR (medication administration report; daily record used by a licensed nurse to document medications and treatments given to a resident), dated March 2025, and confirmed she had a physician order for PRN (as needed) Albuterol inhaler (handheld device that delivers a measured amount of medication as a mist the patient can inhale). RN D confirmed Albuterol was not documented as given on 3/23/25. When asked why she had not given Resident 1 Albuterol, RN D stated Resident 1 was too weak to take it (inhalers require a person to inhale deeply and hold their breath). RN D confirmed Resident 1 had a medication nebulizer (device that converts liquid medication into a mist the patient can inhale easily) at her bedside for administration of other respiratory (lung) medication. When asked if she could have gotten an Albuterol vial (liquid form of the medication to be used with a nebulizer and mask) from the E-kit (emergency kit; facility supply of emergency medication) and given Resident 1 a dose via the nebulizer (does not require deep inhalation or breath-holding), RN D stated she did not know if Albuterol was in the E-kit. Review of Resident 1's MAR (dated March, 2025) revealed a physician order, dated 2/27/2025 at 2:19 p.m., that indicated, ProAir .Inhalation Aerosol Solution . (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for COPD . During the same interview on 4/7/2025 at 1:58 p.m. RN D reviewed Resident 1's SBAR (situation, background, assessment, recommendation; a communication tool used by healthcare workers when there is a change of condition in the resident), dated 3/23/2025 at 3 p.m., and stated it indicated Resident 1's oxygen saturation was 78%. RN D stated the reading of 78% occurred at approximately 11:20 a.m., prior to Resident 1's hospital transfer. RN D was asked if she had attempted to wean Resident 1 to a lower level of oxygen administration and she stated, yes. When asked why she tried to lower the amount of oxygen administered, RN D stated she was not sure why she had done that. Review of Resident 1's SBAR, dated 3/23/25 at 3 p.m., indicated RN D documented the following: .Resident reported difficulty breathing as well as chest congestion . This started on: 03/23/2025 (no time documented) . RN D documented she increased the oxygen from 3L (the increased amount was not identified). RN D documented Resident 1's oxygen saturation was 78% at 11:30 p.m. and, The problem is respiratory due to COPD . She appears with shortness of breath . The SBAR indicated RN D called Physician F one time at 11:20 a.m., prior to her hospital transfer. RN D documented, . Updated MD at 1120. O sat (oxygen saturation) was 78 on NC (nasal cannula) at 4 L SBAR indicated RN D called an RN at Hospital E and gave her report at 11:24 a.m. Review of Resident 1's MAR (dated March, 2025) revealed a physician order that indicated, Titrate (adjust) oxygen from 2L-4L (2 to 4 liters) to maintain (oxygen) saturation of > (greater than) 90% every shift . RN D documented on the MAR that Resident 1's oxygen saturation during the day shift of 3/23/25 was 78%; no specific time was indicated. Review of Resident 1's RN D's nursing progress notes (nurse's documentation of resident care), dated 3/23/25 at 11:30 a.m. indicated, Resident (1) sent to (Hospital E) via 911 (emergency responders). During an interview on 4/7/25 at 2:07 p.m., the DON (Director of Nursing) stated an oxygen saturation of 68% was considered low-low and the nurse should assess the resident's vital signs, increase the oxygen dose level, to increase the oxygen saturation, listen to lung sounds and give a breathing treatment if a PRN medication was ordered. The DON stated if the resident did not improve, the physician should be called (notified). When the DON was asked if a nurse should attempt to wean a hypoxic resident's oxygen administration down, the DON stated, that doesn't make sense. The DON asked why would a nurse wean oxygen down when staff were trying to increase their oxygen (saturation) level. During the same interview and concurrent medical record review on 4/7/25 at 2:07 p.m., the DON stated he advised nursing staff to document their interventions. The DON reviewed Resident 1's SBAR and nurse progress notes from the incident on 3/23/25; he confirmed neither contained documentation that Resident 1's oxygen saturation was 68%, RN D turned up the oxygen to 5L and the resident's saturation increased to 88%, or that RN D listened to Resident 1's lung sounds. When asked about emergency supplies of Albuterol, the DON confirmed Albuterol for nebulizer administration were located in the E-kits. During an interview on 4/7/2025 at 3:15 p.m., Physician F was asked if Resident 1's oxygen saturation level from 68% to 78% was a medical emergency and she stated, yes. She stated staff needed to get the resident to the hospital. Physician F stated a saturation of 68% could indicate the resident was going to crash (code blue; an emergent situation when a patient's breathing or heart has stopped). She stated staff should keep the resident talking (to keep them awake) and not leave them alone. She stated staff should listen to the lungs; if the resident was wheezing, she would use that information to decide on a medication to treat them. Physician F stated she could have ordered oral Prednisone (anti-inflammatory medication) that could be given under the tongue and Albuterol; she stated these medications would give the Emergency doctors a head start (on treatment). Review of Resident 1'a physician notes from Hospital E titled, Admission History & Physical , dated 3/23/25 at 11:57 a.m., indicated, . presenting (came to the hospital) from (the facility) for shortness of breath, patient found to be labored (difficulty breathing), with low oxygen saturation . Today in the ED (emergency department) found to have . respiratory failure (condition were a person does not have enough oxygen or too much carbon dioxide [chemical compound in the blood] in their body), started on Bipap (treatment that uses mild air pressure to keep the airways open), also given . abx (antibiotics to fight infection) . CT (computed tomography scan; imaging that produces detailed images of the inside of the body) shows diffuse (spread out) metastatic disease/infiltrate (cancer that spread to the lungs) . Under the subtitle of Assessment/plan, the physician note indicated . Admit to ICU . Review of Resident 1's physician progress note from Hospital E, dated 3/24/2025 at 9:46 a.m. indicated after coming to the hospital, Resident 1 was, .eventually intubated (a tube is inserted through the windpipe and into the lungs; medical procedure that helps patients who cannot breathe on their own) [on] 3/23/ (2025) . Review of Resident 1's physician's notes from Hospital E titled, Hospitalist Discharge Summary (dated 3/28/2025) indicated, . decision was made for patient (Resident 1) to transition to hospice on discharge . Review of Resident 1's Nursing Care Plan dated 2/27/25 indicated Resident 1 had, .altered respiratory status/difficulty breathing r/t (related to) COPD, metastatic . cancer (cancer that spread to her lungs) . The nursing interventions identified in the care plan indicated, Administer medication/puffers (Albuterol) as ordered. Monitor for effectiveness . Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (physician) . Decreased Pulse oximetry .cough . Accessory muscle usage . Monitor/document/report abnormal breathing .use of accessory muscles .Oxygen settings: (oxygen) via nasal prongs (nasal cannula)/mask 2-4L/min (2 to 4 liters per minute) . Review of facility job description titled, Charge Nurse subtitled, Charting and Documentation (undated), the document indicated, . Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well and the resident's response to the care . Under subtitle, Care Plan and Assessment Functions, the document indicated, Review care plans daily to ensure that appropriate care is being rendered . Review resident care plans for appropriate resident goals, problems, approaches and revisions . Review of facility policy titled, Change in a Resident's Condition or State (revised 2/2021) indicated, Our facility promptly notifies the . attending physician . of changes in the resident's medical .condition and/or status . Under subtitle, Policy Interpretation and Implementation, the policy indicated, . 2. A significant change of condition is a major decline . in the residents status . 3. Prior to notifying the physician . the nurse will make detailed observations and gather relevant and pertinent information for the provider (physician) . Review of facility policy titled, Transfer of Discharge, Facility-Initiated, subtitled, Documentation of Facility-Initiated Transfer or Discharge (dated 10/2022) indicated, When a resident is transferred or discharged from the facility, the following information is documented in the medical record: . a.(1) If the resident is being transferred or discharged because his or her needs cannot be met . documentation will include: a. the specific resident needs that cannot be met; b) this facility's attempt to meet those needs; . f. A summary of the resident's overall medical, physical, and mental condition . Review of facility document titled, Competency (demonstration of appropriate knowledge/skills) Validation Checklist (undated) for licensed nurses indicated, Respiratory Assessment . Observe respiratory rate, pattern, work of breathing . Auscultate (listen via stethoscope) anterior (front), lateral (side) and posterior (back) chest comparing one side to the other; .Ability to determine the following Breath sounds: 1. Wheezing - .usually a sign that something is making your airways narrow or keeping air from flowing through them. Two of the most common causes of wheezing are lung disease . COPD .lung cancer . Online review of the National Library of Medicine indicated the brain is the most sensitive organ, and visual, cognitive, and electroencephalographic (EEG - recording of the spontaneous electrical activity of the brain) changes develop when the oxygen saturation is less than 80% to 85%. (https://www.ncbi.nlm.nih.gov/books/NBK525974/)

Based on observation, interview, and record review, the facility failed to maintain a sanitary environment for food storage and preparation when the kitchen where the residents' food was stored and prepared was found to be infested with rats. This failure resulted in 90 out of 90 residents being served food that had been prepared in a kitchen contaminated with rat droppings and urine. On 4/3/24 at 11:06 a.m., due to the facility's failure to maintain sanitary conditions in the kitchen for food storage and preparation, Administrator and Director of Nursing (DON) were verbally notified of the Immediate Jeopardy. The Health Facilities Evaluator Nurse informed Administrator and DON of the surveyor's findings that rat droppings and gnawed food in the kitchen indicated a rat infestation and residents could not be served food from the kitchen. Lunchtime was in one hour and resident needed a meal to be served from an alternative source. Immediate Jeopardy is a situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident (State Operations Manual, Appendix Q). On 4/11/24 at 12:56 p.m., the facility presented a corrective plan of action, including but not limited to: 1) discarded all contaminated food, 2) food for residents to be prepared off site and delivered to the facility, 3) pest control service every three days and increased rat bait stations until no more activity, 4) hired additional pest control company for rat exclusion work. On 4/15/24 at 4:05 p.m., the removal of Immediate Jeopardy occurred in the presence of Administrator after interviews, observations, and record review confirmed the facility implemented the corrective plan of action. The facility kitchen remained closed for all food preparation and distribution at the time of the exit conference. Findings: During an observation and concurrent interview on 4/3/24 at 9:36 a.m. in the facility kitchen, kitchen staff were preparing food. When queried, [NAME] A stated the dietary manager was out of the country for the past month. Several dark brown droppings were under the ware washing area (area of the kitchen for rinsing and washing pots, pans, and dishes). When queried, Director of Nursing (DON) stated they were droppings. More droppings were under the two-compartment sink, the steam table (appliance used to keep food warm while it is being plated for residents' meals), under the ice machine, and in the dry storage area under shelves of food and on food. Dietary Aide B stated the droppings were rat poop. She stated she had been seeing the droppings in the kitchen for two months. In the dry storage area, multiple food items had been gnawed on, including bananas, a loaf of wheat bread, and a bag of spaghetti. DON verified the food items had been gnawed on and she saw the droppings on the food. DON stated that at a recent stand-up meeting someone had mentioned that they had had to throw away food from the kitchen. On returning to the kitchen from the dry storage area, Dietary Aide B was noted to be preparing sandwiches with wheat bread. During an interview on 4/3/24 at 9:58 a.m., Administrator stated the pest control company had been out to the facility numerous times for reports of rodents in the kitchen. Administrator stated the last time the pest control company was on site was last week. When asked the last time he had been in the kitchen to check for signs of rodents, Administrator stated last week. During a record review and concurrent interview on 4/3/24 at 10:05 a.m., Maintenance Director stated he had been getting complaints of rats in the kitchen for two weeks. When asked how he responded to the complaints, he stated he put poison baits in the kitchen under the dishwasher because they had a nest in the wall under there. He stated he opened the wall behind the dishwashing area and put poison in the nest. He also put steel wool and spray foam in the holes where they were coming in, but he had noticed this morning they were gnawing on the foam. Maintenance Director stated he did see the droppings under the ware washing area this morning. When asked if he told anyone, he said he told the dietary aide. When asked if he called the pest control company, Maintenance Director stated, No, not yet. Review of the pest control visit documentation revealed they had not been to the facility since 3/19/24. Maintenance Director stated he had received complaints from the kitchen staff that there were droppings or gnawed food every day since 3/19/24. The 3/19/24 pest control report indicated a rat was removed from the premises. During an observation on 4/3/24 at 10:20 a.m., Maintenance Director indicated the patched wall where he had found the rats' nest just outside the staff breakroom door. An area approximately 2 feet wide and 1.5 feet high just above the floor was patched over with spackle. On the other side of the wall was the ware washing area of the kitchen. During an interview on 4/3/24 at 11:20 a.m., Infection Preventionist (IP) stated the last time she was in the kitchen was to observe the maintenance staff perform the ice machine cleaning process. IP stated she was not doing a kitchen inspection at that time. IP stated she did rounds twice a month in the kitchen. She stated she had not gotten any complaints of rats from kitchen staff, but she heard they recently caught one. When asked about potential harm to residents with a rat infestation in the kitchen, IP stated rats carried disease, and verified residents could be exposed. IP was shown a photo this surveyor took of the rat droppings in the kitchen. IP verified the kitchen staff cleaned the kitchen every evening, so the droppings were from rats in the kitchen last night. During a phone interview on 4/3/24 at 11:30 a.m., the pest control company's customer service stated that during the last six months the facility had called in reports of rat activity in the kitchen on 11/27/23, 12/19/23, 2/20/24, 2/28/24, 2/29/24, 3/8/24, and 3/19/24. During an interview on 4/3/24 at 11:30 a.m., [NAME] C stated he had been noticing gnawed food in dry storage for two months. During an interview on 4/3/24 at 12:47 p.m., Pest Control Service Specialist was on site and stated that he was assigned this account at the beginning of March 2024. He stated he was last at the facility on 3/19/24 for an extra service request to remove a trapped rat. He stated he did not look in dry storage or under the dishwasher or sink during that visit. He stated he did look in dry storage during his visit on 3/8/24 and saw rat droppings at the time. When asked how he responded to finding rat droppings in dry storage, Pest Control Service Specialist stated he told the staff to clean them up. He stated that today (4/3/24) he found a hole and saw droppings under the dishwasher, he found holes on either side of the kitchen back door, he saw droppings in dry storage and gnawed food. Pest Control Service Specialist verified there had been rats in the facility kitchen. Pest Control Service Specialist stated he set additional traps in the kitchen and the facility would now be on escalation which means visits every three days. He stated to get off escalation the facility would have to have three visits with no catches and his manager must do a final walk-through. Pest Control Service Specialist stated he did not know if the facility had been on escalation before since he was new to the account, but the facility had not been on escalation since he was assigned at the beginning of March 2024. During an observation and concurrent interview on 4/3/24 at 1:10 p.m., County Health Inspector (CHI) D arrived at the facility and inspected the kitchen. CHI D verified the presence of rat droppings and gnawed food in the kitchen, including a bag of hamburger buns, a box of creamy wheat, a bag of corn meal, a bag of pancake mix, a bag of raisin bran cereal, and a box of salt. A tray of coffee mugs, boxes of food, and canned goods also had rat droppings on them. A white cardboard box on a shelf in dry storage had a yellowish dried liquid stain on the top that CHI D stated was likely rat urine. During an interview on 4/3/24 at 1:39 p.m., Registered Dietitian (RD) stated she did kitchen inspections twice a month. RD denied seeing any signs of rat activity or staff reporting rat activity to her. During an interview on 4/3/24 at 2:13 p.m., CHI D stated that due to the rat infestation, the facility kitchen could not be used to prepare or distribute food, and food for the residents needed to be obtained from an outside source until further notice. During a record review on 4/4/24 at 8 a.m., CHI D's emailed report of the facility's inspection titled, Permanent Food Facility Inspection Report, dated 4/3/24, indicated, Placard Status: Red - closed; suspension of permit to operate. The report further indicated major violations cited included rodents inside the facility, contaminated and adulterated food, food contact surfaces not cleaned and sanitized as required, and improper hot and cold holding temperatures for food. During an observation and concurrent interview on 4/6/24 at 5:14 p.m., County Health Inspector (CHI) J arrived at the facility and inspected the kitchen. CHI J verified water damaged wall under the ware washing station had been repaired with spray foam and wood and could be chewed through by rats. CHI J pointed out dried, grayish rat droppings on the floor behind the supports holding the ware washing station. CHI J stated the area behind the oven repaired with plaster could also be chewed through by rats. More dried, grayish rat droppings noted on the floor behind the cook line. CHI J verified the droppings looked old and had been there for some time. During an interview on 4/10/24 at 2:30 p.m., Dietary Manager stated he just got back from a month-long vacation. Dietary Manager denied any knowledge of the calls to the pest control company since November 2024. He stated that all he knew was the pest control guy came and put down the traps prior to his vacaton. When queried, Dietary Manager stated if the kitchen staff saw any signs of rodents while he was on vacation, they should have reported it to Administrator and cleaned it up. During an interview on 4/25/24 at 1:13 p.m., RD stated she did not know who had oversight of the kitchen while Dietary Manager was away for a month. During an interview on 4/30/24 at 10:50 a.m., Administrator stated that while Dietary Manager was away RD had oversight of the kitchen. Review of facility policy Food Receiving and Storage, revised 11/2022, indicated, Non-refrigerated foods . are stored in a designated 'dry storage' unit which is temperature and humidity controlled, free of insects and rodents and kept clean. Review of facility policy Food Preparation and Service, revised 11/2022, indicated, Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Review of the Food and Drug Administration (FDA) Food Code, last revised 2022, Chapter 6: Physical Facilities indicated, 6-202.16 Exterior Walls and Roofs, Protective Barrier. Perimeter walls and roofs of a FOOD ESTABLISHMENT shall effectively protect the establishment from the weather and the entry of insects, rodents, and other animals. 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under SS 7-202.12, 7-206.12, and 7-206.13; Pf and (D) Eliminating harborage conditions.

During a record review for Resident 59, the Face sheet (A one-page summary of important information about a resident) indicated Resident 59 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems), Schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others) and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for resident 59, the Care Plan for ADL (Activities of Daily Living) Self Care Deficit initiated on 7/09/2022 indicated, [Resident 59] ambulating independently without any assistive device. During a record review for Resident 59, the document titled Morse Fall Scale dated 7/08/2022 indicated Resident 59 had a total score of 70 points (A patient who scores under 25 points is considered to be at low risk of falling, a patient who scores between 25-45 points is considered to be at moderate risk of falling, and a patient who scores higher than 45 points is considered to be at high risk of falling). The document indicated Resident 59 had an impaired gait (manner of walking). The document indicated, [Resident 59] overestimates or forgets limit of her ability to walk. During a record review for Resident 59, the document titled Clinical Functional Abilities Evaluation dated 7/10/2022 indicated Resident 59's ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed was dependent on staff. She required maximum assistance with walking. During a record review for Resident 59, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 7/15/2022 indicated Resident 59 had a BIMS score of zero out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). Resident 59 required extensive (resident involved in activity; staff provide weightbearing support) one-person physical assistance with all transfer needs, toilet use and limited (resident highly involve in activity; staff provide guided maneuvering of limbs or other non-weightbearing assistance) one-person physical assistance with walking in room and walking in corridor. First Fall (8/30/2022) During a record review for Resident 59, the document titled Progress Note dated 8/30/2022 at 3:54 p.m. indicated Resident 59 had complained of right hip pain. The progress note indicated Resident 59's left leg appeared longer that the right leg and was unable to stand up and walk as she could previously. The progress note indicated Resident 59 was asked if she had fallen and Resident 59 stated she fell yesterday. The progress note indicated, There were no reported falls. The progress note indicated Resident 59 was sent to the hospital for further evaluation. During a record review for Resident 59, the fall care plan initiated on 8/30/2022 interventions to include: provide hip padding when she returns for further protection; PT/OT (Physical Thrapy/ Occupational Therapy) eval and treat as appropriate; Will move patient close to the nurses' station when a bed becomes available; and IDT to request medication review and lab test as appropriate. During a record review for Resident 59, the document titled Progress Note dated 9/01/2022 at 7:35 p.m. indicated the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) met to discuss about the fall incident involving Resident 59. The Progress Note indicated, NOC (night) shift Nurse stated that around 1-2am, she saw her walking and she assisted her back to her bed. PM shift stated that she was also walking independently like her usual. The Progress note indicated Resident 59 had Displaced Thigh Femoral Neck Fracture (displaced fracture occurs when the bone fragments on each side of the break are not aligned) and will undergo surgery. During a record review for Resident 59, the document titled Progress Note dated 9/04/2022 at 10:19 p.m. indicated Resident 59 came back from hospital with right femur fracture (a break in the thigh bone). During a record review for Resident 59, the document titled Progress Note dated 9/05/2022 at 12:03 p.m. indicated Resident 59 was readmitted with surgical incision to her right hip. During a record review for Resident 59,the document titled Physical Therapy Evaluation and Plan of Treatment dated 9/7/2022 indicate Resident 59 required minimal assist (when the assisting person(s) or device(s) are required to perform approximately 25 percent of the work of a mobility task while resident perform 75 percent of the work) with transfer and ambulation. During a record review for Resident 59, the document titled Progress Note dated 9/07/2022 at 9:28 p.m. indicated Resident 59 had multiple attempts of ambulating without assist/walker. During a record review for Resident 59, the document titled Physical Therapy Discharge Summary dated 9/29/2022 indicated Resident 59 required supervision with transfer and ambulation. Second Fall (11/05/2022) During a record review for Resident 59, the document titled Weekly Summary dated 10/31/2022 at 1:51 p.m. indicated Resident 59 required extensive assist with transfers, ambulation, and toilet use. The document indicated Resident 59 was continent with both bowel and bladder function. During a record review for Resident 59, the document titled Progress Note dated 11/06/2022 at 5:33 a.m. indicated, [Resident 59] came back from (hospital) related to fall, at 0030 AM . staff supervision at the point of service, . Res. independent to bed mobility and transfer. During a record review for Resident 59, the document titled Progress Note dated 11/06/2022 at 1:36 p.m. indicated Resident 59 had, unsteady gait to right lower extremity observed when patient took few steps during transferring from bed to wheelchair. The progress note indicated, ROM (range of motion) is decreased on her RLE (right lower extremity) after fall. During a record review for Resident 59, the document titled Progress Note dated 11/07/2022 at 5:11 a.m. indicated Resident 59 was given oxycodone (used to relieve pain severe enough to require opioid (powerful pain-reducing medications) treatment and when other pain medicines did not work well enough or cannot be tolerated) 5 mg (milligram) when she was observed grimacing and guarding her right hip. During a record review for Resident 59, the document titled Progress Note dated 11/07/2022 at 7:30 p.m. indicated, IDT discussed this morning regarding resident's recent unwitnessed fall on 11/05/22.at approximately 1745, staff heard a noise from the resident's room which is adjacent to the nurses' station. [Resident 59] was noted to be sitting on the floor with her back against the closet door. She was noted to be holding her pants. The progress note indicated Resident 59 was sent to the hospital for evaluation. During a record review for Resident 59, the document titled Progress Note dated 11/07/2022 at 8:42 p.m. indicated Resident 59 was given oxycodone 5 mg due to facial grimacing when propelling her wheelchair. During a record review for Resident 59, the fall care plan initiated on 11/07/2022 indicated intervention to offer [Resident 59] wheelchair and encourage to sit down in between walks. Third Fall (12/11/2022) During a record review for Resident 59, the document titled Weekly Summary dated 12/05/2022 at 2:59 a.m. indicated Resident 59 required extensive assist with transfers, ambulation, and toilet use. The document indicated Resident 59 was continent with both bowel and bladder function. During a record review for Resident 59, the document titled Progress Note dated 12/12/2022 at 12:42 p.m. indicated [Resident 59] is under monitoring for s/p unwitnessed fall day 1. No changes in LOC (level of consciousness) but decreased ROM to BLE (bilateral lower extremity) from her baseline noted as she c/o (complaint of) pain during transferring from bed to wheelchair and wheelchair to bed. During a record review for Resident 59, the document titled Progress Note dated 12/13/2022 at 6:00 a.m. indicated, [Resident 59] had tendency to ambulate with limitation. During a record review for Resident 59, the document titled Progress Note dated 12/13/2022 at 6:17 p.m. indicated, IDT discussed this morning regarding resident unwitnessed fall when she was found lying on her left side.[Resident 59] seems to be back in her normal baseline, ambulating without any assistive device. During a record review for Resident 59 with the DON on 1/13/2023 at 3:22 p.m. the DON verified the fall care plan for Resident 59 did not have new interventions after the 12/05/2022 fall. Fourth Fall (12/16/2022) During a record review for Resident 59, the document titled Progress Note dated 12/17/2022 at 1:29 p.m. indicated, [Resident 59] remains under S/P (status post - just an event, that a resident has experienced previously) unwitnessed fall day 1 STAT (immediately) bilateral hip x-ray (a type of radiation that can go through many solid substances such as bones and organs in the body to be photographed) pending still at this time Facial grimacing noted when personal care provided. Given Oxycodone 2.5 mg. During a record review for Resident 59, the document titled Progress Note dated 12/19/2022 at 3:33 p.m. indicated, On 12/16/22 [Resident 59] was noted after falling on the floor in the middle of her room, no witnesses Review of the Fall Care Plan initiated on 12/16/2022 indicated intervention, Will frequently reorient patient for use of wheelchair when out of bed. During an observation on 1/10/23 at 11:24 a.m. in Resident 59's room, Resident 59 was in her bed, awake; however, she did not respond when spoken to. During an interview with the DON on 1/13/2023 at 3:31 p.m. when asked how supervision was provided to Resident 59 to prevent her from falling, the DON stated Resident 59 gets easily agitated when staff try to stand beside her. The DON stated Resident 59 was moved close to the nurse's station to provide line of sight supervision. During an observation at the nurse's station on 1/13/2023 at 4:23 p.m. Resident 59 was observed transferring from her bed to her wheelchair without assistance. Two licensed nurses were at the nurses' station; however, none of the licensed nurses observed Resident 59 transferring. During an interview with Unlicensed Staff D on 1/17/2023 at 11:20 a.m. when asked how much assistance was provided to Resident 59, Unlicensed Staff D stated, Resident 59 required limited assistance when getting up. Unlicensed Staff D stated, Resident 59 had trouble walking, could be independent but sometimes needs assistance. Unlicensed Staff D she would constantly check Resident 59 in her room. When Unlicensed Staff D was asked about the risks for Resident 59 when she had repeated falls, she stated, resident could have fracture. During a review of facility's policy and procedure (P&P) titled Fall Policy, revised 6/15/22, the P&P indicated the staff will identify interventions related to residents specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling .if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . if the resident continuous to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 46132 Based on observation, interview and record review, the facility failed to ensure residents were free from accidents by implementing interventions to reduce hazard(s) and risk(s) monitoring for effectiveness and modifying interventions when necessary for two out of two sampled residents (Resident 169 and 59). This failure resulted in: 1) Resident 169 sustaining a Comminuted (bone broken into 2 more pieces), mildly displaced fracture involving the left parasymphyseal pubic bone (a unique joint consisting of a fibrocartilaginous (a dense, whitish tissue with a distinct fibrous texture) disc sandwiched between the articular surfaces of the pubic bones or bones that make up the pelvis) and Non displaced fracture of the anterior cortex of the left sacral ala ( bone called the sacrum, a large triangular bone at the bottom of the spine, breaks.(broken pelvis and spine) 2) Resident 59 sustained Right Femur Fracture (a break in the thigh bone) with surgical repair. Findings: 1)A review of Resident 169's facesheet ( demographics) indicated she was [AGE] years old, initially admitted on [DATE]. Her diagnoses includes Anemia (a low blood count that can make you tired and short of breath), Depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) and Schizoaffective Disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). During a concurrent observation in Resident's 169's room at 108A and interview on 1/11/23 at 9:09 a.m., Resident 169 was in her wheelchair, asleep. Unlicensed Staff M stated, Resident 169 was under her care today. Unlicensed Staff M stated, Resident 169 was a fall risk. Unlicensed Staff M stated, staff knew a resident was a fall risk if she had a bracelet and a signage that stated she was a fall risk. Unlicensed Staff M visually and verbally verified Resident 169 does not have either one of those. Unlicensed Staff M stated the facility policy was also for Resident 169 who was a fall risk to wear an orange bracelet indicating she was a fall risk. Unlicensed Staff M stated Resident 169 should be wearing an orange bracelet because she was a fall risk. Unlicensed Staff M stated since Resident 169 was not wearing it, the facility policy was not followed. She stated it was important to have this bracelet so other staff could identify residents that were a fall risk. Unlicensed Staff M stated if a resident was not wearing this orange bracelet, staff would not know they were a fall risk and residents could fall and hurt themselves. During a concurrent observation in Resident's 169's room at 108A and interview on 1/11/23 at 9:20 a.m., Resident 169 1 staff per 1 resident sitter (they can only observe one patient at any given time) stated her service was provided by the Veterans Administration (VA, an outside medical provider) to ensure Resident 169's safety and decrease her risk for falling. During a fall care plan and Minimum Data Set Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) record review on 1/11/23 at 12:09 p m., the fall care plan indicated Resident 169 should have a signage in the bathroom and at her bedside table stating, call for help, do not fall. A review of Resident 169's MDS, dated [DATE], indicated the Brief Interview for Mental Status (a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) assessment score of 9 indicating a moderately impaired cognition. During a concurrent observation in Resident's 169's room at 108A and interview on 1/11/23 at 12:19 p.m., Unlicensed Staff D visually and verbally verified Resident 169 had no signage in the bathroom and bedside table to remind Resident 169 to call for help and not fall. Unlicensed Staff D verified Resident 169 used to have that signage in her previous room. Unlicensed Staff D stated if the signage was not transferred to Resident 169's current room, the fall care plan was not followed and was a safety risk for the resident because it could result in a fall and resident could end up hurting themselves. During a concurrent observation and interview on 1/13/23 at 9:47 a.m., the Director of Nursing (DON) stated the facility's fall protocol included assessing for fall risk upon admission, fall care plan initiation upon admission and rehabilitation services to evaluate for durable medical equipment (DME, a medical equipment and supplies ordered by a healthcare provider for a patient's routine, long-term use) to be used, functional assessment/limitation. The DON stated she had initiated a fall reduction program, however, the program was not successful because of the lack for follow through. The DON stated when Resident 169 had multiple falls, the DON reached out to VA to notify them the facility was unable to care for Resident 169 due to her behaviors and impulsivity. The DON stated VA responded by providing the facility with 24 hour one on one staff to monitor for Resident 169's safety. The DON verified there was no signage on Resident 169's bedside table or the bathroom despite the fact it was care planned. The DON stated the facility should be following care plans. The DON stated the care plan was designed to guide staff on how to care for residents safely. The DON stated Resident 169's fall care plan was not updated but instead a new one was created every time she falls. When asked what happened to the old fall care plan, the DON stated, it's just in the system. The DON verified the facility does not update the care plan and the facility does not resolve a care plan even when it was not effective. DON stated the care plans not updated nor resolved would indicate the care plan was still in effect. The DON stated the call do not fall signage care plan was active, meaning it was still in effect when she moved to her current room. The DON verified the facility did not follow the fall care plan when the signage was missing from Resident 169's room. The DON stated if the care plan was not followed, the facility was not in compliance. The DON stated it was important to follow the care plan for safety. The DON stated if the care plan was not followed, this could put Resident 169 at risk for falls and accidents. During a concurrent interview, care plan and bowel/bladder log review on 1/13/23 at 11:30 a.m., the DON verified Resident 169 was on bowel and bladder program (B/B, goal was to help patients manage incidence of incontinence or accidents effectively with a combination of exercises, techniques, and lifestyle changes) since 4/2022, however the log had days when there was incomplete entry and there was no entry noted after 4/2022. The DON verified, the April log, was also the only log for Resident 169's B/B monitoring. The DON verified this meant their fall care plan was not followed. The DON stated Resident 169's fall on 8/25/22 might have been prevented if Resident 169 continued to be on the B/B program per fall care plan. Resident 169 should have been placed on prompted voiding program (a behavioural therapy used to improve bladder control for people with or without dementia (impaired thinking, remembering or reasoning that can affect a person's ability to function safely) using verbal prompts and positive reinforcement per her care plan on 9/9/22. The prompted voiding program was necessary due to the fact Resident 169 would go to the bathroom frequently unassisted. She stated this was also in place to help prevent future falls. The DON stated that since this care plan was not carried out, it could be a safety risk. During a concurrent interview, Xray ( Xray imaging creates pictures of the inside of your body) and Computerized Tomography scan (CT, a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) and care plan record review on 1/17/23 at 10:10 a.m., the DON verified Resident 169 fall on 8/25/22 resulted in fracture, however it was missed by the X ray initially. The DON stated after the fall on 8/25/22, Resident 169 continued to complain of pain. The DON suspected it was hairline fracture (a small crack or bruise within a bone) which was why it was probably missed when Resident 169 was initially Xrayed. The DON verified Resident 169 fell again on 8/27/22 and was sent out on 8/27/22 due to persistent pain. The DON stated the hospital did an Xray of the right hip again but was negative for fracture. However, since Resident 169 continued to be in pain, a CT scan of the right hip was done which showed right hip fracture. Resident 169 was admitted to the hospital from 8/28/22 to 9/9/22. Resident 169 care plan on 9/9/22 indicated she would be placed on prompted voiding program. The DON stated the prompted voiding program was necessary due to the fact that Resident 169 would often go to the bathroom unassisted. She stated the prompted toileting program should be in place to help prevent future falls. She stated that since this care plan was not followed, it could be a safety risk. DON verified one on one staff provided by the VA (due to falls and behaviors) was initiated on 9/9/22 at 11:00 p.m., after Resident 169 had already fallen. The DON verified Resident 169 was readmitted at around 8:00 p.m. on 9/9/22 and fell at 10:15 p.m., and the one on one staff, provided by the VA, was not yet available at that time. The DON was not sure what was the staffing ratio for her on the days that she fell on [DATE], 8/27/22 and 9/9/22. Review of the fall care plan with the DON, who verified staffing wise it would appear staffing ratio for Resident 169 would be 1 staff per 2 to 3 residents per care plan. DON stated due to Resident 169's frequent falls, the Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) decided to lessen number of residents per staff that cared for her. The DON stated that based on the care plan, they were not following the staffing ratio for Resident 169. She stated the main purpose of staffing ratio of 1 staff per 2 to 3 resident was because of safety concerns due to Resident 169's falls and behaviors as well. The DON stated not following the staffing ratio for Resident 169 could increase her risk for falls. DON stated the fall could have been prevented if the facility was following the staffing ratio as per care planned. The DON verified, the staffing ratio was not followed on these dates 8/25/22: morning shift 1 staff to 6 residents, afternoon shift 1 staff to 6 residents and night shift 1 staff to 18 residents; 8/27/22 morning shift 1 staff to 8 residents, afternoon shift 1 staff to 7 residents, night shift 1 staff to 15 residents; 9/9/22: afternoon shift 1 staff to 9 residents and night shift 1 staff to 15 residents. During a concurrent interview and daily staffing record review on 1/17/23 at 11:07 a.m., the Staffing Coordinator verified that based on the facility record, the staffing ratio was not followed on these dates 8/25/22: morning shift 1 staff to 6 residents, afternoon shift 1 staff to 6 residents and night shift 1 staff to 18 residents; 8/27/22 morning shift 1 staff to 8 residents, afternoon shift 1 staff to 7 residents, night shift 1 staff to 15 residents; 9/9/22: afternoon shift 1 staff to 9 residents and night shift 1 staff to 15 residents.

Based on observation, resident and nursing staff interview, medical record review, and policy review, the facility failed to develop and implement effective interventions for pressure injury prevention and treatment for 1 of 24 sampled residents (Resident 30) when: 1) The physical therapy department did not notify nursing staff that Resident 30 was wearing a trial foot brace; Licensed nursing staff were unaware Resident 30 was wearing a foot brace and did not monitor the brace (for circulation, skin integrity, pain, etc.); Resident 30 subsequently developed a pressure ulcer on the plantar (bottom) surface of his foot from the brace; 2) Licensed nursing staff did not accurately assess/document/monitor the progression of Resident 30's pressure ulcer; and 3) Licensed staff did not notify Resident 30's Physician (Physician E) or Nurse Practitioner (NP F) timely regarding the progression of the pressure ulcer. These failures contributed to Resident 30's development of a pressure ulcer, decline in function (inability to walk), decreased quality of life (inability to walk around the facility, which he enjoyed), potential delay in treatment, and transfer to a hospital for intravenous antibiotics to treat osteo[DIAGNOSES REDACTED] (bone infection). According to the Institute for Healthcare Improvement, pressure ulcers (which are preventable in most cases) are localized injury to the skin and/or underlying tissue, as a result of pressure, or pressure in combination with shear (gravity force pushing down on the patient's body) and/or friction (force of rubbing two surfaces together). Pressure ulcers can cause considerable harm to patients, hinder functional recovery, and frequently cause pain and the development of serious infections. Pressure ulcers have also been associated with an extended length of stay,[MEDICAL CONDITION], and mortality. (http://www.ihi.org/Topics/PressureUlcers/Pages/default.aspx) Findings: 1) During an observation and interview on 2/27/19 at 16:30 p.m., Resident 30 way lying in his bed and stated he had a sore on the ball of his right foot. He stated he had worn a brace inside his shoe, which created a blister. He stated the brace was for right leg weakness and positioning and he got the brace from the RNA (Restorative Nurse Assistant, facility staff). He stated he wore the brace a couple of days before the blister developed. He stated the blister occurred approximately ten days to two weeks earlier. When asked if his doctor had seen his foot, he stated he had not seen his doctor in a long time. He stated he had not seen his Nurse Practitioner (NP F) lately. He stated he was now confined to bed. When asked if his foot wound kept him from walking, Resident 30 stated, yes. Resident 30 stated he liked to walk, and stated he used to walk all over this place. He stated he recently had cataract surgery and missed two eye appoints (post-surgical) due to his current inability to walk. When asked if he had pain in his foot, he stated he did not have much feeling in his feet due to diabetes. He stated he was worried about his feet and had to be very careful about his feet because of his diabetes (Diabetes Mellitus is a disease causing increased concentrations of glucose in the blood, which in turn damages many of the body's systems, in particular the blood vessels and nerves). According to the World Health Organization (WHO), diabetic foot disease, due to changes in blood vessels and nerves, often leads to ulceration and subsequent [MEDICAL CONDITION]. Diabetes is the most common cause of non-traumatic amputation of the lower limb, which may be prevented by regular inspection and good care of the foot (https://www.who.int/mediacentre/factsheets/fs138/en/) Review of Resident 30's Minimum Data Set (MDS, a screening and assessment tool), revealed he had a BIMS score of 15 (out of 15), which indicated he was cognitively intact. Review of Resident 30's Care Area Assessments (dated 5/1/18) indicated he was at risk for development of pressure ulcers, had a history of [REDACTED]. During an interview and record review on 3/01/19 at 11:20 a.m., Physical Therapist G (PT G) was asked to describe his treatment course for Resident 30. PT G stated Resident 30 had begun physical therapy after having a fall at the facility. PT G stated he had performed the initial evaluation on 2/6/19, and his therapeutic treatment included therapeutic exercise, gait training (therapy to improve stand/walk ability) , group (exercising) and, various therapeutic activities. During the same interview on 3/01/19, PT G stated Resident 30 had foot drop (dropping of the forefoot), his toes dragged when he walked, and he would likely trip on stairs. PT G stated he began a trial with a foot brace (AFO, ankle foot orthotic) to help prevent Resident 30's foot from dropping. PT G selected a, toe-off AFO (specific type of AFO) for Resident 30. He stated the facility had one onsite and Resident 30 began using it (on a trial basis). PT G stated the AFO foot plate fit inside Resident 30's shoe and his shoe's insole was placed over the plate to protect the foot. PT G stated Resident 30 knew how to put the AFO in and out of his shoe himself. When asked for a definition of, trial, PT G stated that meant wearing the device when walking. He stated he was to wear it when he was out and about, but not to wear it in bed. During the same interview on 3/01/19, PT G stated Resident 30 wore the brace (toe-off AFO) when he went to an appointment out of the facility. When asked if he had reevaluated the AFO (for fit, comfort, etc.) or Resident 30's ability (to properly use) the AFO prior to allowing him to leave the facility wearing it, PT G stated he had not reevaluated the device. When asked if anyone evaluated the AFO brace prior to Resident 30 leaving the building, PT G stated he did not know. When asked how long Resident 30 was out of the facility wearing the AFO brace, PT G stated he did not know. PT G stated nursing staff notified him the following day that Resident 30 had developed a blister. He stated Resident 30 had taken the pad (insole) out. When asked why Resident 30 had removed the pad, PT G stated he said it was not comfortable. PT G stated Resident 30 had been on the toe-off AFO trial approximately two days prior to developing the blister. Review of Resident 30's Physical Therapy Initial Evaluation, dated 2/6/19, indicated he had a, gait pattern consistency with R (right) foot drop. The evaluation treatment approaches included therapeutic exercise, gait training, group therapeutic procedures, PT evaluation, and therapeutic activities. The treatment approaches did not indicate an AFO trial. The evaluation was not signed by Physician E. Review of Resident 30's Physical Therapy Treatment Encounter Notes, dated 2/7/19, indicated the AFO trial had started. PT Encounter notes, dated 2/8/19 and 2/12/19, indicated gait training continued with the toe-off AFO. PT Encounter notes, dated 2/13/19, indicated Resident 30 was able to put on and take off his AFO without assistance and PT issued toe-off AFO. Review of Resident 30's Physical Therapy Treatment Encounter Notes, dated 2/14/19, indicated, .Nursing discovered pressure wound on the plantar surface of R (right) forefoot most likely caused by toe-off AFO. Pt (patient) had removed protective insert covering AFO . Review of Resident 30's Nursing Notes, dated 2/15/19, indicated he had a, wound on R (right) foot related to pressure from foot brace . Review of facility-provided manufacturer's instructions for the AFO titled, Allard USA, subtitled, Skin Monitoring, (undated) indicated, Check the condition of your lower leg and foot daily, especially if you are suffering from loss of feeling on you lower leg. In the case of skin irritation or discoloration discontinue use immediately and contact your fitter/prescriber immediately . During an interview on 03/04/19 at 10:10 a.m., PT G was asked if he had gotten a physician order [REDACTED]. During an interview on 3/04/19 at 10:33 a.m., Licensed Nursing Staff P was asked how PT communicated new devices (brace) to nursing. Licensed Staff P stated PT should call the doctor and get a telephone order, then we (nursing) would see the order. She stated PT may order to trial a device for five days, or just at night, for example. During an interview and record review on 3/01/19 at 3:35 p.m., the DON (Director of Nursing) reviewed Resident 30's medical record. The DON stated Resident 30 used to walk a lot (around the facility), almost all day (prior to his pressure ulcer). The DON stated nursing staff notified her when Resident 30's blister was identified on the evening of 2/13/19. She stated Resident 30 had only one pressure ulcer, not two, and it had purple coloring in the center. She stated she assessed the pressure ulcer on 2/13/19, but did not investigate or document about it until 2/15/19 (Interdisciplinary Team note). When asked what had caused the pressure ulcer, the DON stated PT G told her Resident 30 had been wearing an AFO brace on a trial basis. During the same interview 3/01/19, the DON was asked how nursing staff was monitoring Resident 30's AFO brace during the trial. The DON stated nursing staff did not know Resident 30 was on a trial or wearing an AFO brace. The DON stated she could not locate any nursing documentation in the medical record regarding monitoring the brace. She stated nursing was unaware of the brace, so they did not monitor it or create a nursing care plan to address it. When asked what her expectation would be from staff regarding a resident trial of an AFO brace, the DON stated therapy (Physical Therapy) should tell nursing specifically (about the trial), nursing should monitor positioning, circulation, and pain, and the AFO trial should be care planned. 2) Review of Resident 30's medical record revealed a Nurse's Note documented by LN D, titled, SBAR Communication Form (dated 2/13/19), indicated, open blister to the right plantar (sole of foot) by 4.5 x 2.8 cm, no s/sx (sign/symptom) of infection. LN D documented on the form that she notified Physician E. Review of Resident 30's Weekly Skin Evaluation form, dated 2/13/19, indicated the stage of Resident 30's the pressure ulcer was, UTD (unstageable/unable to determine), not a simple blister. According to the facility's Operations Manual Skin Integrity Definitions titled, Unstageable/Unclassified (UTD): Full thickness skin or tissue loss - depth unknown (updated 2014), indicated UTD skin injury included full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Further description indicated an UTD injury wound bed is eventually exposed, an UTD .will be either a Category/Stage III or IV (Stage 3 injury includes full thickness skin loss where subcutaneous fat may be visible, slough (dead tissue) may be present, and may include undermining and tunneling (channels that extend from a wound into and through subcutaneous tissue or muscle); Stage 4 injury additionally includes exposed bone, tendon, cartilage, or muscle). Review of Resident 30's medical record revealed a Physician note, documented by Physician E (dated 2/13/19), which indicated Resident 30 had a new pressure ulcer to the plantar (bottom) of his foot. Review of Resident 30's IDT note (Interdisciplinary Team), dated 2/15/19, (two days after the pressure ulcer was identified), indicated, Resident has a 4.5 x 2.8 x 0.2 broken blister on RT (right) plantar area (ball of foot) characterized by total loss of [MEDICATION NAME] tissue with about 30% purple discoloration area in the middle, which was first noted on the evening of 2/13/19. The note indicated Physical Therapy (PT) had given Resident 30 a brace (AFO type) for walking and, .friction caused by metal base of AFO brace by making direct contact with ball of foot . was a likely cause of the current skin issue. The IDT note was signed by the DON and Management Staff M. Review of the Nurse's Progress Note for the time period 2/9/10 - 2/16/19 (dated 2/16/19), indicated his skin was, intact (no pressure ulcers). Nursing documented, on 2/10/19 (three days prior to notifying Physician E on 2/13/19), that staff were, monitoring open blister on R (right) plantar. Nursing Notes dated 2/15/19 at 5 p.m., 2/15/19 at 10:15 p.m., 2/16/19 at 10 p.m., indicated Resident 30 had a blister, not an UTD pressure injury, on his foot. Review of Resident 30's Weekly Skin Evaluation form, dated 2/17/19, indicated the stage of Resident 30's pressure ulcer was, UTD and also Stage II (2). Licensed Staff documented the wound bed had, [MEDICATION NAME] 100% (process of covering damaged [MEDICATION NAME]/skin surface). The evaluation did not indicate Resident 30 had an UTD injury with purple discoloration. Review of the Nurse's Progress Note, dated 2/23/19, indicated Resident 30 had a right, plantar opened blister, ongoing tx (treatment) and 100% [MEDICATION NAME] . The note did not indicate he had an UTD pressure injury with purple discoloration. Review of a Nursing Care Plan titled, Skin Integrity Care Plan, dated(2/13/19), indicated, Pressure sore to R (right) plantar (bottom) . of foot. Interventions identified on 2/14/19, indicated, Provide Draco shoe (medical shoe that can help decrease pressure on wounds) when available. The care plan did not identify the stage of the pressure ulcer (UTD), the ordered dressing changes (ordered by Physician E on 2/13/19), or notification of provider if the pressure sore worsened. The Skin Integrity Care Plan indicated Resident 30 had approximately three pressure ulcers in the past (healed in 5/30/18, 6/29/18, and 10/4/18), and interventions for the past pressure ulcers included complete skin check every shift - report problems to Charge Nurse, pressure-relieving mattress, Dietary consult, Pharmacy consult, provide treatments per Physician order, and notify Physician if any further change of condition / skin breakdown. Review of Resident 30's Nursing Notes dated 2/24/19, at 11:24 a.m., indicated Resident 30 had a right, plantar area pressure sore SDTI (suspected deep tissue injury) that was, purple colored, and, measured 3.5 cm x 2.7 cm, and was, UTD (unable to determine) depth The note did not indicate staff notified Physician E. (The National Pressure Ulcer Advisory Panel defines an SDTI as a, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear, [DATE], (YEAR)). Review of Resident 30's medical record revealed an, SBAR Communication Form, (dated 2/27/19, approximately three days after nursing staff documented SDTI), that indicated Physician E was notified Resident 30's wound contained 100% slough. The SBAR did not contain documentation regarding SDTI. During on observation and concurrent interview on 2/28/19 at 9:10 a.m., Licensed Nurse D (LN D) changed the pressure ulcer dressing on Resident 30's right foot. LN D put on gloves, used scissors to cut away the old dressing, and exposed the bottom of Resident 30's foot. Resident 30's foot had two (not one, as documented) areas of skin injury: The first area was located on the ball of the foot (below the big toe) and was red in color (LN D did not measure this lesion); the second area was located to the right of the first, was approximately 1.5 cm X 1.5 cm (per LN D's estimation) and appeared black in color. LN D spoke to Resident 30, and stated the facility had made a referral to Podiatry (doctors specializing in disorders of the foot, ankle, and lower extremity) and called his Physician (regarding his pressure ulcers) the day prior. LN D cleansed the two ulcers, applied Santyl and Calcium Alganate (medication) and applied a new dressing. During an interview on 2/28/19 at 9:30 a.m., LN D stated she had performed Resident 30's dressing change the day prior, and the wound had 100% slough and was white in color. LN D stated she documented her dressing changes in the TAR (Treatment Administration Record). Review of Resident 30's TAR (dated 2/14/19 - 2/26/19), indicated dressing change orders for a, Right plantar opened blister. The TAR did not indicate Resident 30's skin injury was an UTD injury (which would likely be a Category/Stage III or IV, once the wound bed was exposed). During an interview and record review on 3/01/19 at 3:35 p.m., the DON reviewed the Physician's dressing change order (a verbal order obtained by the licensed nurse), dated 2/13/19, which indicated, Right plantar open Blister. When asked if that was an accurate order (accurately documented by Nursing), the DON stated, no and stated the pressure ulcer was unstageable. The DON reviewed the weekly skin report, dated 2/17/19 (where LN D documented Resident 30 had both an UTD pressure ulcer or a Stage II). The DON stated LN D had made a mistake, and the pressure ulcer was UTD at that time. The DON reviewed Nursing documentation, dated 2/24/19, which indicated Resident 30's pressure ulcer was SDTI (Suspected Deep Tissue Injury). She stated Resident 30 refused to allow her to assess the wound at that time but currently, Resident 30's pressure was a SDTI. During the same interview on 3/01/19, the DON was asked when Resident 30's second pressure ulcer was identified. The DON stated it was new to her, and she had seen it for the first time yesterday, (2/28/19). The DON reviewed the Nurses' Notes and could not find any documentation regarding the second pressure ulcer. 3) During an interview on 03/04/19 at 12 noon, NP F stated she worked with Physician E and had taken care of Resident 30 in the past. NP F was asked when she had learned about the pressure ulcers on Resident 30's foot. She stated she learned of the pressure ulcers late last week (approximately two weeks after they were first identified), and she stated she just learned the facility no longer had a wound doctor. When asked what her expectation would be if Nursing staff noted a blister had developed a purple/dark color (as noted on 2/24/19), she stated she should be notified because that would be considered a significant change. NP F was asked if Resident 30 should have been seen by a provider (Nurse Practitioner or Physician) between 2/20/19 (the last documented provider note), and today, 3/4/19, she stated, probably. During the same interview on 03/04/19, NP F stated she had assessed Resident 30 earlier in the day (3/4/19), and his pressure ulcer was now necrotic (containing dead tissue), had an odor (which indicated infection), and was purple/black in color. She stated she would recommended debridement (the medical removal of dead, damaged, or infected tissue to improve the healing) as soon as possible. When asked if Resident 30 should have had a Physician order [REDACTED]. During a telephone interview on 3/12/19 at 4:10 p.m., Physician E was asked about Resident 30's pressure ulcer. He stated he thought a miscommunication had occurred between Nursing and PT regarding the brace (AFO), and it was eventually brought to Nursing (Nurses' attention). During the same telephone interview on 3/12/19, Physician E stated he had no real head's-up until it (the wound) was significant. He stated Nursing notified him Resident 30 had a blister on his foot. He stated when a blister was noted, Nursing did routine checks and monitoring. He stated he was not notified further about the blister until it was a, full-blown, wound, shortly before the State (survey team) entered the building (2/26/19). He stated he and NP F were notified of the pressure ulcer at approximately the same time. When asked if he was aware Nursing had documented the wound was UTD, he stated, No, and stated he would have done something about it. During the same telephone interview on 3/12/19, Physician E was asked what should have been done for Resident 30's pressure ulcer. Physician E stated the facility was concerned about wounds, especially in diabetic patients. He stated the facility had a wound doctor who used to see the patients. Physician E stated this (Resident 30's pressure ulcer issues) might not have happened if he (the wound doctor) was still at the facility. Physician E stated the facility should have notified him, or NP F, or the wound doctor in time, for them to take action. When asked what type of action would have been taken, he stated they would write orders to address the wound, orders to notify the wound doctor, and dressing change orders. He stated he communicated with Nursing staff via telephone calls and texts, and stated he did not know why he was not notified. During a same telephone interview on 3/12/19, Physician E stated NP F told him the wound was now necrotic. He stated they obtained an x-ray which showed osteo[DIAGNOSES REDACTED] (bone infection). He stated they had sent Resident 30 to the hospital for intravenous antibiotics. He stated Resident 30 had diabetes, and wounds could progress quickly. Review of facility policy titled, Skin Integrity, subtitled, Procedure, (updated 3/2018,) indicated, 8. If skin impairment is noted after admission .the LN: (Licensed Nurse) . b. Completes (and documents) notifications to the physician . 10. Wounds are evaluated weekly by Center clinicians (physicians/NP) .

Based on observation, interview and record review, the facility failed to provide necessary care and services to ensure the highest practicable level of physical and psychological well-being related to dementia care and implement person-centered interventions for three of seven sampled residents (Residents 1, 4 and 7) as evidenced by: * For Resident 7 who was at risk for constipation, the licensed nursing staff failed to adequately assess and monitor constipation in accordance with the plan of care and facility bowel care policy and administer laxative medications in accordance with the physician's orders [REDACTED]. * For Resident 1, the facility failed to provide documented assessments related to the resident's [DIAGNOSES REDACTED]. * For Resident 4, the facility failed to provide documented assessments related to the residents [DIAGNOSES REDACTED]. These failures had adversely affected residents with dementia causing further decline and psychological distress. Findings: 1. Clinical record review for Resident 7 was initiated on 8/13/14. Resident 7 was a [AGE] year-old admitted to the facility's dementia care unit on 12/6/13, with [DIAGNOSES REDACTED]. Review of Resident 7's multi-disciplinary quarterly MDS dated [DATE], showed she was able to able to express herself and usually understood most conversations but had memory problems with moderately impaired cognition. The assessment further indicated Resident 7 was continent of bowel function. Review of Resident 7's physician orders [REDACTED]. Resident 7's [MEDICAL CONDITION] (behavior management) medication orders included Klonopin (an antianxiety medication) 0.5 mg every 12 hours as needed for anxiety. Resident 7's bowel stimulant laxative orders included MOM as needed for no BM in 3 days. According to drugs.com (web based internet site), [MEDICATION NAME] (an opioid medication) commonly causes constipation as a side effect. According to Lexi-Comp online (a nationally recognized medication reference resource), elderly persons may be particularly sensitive to the constipating effect of opioid medications. On 8/14/14 at 0620 hours, Resident 7, who was wearing a short-sleeved long hospital gown and non-skid socks, was observed walking rapidly down the dementia unit hallway in a distressed manner. Resident 7 was speaking rapidly and unintelligibly and appeared somewhat drowsy and unsteady as she paced back and forth, then pushed through the closed doors of the unit near the nursing station. CNA 1 was at Resident 7's right side. A trickle of blood was observed to be running down Resident 7's right upper arm. During a concurrent interview, RN 1, who was at the nurse's station and confirmed having worked the night shift, stated Resident 7 had sustained skin tears to her right arm. RN further 1 stated Resident 7 had been exhibiting "a lot of behaviors" and "just had a large BM" and had been administered MOM the previous day. During a subsequent interview on 8/14/14 at 0640 hours, CNA 1, who indicated she usually did not work on the dementia unit, stated Resident 7 had almost fallen to the floor approximately 1/2 hour prior to the interview. CNA 1 further stated she had quickly grabbed Resident 7's right arm to prevent the fall, incurring skin tears to the resident's right arm. RN 1 documented the following in Resident 7's nursing notes on 8/14/14 at 0615 hours: "Res (resident) was up pacing the hall (had an extra large BM p (after) bowel care) CNA was redirecting her when res leaned back CNA caught her by grabbing her (right) upper arm to avoid her falling backwards, sustaining 2 skin tear(s) on RUA (right upper arm), 1.5 cm (centimeters) x 1.5 cm and another is 3.5 cm x 3.5 cm." 3.5 cm is approximately equivalent to 1 3/4 inches. Review of the facility's dementia care guidance policy titled Challenging Behaviors/Understanding Difficult Behavior dated January 2013, indicated "An unmet emotional or physical need is behind most challenging behaviors...I. Causes related to the person's physical and emotional health...E. Constipation." Review of Resident 7's bowel monitor flowsheet indicated CNA staff documented a medium size BM on 8/8/18 and no BMs on 8/9, 8/10, 8/11, 8/12 and 8/13/14. Therefore, on 8/14/14 Resident 7 had been without a BM for more than 5 days. Review of Resident 7's August 2014 MAR indicated [REDACTED]. Further review of Resident 7's nursing notes indicated Resident 7 had complained of lower back pain on 8/12/14 (four days after the previous BM on 8/8/14) and had been administered an as needed dose of [MEDICATION NAME] 10 mg. On 8/13/14 at 2230 hours, (five days after the previous BM on 8/8/14) a licensed nurse had documented, "Noted 4 days (no) BM enema administered awaiting for result." Resident 7's Behavior Monitoring Form dated August 2014, indicated her behavior had been generally stable until 8/11/14, when an increase in irritability was documented by licensed nursing staff. The MAR further indicated Resident 7 was administered a dose of Klonopin 0.5 mg for anxiety on 8/13/14 at 2000 hours. Review of Resident 7's plan of care included one care plan problem dated 12/6/13, for constipation due to routine narcotic use. The interventions included to monitor frequency and consistency of stool and administer laxatives as ordered. Review of the facility's P&P titled Fecal Impaction revised 1/1/13, indicated: "2. Each resident is placed on a daily bowel monitoring program...4. The licensed nurse reviews the bowel monitors daily. 5. If a resident does not have a bowel movement for 3 days...administer Milk of Magnesia per physician order [REDACTED]. During an interview on 8/15/14 at 1150 hours, the DON confirmed Resident 7's clinical record findings and acknowledged Resident 7 was at risk for constipation due to use of opioid pain medication. The DON further acknowledged licensed nursing staff did not adequately assess and monitor Resident 7's constipation in accordance with facility policy, implement her plan of care or bowel care drug regimen as prescribed by her physician, resulting in escalating and preventable physical and psychological distress for several days. The DON also acknowledged Resident 7 was medicated for back pain on 8/12/14, and anxiety on 8/13/14, for symptoms that were most likely related to her constipation. According to www.dementiacarecentral.com (web based internet site): a. No dementia: very mild cognitive decline, this stage is used to describe normal forgetfulness associated with aging, for example, forgetfulness of names and where familiar objects were left. Symptoms are not evident to loved ones or the physician. b. Early-stage of dementia: moderate cognitive decline, this stage includes difficulty concentrating, decreased memory of recent events, and difficulties managing finances or traveling alone to new locations. People have trouble completing complex tasks efficiently or accurately and may be in denial about their symptoms. They may also start withdrawing from family or friends, because socialization becomes difficult. At this stage a physician can detect clear cognitive problems during a patient interview and exam. c. Late-stage of dementia: very severe cognitive decline. People in this stage have essentially no ability to speak or communicate. They require assistance with most activities (e.g., using the toilet, eating). They often lose psychomotor skills (for example, the ability to walk). According to Lexi-Comp Online, donepezil is used in the treatment of [REDACTED]. During the initial tour rounds on 8/13/14 at 1020 hours, the SSD stated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Clinical record review for Resident 1 was initiated on 8/13/14. Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 1's admission face sheet identified a family member was the responsible party for his care. Review of Resident 1's physician order [REDACTED]. Review of Resident 1's H&P dated 5/1/14, showed he did not have the capacity to understand and make decisions related to his [DIAGNOSES REDACTED]. Review of Resident 1's MDS dated [DATE], showed he is cognitively intact and had no behavior episodes. His active [DIAGNOSES REDACTED]. Review of Resident 1's IDT notes dated 6/11/4, showed his behavior review was for his depression. Additional IDT notes dated 7/9, 7/22 and 7/23/14, showed documentation related to falls. No documentation was available to show Resident 1 had any behavior episodes or dementia. Review of Resident 1's Social Service Progress Notes dated 6/11 and 7/25/14, showed no documentation related to any behavior episodes or dementia. No documentation was available to show Resident 1 was evaluated to confirm his [DIAGNOSES REDACTED]. On 8/13/14 at 1600 hours, Resident 1 was observed in bed with the light off. The resident's eyes were closed and he appeared to be sleeping. During an interview on 8/13/14 at 1525 hours, LVN 1 stated Resident 1 has intermittent confusion and forgetfulness. She stated Resident 1 is able to make his needs known, but he forgets to use his call light to call for assistance. LVN 1 stated Resident 1 had no behaviors. He just does not like to socialize. The LVN further stated she was unaware of Resident 1's [DIAGNOSES REDACTED]. During an interview 8/13/14 at 1535 hours, the SSD stated Resident 1 is alert and oriented and able to make his needs known. She stated Resident 1 can feed and transfer himself. The SSD stated Resident 1 is non-compliant in asking the staff for help. The resident is pretty calm and likes to do his own thing. When the SSD was asked how Resident 1's [DIAGNOSES REDACTED]. The SSD stated Resident 1 had not been seen by a psychiatrist or psychologist because the resident is "very, very stable." In addition, the SSD confirmed she had no documentation in Resident 1's progress notes that addressed his psychosocial issues or behaviors. During an interview on 8/13/14 at 1605 hours, CNA 2 stated Resident 1 was alert and oriented and able to make his needs known. He stated Resident 1 is always nice and has no behaviors, except the resident likes to stay in his room with the curtain drawn around his bed. On 8/14/14 at 0610 hours, Resident 1 was observed in bed with the light off. The resident appeared to be sleeping. Interview with the night shift RN 3 showed the resident stays in bed most of the night and is able to use the bedside commode independently. The RN stated Resident 1 does not have any aggressive behavior. The RN further stated the resident watches after his roommate and would alert the staff if his roommate tries to get out of bed unassisted. An interview with CNA 4 was conducted on 8/14/14 at 0620 hours. The CNA stated Resident 1 always eats in his room and does not want to go to the dining room for meals. During an interview on 8/14/14 at 0625 hours, CNA 3 stated Resident 1 is alert and oriented and able to make his needs known. She stated Resident 1 slept through the night and had no behavior episodes. On 8/14/14 at 0635 hours, RN 3 was observed administering medication to Resident 1. The resident was very compliant with the RN during the medication administration. On 8/14/14 at 0640 hours, CNA 5 was interviewed. The CNA stated he is the morning shift CNA and has been taking care of the resident regularly. The CNA stated the Resident 1 is very alert, not forgetful and does not have any aggressive behaviors. During an observation on 8/14/14 at 0645 hours, Resident 1 was observed going back to his bed after using the bedside commode. The resident was able to perform the task without assistance. On 8/14/14 at 0705 hours, RN 4 was interviewed. She stated Resident 1 is alert, keeps to himself and tries to do things by himself. RN 4 stated the staff has instructed Resident 1 to call for assistance, but the resident still wants to do things by himself. The RN further stated the resident prefers the privacy curtain to be closed around the bed, but he is not depressed. When asked if the resident has dementia, she stated Resident 1 does not have dementia. During an observation on 8/14/14 at 0754 hours, Resident 1 was able to set up his breakfast tray himself and fed himself independently. On 8/14/14 at 1005 hours, a telephone interview was conducted with the Associate Medical Director. He confirmed he was Resident 1's current attending physician. When the Associate Medical Director was asked how he determined Resident 1 had a [DIAGNOSES REDACTED]. He stated he would have to reevaluate Resident 1 to determine if he actually had a [DIAGNOSES REDACTED]. During the initial tour rounds on 8/13/14 at 1020 hours, the SSD stated Resident 4 was admitted to the facility with [DIAGNOSES REDACTED]. Clinical record review for Resident 4 was initiated on 8/14/14. Resident 4 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 4's admission face sheet identified a family member was the responsible party for his care. Review of Resident 4's hospital transfer summary dated 5/23/13, showed he had progressive [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. Review of Resident 4's MDS dated [DATE], showed he had severe cognitive impairment and behaviors that interfered with resident participation. Review of Resident 4's IDT notes dated 7/23 and 8/13/14, showed documentation related to falls. No documentation was available to show Resident 4 had any behavior episodes or dementia. Review of Resident 4's Social Service Progress Notes dated 2/20/14 showed he had thrown soda at his roommate. No interventions were addressed. On 6/11/14, a social service note showed no documentation related to any behavior episodes or dementia. No documentation was available to show Resident 4 was evaluated to confirm his [DIAGNOSES REDACTED]. Review of Resident 4's Nurse's Progress Notes dated 7/14, 7/28 and 8/4/14, showed Resident 4 was disoriented and had impaired decision making abilities. On 8/13/14 at 1600 hours, Resident 4 was observed standing next to his bedroom door. He then walked back inside his room and laid down on his bed. The TV was on showing a baseball game. When asked if he is going to eat his dinner in his room, the resident stated, "No, everywhere." On 8/14/14 at 0610 hours, Resident 4 was observed in bed and appeared to be sleeping. RN 3, the night shift RN was interviewed. The RN stated Resident 4 had a tendency to yell at CNAs if being guided or if CNA wanted to give him care. RN 3 stated the resident is compliant and can be redirected. She stated Resident 4 would get up at night at least 3 to 4 times especially if he is hungry. On 8/14/14 at 0620 hours, CNA 4 was interviewed. The CNA stated Resident 4 always eats meals in his room and does not want to go to the dining room. During an interview on 8/14/14 at 0625 hours, CNA 3 stated Resident 4 is alert and oriented sometimes. She stated Resident 4 has aggressive behaviors and is resistant to care but can be redirected. During an observation on 8/14/14 at 0645 hours, RN 3 was administering the medications to Resident 4. The resident was very compliant during the medication administration. On 8/14/14 at 0755 hours, Resident 4 was observed eating his breakfast without assistance after the CNA set up his tray. During an observation on 8/14/14 at 0800 hours, Resident 4 ambulated to the bathroom independently. During an interview on 8/14/14 at 0830 hours, the SSD stated Resident 4 is alert to name only. She stated Resident 4 is resistant to care and usually stays in his room. The SSD stated she was unaware if Resident 4 had a psychiatrist or psychologist's evaluation.

The facility failed to provide the necessary care and service to attain or maintain the highest practicable physical, mental and psychosocial well-being, for Resident 1, when care was delayed due to confusion regarding her most recent advanced directive, resulting in delayed treatment and death. The clinical record for Resident 1 was reviewed on 6/2/2010 at 11:45 a.m. Resident 1 was admitted on [DATE], with multiple [DIAGNOSES REDACTED]. A Discharge Summary from the acute care hospital, dated 8/21/09, indicated the resident was treated for [REDACTED]. An Advance Care Directive form (instructions to family and medical personnel that explain what medical treatment the resident desires), signed and dated by Resident 1, on 8/23/09, indicated Resident 1 wanted, "...all measures taken to revive me in the event that my heart stops beating, or I stop breathing." Nurses Notes, dated 5/13/2010 at 2:00 p.m., indicated Resident 1 had a sudden change of condition with skin cool to touch, dark and odiferous urine in the foley catheter drainage bag, fluctuating blood pressure, and rapid and then slowing pulse. The physician was called and an antibiotic started. A second assessment, documented at the same time and on the same date, indicated the resident continued with clammy and cold skin. Staff again called the physician, who ordered a transfer for Resident 1 to the acute care hospital for evaluation and treatment. Nurses Notes, dated 5/13/10 at 4:15 p.m., indicated the blood pressure reading was 165/110, pulse 65, respirations 20, and axillary temperature 96.4 when Resident 1 was sent to the acute care hospital. Her skin was cold, clammy, and cyanotic (gray/blue). Nurses Notes, dated 5/13/2010 at 6:30 p.m., indicated Resident 1 was sent back to the long term care facility. The physician from the acute care hospital, encouraged staff at the long term care facility, to speak to the Social Worker and Resident 1 regarding comfort care plan in the future. According to the note, Resident 1 continued to be diaphoretic (sweaty) and clammy, and became more confused. The Physician was notified and orders given for Resident 1 to be returned to the acute care hospital. Nurses Notes indicated staff were unable to obtain vital signs for Resident 1 at the time of transfer. Emergency 911 was called and Resident 1 was transported to the acute care hospital at 7:40 p.m. A faxed form from the Petaluma Fire Department (FH incident #10-1792), dated 5/14/10 at 7:44 a.m., indicated the following; "...had a weird call.... On 5/13/10.... responded for a female patient with ALOC (altered level of consciousness) .... patient had been transferred to the acute care hospital earlier in the day....released from the acute care hospital and sent back...with minimal treatment done due to the patient's code status (DNR). We were called after one of the Nurses ..... found out she did not have a DNR, her advanced directive asked for full supportive care. She was in need of immediate ALS (advanced life support) care and 911 was called. The time without medical care could have been up to 4 hours, her medical status on our arrival was poor. Medic 991's treatment included intubation and IV using a bone gun (was a near code blue). Minimal treatment had been done by facility name staff." During an interview, on 6/2/2010 at 1:15 p.m., the Director of Nurses stated that the normal process for handling changes in advance directives was to send the old directive to file in Medical Records, and to place the newest directive in the clinical record. The DON was unable to locate a policy or procedure delineating the process. The facility failed to provide the necessary care and service to attain or maintain the highest practicable physical, mental and psychosocial well-being, for Resident 1, when care was delayed due to confusion regarding her most recent advanced directive, resulting in delayed treatment and death. This failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.