Every finding on record at Norwalk Skilled Nursing & Wellness Centre, LLC

Based on interview and record review, the facility failed to ensure two out of two resident council meetings held on 6/15/2026 and 8/14/2026, where complaints regarding delayed light response time were addressed as stated by the facility on the Resident Council Department Response form.This deficient practice resulted in the delaying of tracking issues mentioned during the resident council meetings and notifying the Quality Assurance/Quality Assurance and Performance Improvement ([QA/QAPI] a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee in a timely manner to address ongoing problems resulting in a delay in care of services for the residents. Findings: During a review of the facility's Resident Council Minutes (official, written records of what took place during a resident council meeting in a long-term care facility or nursing home) dated 6/15/2026, the minutes indicated four residents were not satisfied with the call light response time. During a review of the facility's Resident Council Department Response Form (structured document used in long-term care settings to formally record a department's response to issues or recommendations raised by the resident council), dated 6/15/2026, the form indicated the facility implemented a resident satisfaction interview/survey process to obtain ongoing feedback from residents regarding the quality of services and care provided times one month every week and social services will provide room visits to monitor resident satisfaction for one month. During a review of the facility's Resident Council Minutes, dated 8/14/2026, the minutes indicated the two residents expressed concerns regarding call light response. The minutes did not include a resident council department response form. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had diagnoses including asthma (long-term lung condition where the airways become inflamed and narrowed, making it hard to breathe and causing symptoms like wheezing and coughing), chronic obstructive pulmonary disease (COPD- chronic lung disease causing difficulty in breathing) and muscle weakness (reduced ability to generate normal force with one or more muscles). During a review of Resident 1's History and Physical (H&P), dated 3/29/2026, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 6/19/2026, the MDS indicated Resident 1's cognition (ability to register and recall information) intact was able to understand and be understood by others. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) for personal hygiene, oral hygiene, toilet hygiene, upper and lower body dressing and putting on/taking off footwear. During an interview on 8/25/2026 at 3 p.m., Resident 1 stated he often waits 30 to 50 minutes for call lights to be answered. Resident 1 stated this occurs on all shifts. Resident 1 stated he has informed numerous staff members regarding the issue. Resident 1 stated once he complains to the staff, the issue gets better for a few days then it gets bad again. Resident 1 states he gets frustrated that the improvement is not consistent. Resident 1 stated I just stop complaining because nothing changes. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses that included hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, usually caused by damage to the brain or nerves) weakness and contracture (stiffness/shortening at any joint, that reduces the joint's range of motion) of the right knee. During a review of Resident 2's History and Physical (H&P), dated 7/13/2026, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 7/31/2026, the MDS indicated Resident 2's cognition (ability to register and recall information) intact was able to understand and be understood by others. The MDS indicated Resident 2 was dependent on staff (helper does all the effort, resident does none of the effort to complete the activity) for toilet hygiene, bathing, lower body dressing and putting on/taking off footwear. During an interview on 8/26/2026 at 10 a.m., Resident 2 stated he often waits over 30 minutes for call lights to be answered. Resident 2 stated this occurs on all shifts. Resident 2 stated he informed staff regarding the issue, such as the social worker. Resident 2 stated the call lights response times get better for about a day but then it is bad again. Resident 2 stated he feels angry having to wait for help. During an interview on 8/26/2026 at 11 a.m., the Social Services Director (SSD) stated she has been made aware of the delay in call light response times during the facility meetings. The SSD stated the Resident Council Department Response Form, is a form used to identity the concerns brought up in the Resident Council meetings, and it is a tool used to document how the facility is working to improve the situation. The form is presented to the residents in the facility. The SSD stated during her morning rounds, she interviews residents to ask them if their call lights were answered and if they have any concerns. The SSD stated sometimes the residents will have complaints regarding delays in the call light response, and she directs the concerns to the Director of Staff Development (DSD). The SSD stated to her knowledge there has not been a consistent interview/survey process implemented as indicated on the Resident Council Department Response Form. During an interview on 8/26/2026 at 11:40 a.m., the DSD stated the facility was aware of residents' concerns regarding delayed call light responses. The DSD stated when she conducts her daily rounds, she asks the residents questions such as do you have any concerns? and did your call light get answered. The DSD stated she never thought to ask the residents specifically how long they waited. The DSD stated she is unsure how long residents wait for the call lights to be answered because she did not ask them that specific question. The DSD stated there is no formal or consistent interview or survey process the facility has implemented to measure the call light response form. The DSD stated to her knowledge, there have not been any audits conducted to observed call light response times. During an interview on 8/26/2026 at 4 p.m., the Director of Nursing (DON) stated she was new to the facility and had started working at the facility approximately a week prior. The DON stated the facility had not implemented a structured survey to monitor feedback from residents. The DON stated she was not aware of any audits in process to monitor call light response times. The DON stated in-services had been conducted with staff to educate them on the importance of timely call light responses; however, there was no data collected to ensure the actions discussed were being implemented by the staff. The DON stated call lights response times are now being included in the facility's QAPI program. The DON stated that without using a tool, the facility lacked a way to confirm that their actions were effective or to monitor progress. The DON stated this placed residents at risk for a decline in their mental health and also their physical health, as it placed residents at risk for skin breakdown and infection as a result of not being provided with toilet hygiene in a timely manner. The DON stated delayed call light responses delayed residents' right to dignity. During a review of facility's Policy and Procedure (P&P) titled Quality Assurance and Performance Improvement Program (QAPI), dated 6/4/2024, the P&P indicated, each department or service reviews its approaches to monitoring performance and outcomes and provides a summary of its findings to the QAPI committee annually and as needed. During a review of facility's P&P, titled Communication -Call System dated 1/1/2012, the P&P indicated nursing staff will answer call lights promptly and in a courteous manner. During a review of facility's P&P, titled Resident Rights dated 1/1/2012, the P&P indicated residents have the right to voice grievances and have the facility respond to those grievances in a prompt manner. During a review of facility's P&P, titled Resident Council dated 1/30/2026, the P&P indicated the following, a Resident Council Response Form is utilized to track issues and their resolutions, the administrator reviews the minutes and any responses from departments, responses are presented at the next meeting or sooner, the facility's quality assessment and assurance committee reviews the resident council minutes from the resident council as part of their review.

Based on observation, interview, and record review, the facility failed to assess, monitor, document, and provide care for one of seven sampled residents (Resident 11) who had a urinary indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine).This failure had the potential to result in Resident 11 developing a urinary tract infection (UTI- an infection in the bladder/urinary tract) and sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death).Findings:During a review of Resident 11's admission Record (Face sheet- front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 11 on 6/24/2026 with diagnoses UTI, Sepsis, Benign Prostatic Hyperplasia (BPH- Age-associated prostate gland enlargement that can cause urination difficulty), and chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood).During a review of Resident 11's History and Physical (H&P), dated 6/26/2026, the H&P indicated that Resident 11 had the fluctuating (variable) capacity (ability) to understand and make decisions.During a review of Resident 11's Minimum Data Set (MDS - resident assessment tool), dated 7/1/2026, the MDS indicated that Resident 11 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, shower, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, dressing, hygiene, and set up or clean up assistance (Helper sets up or clean up) from one staff for eating.During a concurrent observation and interview on 7/21/2026 at 9:23 a.m. with Resident 11 in his room, Resident 11 had a urinary catheter and cloudy urine with sediment was noted in the urinary catheter tubing. Resident 11 stated nursing staff inserted the urinary catheter because he had trouble urinating. Resident 11 stated he could not recall whether any nursing staff flushed the urinary catheter tubing.During an interview on 7/23/2026 at 8:59 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated she provided urinary catheter care for Resident 11 by cleaning the catheter site with soap and water. CNA 2 stated she did not measure intake and urine output because no one instructed her to do so. CNA 2 stated monitoring and assessing urine characteristics was the responsibility of licensed nursing staff. CNA 2 stated she believed it would have been beneficial for Resident 11 if urine output had been measured because urine output would be a good indicator of kidney function.During a concurrent interview and record review on 7/23/2026 at 9:19 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 11's Order Summary Report (OSR) dated 7/1/2026 was reviewed. The OSR indicated an order dated 6/25/2026 to assess urinary drainage for signs and symptoms of infection by noting cloudiness, color, sediment, blood, odor, and the amount of urine output every shift. The OSR indicated an order dated 6/25/2026 to irrigate the urinary catheter tubing with 60 milliliters (ml) of normal saline (a safe mix of salt and purified water that matches the salt level in human blood) as needed for clogging or obstruction. The OSR indicated an order dated 6/25/2026 to consult with a urologist (a medical doctor who treats problems with the urinary tract and male reproductive organs, including the kidneys, bladder, and prostate) due to severe urinary retention (the inability to completely empty the bladder). RNS 1 stated that if staff noticed cloudy urine with sediment in the urinary catheter tubing, staff should have flushed and irrigated the tubing with sixty milliliters of normal saline per the order. RNS 1 stated urine output should have been measured, and urine characteristics should have been assessed and documented as ordered. RNS 1 stated she did not see that a urology appointment had been scheduled for Resident 11.During a concurrent interview and record review on 7/23/2026 at 9:29 a.m., with RNS 1, Resident 11's Care Plan (CP) titled, Resident 11 was at risk for Impaired Urinary Elimination related to history of acute on chronic Urinary Retention, revised on 7/7/2026 was reviewed. The CP Goal indicated Resident 11 would show no signs and symptoms of infection by target date of 10/13/2026. The CP Interventions indicated evaluation of urine characteristics and monitoring the amount of urine. RNS 1 stated physician orders and Care Plan interventions both indicated the need to assess and monitor signs and symptoms of urinary tract infection and to monitor urine output to evaluate kidney function.During a concurrent interview and record review on 7/23/2026 at 10:14 a.m., with Treatment Nurse (TXN) 1 in the hallway, Resident 11's Treatment Administration Record (TAR) dated from 6/1/2026 to 7/23/2026 was reviewed. The TAR indicated there was no documentation of irrigating the urinary catheter tubing with 60 ml of normal saline as needed for clogging or obstruction. TXN 1 stated she realized no one had documented irrigation of the urinary catheter tubing. TXN 1 stated there was no documentation of monitoring for signs and symptoms of infection, urine characteristics, or urine output every shift. TXN 1 stated there were check marks on the TAR, but staff should have documented measurable assessments such as urine color and the amount of urine in ml as ordered instead of using check marks.During an interview on 7/24/2026 at 9:03 a.m., with the Social Service Director (SSD), the SSD stated Resident 11 was supposed to have an appointment with a urologist on 7/21/2026. The SSD stated the urologist's office called and cancelled the appointment. The SSD stated there was no documentation regarding follow up or the reason for cancellation. The SSD stated a urologist appointment was important because Resident 11 had a long history of kidney disease with complications. The SSD stated staff should have followed up and documented the status of Resident 11's urologist appointment.During an interview on 7/24/2026 at 1:20 p.m., with the Director of Nursing (DON), the DON stated the staff should have assessed, monitored, and documented urine characteristics and urine output as ordered by the physician and as outlined in the care plan. The DON stated all care plan interventions came from the Interdisciplinary Team (IDT- a group of health experts including doctors, nurses, and social workers who work together to plan and manage a resident's daily care) meeting recommendations and should have been carried out to provide the best care possible. The DON stated the reason for monitoring, assessing, and documenting urine characteristics and urine output was to prevent UTI, sepsis, and kidney failure (kidneys stop working well enough to clean your blood and remove extra waste). The DON stated cloudy urine was one of the characteristics of UTI and staff should have irrigated and documented as ordered. The DON stated the urologist appointment should have been followed up as soon as the appointment was cancelled to prevent a delay in care.During a review of Resident 11's Care Plan (CP) titled, Resident 11 had renal insufficiency, dated 6/25/2026, the CP Goal Resident 11 would not have signs and symptoms of complications related to fluid deficit through the target date of 10/31/2026. The CP Interventions indicated monitoring, documenting, and reporting any signs and symptoms of kidney failure such as oliguria (urine output less than 400 ml per 24 hours).During a review of the facility's Policy and Procedure (P&P) titled, Care of a Urinary Catheter, dated 2022, the P&P indicated, Monitoring Fluid Balance: A catheter makes it easier for healthcare providers to watch for proper fluid balance. The amount of fluid taken into the body should be close to the amount that is drained by the catheter. That is why we measure intake and output. It is a good way to predict possible medical problems. Notify the nurse if you notice that a person in your care is drinking fluids, but they do not have much output . Notify the nurse immediately if you notice any of the following: Blood or cloudiness in the urine. Dark or discolored urine, Bad smell to the urine . These are signs that the person may have a urinary tract infection. If so, they must get treatment right away . Urinary catheters present many risks, including urinary tract infections. The majority of catheter related urinary tract infections are preventable.During a review of the facility's Policy and Procedure (P&P) titled, Intake and Output, revised 2/27/2025, the P&P indicated, Purpose: To provide a record of the Resident's fluid intake and/or output. Process: Fluid intake and output shall be recorded for each resident as follows: a. If ordered per physician. b. For each resident with an Indwelling Urinary Catheter -i. Intake and output records shall be evaluated at least weekly, and each evaluation shall be included in the licensed nurses' weekly summary progress notes.

Based on interview and record review, the facility failed to ensure one of two residents reviewed for Preadmission Screening and Resident Review (PASARR- a federal assessment requirement to help ensure that individuals who have a mental disorder -MD- are placed in facilities that can provide the appropriate care) were reassessed appropriately by failing to ensure a PASARR level 1 resident review screening was resubmitted for Resident 9's new mental health diagnosis and medication.This deficient practice placed Resident 9 at risk of not receiving necessary care and services needed for mental illness or developmental disability.Findings:During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 5/7/2026 and was readmitted on [DATE] with diagnoses including depression (a mental health condition where someone feels very sad, empty, or loses interest in things for a long time) and dementia (a progressive state of decline in mental abilities).During a review of Resident 9's History and Physical (H&P) dated 5/19/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool) dated 5/24/2026, the MDS indicated Resident 9's ability to think and make decisions was moderately impaired. The MDS indicated Resident 9 was dependent on staff with toileting hygiene, showering, upper and lower body dressing, and putting on or taking off footwear. The MDS indicated Resident 9 needed maximum staff assistance (helper does more than half the effort to complete the activity) with oral hygiene and personal hygiene. The MDS indicated Resident 9 needed moderate staff assistance (helper does less than half the effort to complete the activity) with eating. During a review of Resident 9's PASARR level 1 screening dated 5/7/2026, the PASARR level 1 screening did not indicate Resident 9 had a diagnosis of depression.During a concurrent interview and record review on 7/23/2026 at 3:16 p.m., with the Minimum Data Set Nurse (MDSN), Resident 9's Psychiatric (medical specialty in treating mental illness) follow up note dated 6/17/2026, Physician Orders dated 7/24/2026 and PASARR level 1 screening dated 5/7/2026 were reviewed. The MDSN stated the Psychiatric follow up noted dated 6/17/2026 indicated Resident 9 was diagnosed with depression and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and the psychiatrist prescribed Resident 9 Remeron (a medication used to treat depression) 7.5 mg (milligrams - a unit of measurement) oral at bedtime for depression manifested by poor oral intake less than 50% for breakfast, lunch, and dinner on 6/17/2026. The MDSN stated the Physician Order dated 7/24/2026 indicated Resident 9 was prescribed Mirtazapine (Remeron) 7.5 mg Give one tablet by mouth at bedtime for depression manifested by persistently low oral intake of less than 50% of meal for breakfast, lunch, and dinner on 6/17/2026. The MDSN stated the PASARR level 1 screening dated 5/7/2026 did not indicate Resident 9's diagnosis of depression or Remeron. The MDSN stated a PASARR level 1 screening for resident review indicating Resident 9's diagnosis of depression and psychosis and the newly prescribed Remeron should be resubmitted to ensure Resident 9 was re-evaluated for services and provided the appropriate treatment plan. The MDSN stated there would be potential for Resident 9 not to receive the proper treatment or care for the new diagnosis of depression.During an interview on 7/24/2026 at 1:53 p.m. with the Director of Nursing (DON), the DON stated the importance of making sure Resident 9's PASARR level 1 screening was reviewed and resubmitted for the a new diagnosis of depression was to ensure Resident 9 was treated and provided services appropriately according to his new diagnosis. The DON stated there would be potential for Resident 9 not to be treated and provided services in accordance to his psychiatric diagnosis.During a review of the facility's policy and procedure (P&P) titled Pre-admission Screening Resident Review (PASRR) dated 7/2018, the P&P indicated X. The facility will add PASRR Review to the daily stand up meeting agenda. The P&P did not indicate procedures specific to resubmitting a PASARR level 1 screening for resident review when a resident was diagnosed with a new psychiatric diagnosis or new psychiatric medications.

Based on observation, interview, and record review the facility failed to ensure a care plan was developed to address refusal or preference not to wear a smoking apron and identify interventions to reduce risks for smoking-related accidents for one of one resident (Resident 6).This failure placed Resident 6 at an increased risk for burn injuries, clothing catching fire/burning, and other smoking-related accidents. Findings:During an observation on 7/22/2026 at 9:04 a.m. in the smoking patio, Resident 6 was observed smoking without a smoking apron.During a review of Resident 6's admission Record dated 7/24/2026, the admission Record indicated the facility admitted Resident 6 on 5/4/2024 and was readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). During a review of Resident 6's History and Physical (H&P) dated 5/22/2026, the H&P indicated Resident 6 had the capacity to understand and make medical decisions.During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 2/6/2026, the MDS indicated Resident 6's cognition (ability to think or make decisions) was intact. The MDS indicated Resident 6 needed set-up assistance by staff with eating and oral hygiene, maximum staff assistance (helper does more than half the effort to complete activity) with showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 6 was dependent on staff for toileting hygiene. The MDS indicated Resident 6 was a tobacco user.During a review of Resident 6's Care Plan dated 5/20/2026, the Care Plan indicated Resident 6 was a smoker. The Care Plan indicated goals including resident would not smoke without supervision, resident would smoke safely in accordance with facility protocols, and resident would not suffer injury from unsafe smoking practices. The Care Plan interventions indicated Resident 6 required a smoking apron (a flame retardant protective garment) while smoking. The Care Plan did not address Resident 6's refusal or preference not to wear a smoking apron while smoking.During a concurrent observation and interview on 7/22/2026 at 9:09 a.m., with the Activities Director (AD) in the smoking patio Resident 6 was observed smoking without an apron, the AD stated Resident 6 refused to wear the smoking apron.During a concurrent interview and record review on 7/23/2026 at 3:04 p.m., with the Minimum Data Set Nurse (MDSN) Resident 6's Care Plan dated 5/20/2026 was reviewed. The MDSN stated Resident 6's Care Plan indicated Resident 6 was a smoker. The MDSN stated there was no Care Plan for Resident 6's refusal or preference of not wearing a smoking apron. The MDSN stated the importance of developing a Care Plan for Resident 6's refusal or preference of not wearing a smoking apron was to ensure there was a plan of care to guide staff on how to take care of Resident 6. The MDSN stated there would be potential for Resident 6 to have increased risk for smoking-related accidents or injuries.During an interview on 7/24/2026 at 2:01 p.m. with the Director of Nursing (DON), the DON stated the importance of making sure a care plan for refusal or preference of not wearing a smoking apron while smoking was to ensure Resident 6 had a plan of care that would guide staff on how to take care of Resident 6 while smoking. The DON stated there would be potential for Resident 6's needs for staying safe were not being met because staff would not know how to prevent smoking-related injuries or accidents. During a review of the facility's policy and procedure titled Person-Centered Care Planning revised 4/24/2025, the P&P indicated 4. Comprehensive Care Plan a. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that include measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs.d. Prepared by an interdisciplinary team, that includes but is not limited to: vi. Other appropriate staff or professionals and disciples as determined by the resident's needs or as requested by the resident.

Based on observation, interview, and record review, the facility failed to provide care and services to maintain fingernails were clean, trimmed, and short for one of seven sampled residents (Resident 56).This failure resulted in Resident 56 experiencing embarrassment and increased risk of injury or infection due to unkempt fingernails.Findings:During a review of Resident 56's admission Record (Face sheet- front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 56 on 4/10/ 2025, and the most recent re-admission was on 12/30/2025 with diagnoses included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage caused by diabetes), functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), and muscle weakness.During a review of Resident 56's History and Physical (H&P), dated 12/31/2025, the H&P indicated Resident 56 had the capacity (ability) to understand and make decisions.During a review of Resident 56's Minimum Data Set (MDS - resident assessment tool), dated 6/17/2026, the MDS indicated Resident 56 required dependent assistance (Helper does all of the effort) from two or more staff for bed mobility, transfer, lower body dressing, toileting hygiene, maximal assistance (Helper does more than half the effort) from one staff for oral hygiene, upper body dressing, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for eating.During a concurrent observation and interview on 7/21/2026 at 10:08 a.m., with Resident 56 in the room, Resident 56's fingernails were noted to be overgrown, crooked, jagged, dirty, and greenish dark yellow. Resident 56 stated it was really difficult to pick something up because of the overgrown nails. Resident 56 stated the jagged long nails also caused pain at times. Resident 56 stated she felt embarrassed and worried she might get an infection when she scratched her skin. Resident 56 stated she had asked the staff (unkown) to cut her fingernails, but no one did. Resident 56 stated she called her niece to come over when her niece would be free to cut her fingernails.During a concurrent interview and record review on 7/23/2026 at 8:59 a.m., with Certified Nurse Assistant (CNA) 2, Resident 56's Task-Nail Care, dated from 7/11/2026 to 7/23/2026 was reviewed. The Task-Nail Care indicated Resident 56's nail care was done on 7/14/2026 (1:48 p.m.), 7/15/2026 (1:07 p.m.), 7/16/2026 (2:59 p.m.), 7/21/2026 (1:22 p.m. and 4:31 p.m.), 7/22/2026 (11:12 a.m.), and 7/23/2026 (1:13 p.m.). The Task Nail Care did not indicate Resident 56 refused nail care. CNA 2 stated she agreed Resident 56's fingernails should have been cut, trimmed, and cleaned but they were not. CNA 2 stated when nail care was documented as Yes, the nails should have been cleaned, cut, trimmed, and filed. CNA 2 stated she understood Resident 56 would feel embarrassed and have difficulty picking up items with her fingernails. CNA 2 stated the documentation was incorrectly completed.During a concurrent interview and record review on 7/23/2026 at 9:19 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 56's Care Plan (CP) titled, Resident 56 had potential/actual impairment to skin integrity of the Moisture-Associated Skin Damage (MASD -moisture associated skin damage caused from prolonged exposure to moisture) under breast folds, initiated 10/14/2025 and revised on 4/2/2026 was reviewed. The CP Goal indicated, Resident 56 would maintain or develop clean and intact skin by target date of 9/15/2026. The CP Interventions indicated avoidance of scratching and keeping fingernails short. RNS 1 stated, Resident 56 had a tendency to scratch her skin, and long unclean fingernails could cause skin injury and infection.During an interview on 7/24/2026 at 1:20 p.m., with the Director of Nursing (DON), the DON stated the staff should have cleaned and trimmed Resident 56's fingernails and should have documented if and when Resident 56 refused nail care. The DON stated Resident 56 was at risk of infection and skin injury due to complicated medical conditions such as DM. The DON stated this could affect Resident 56's psychosocial well being and could contribute to social isolation.During a review of the facility's Policy and Procedure (P&P) titled, Grooming Care of the Fingernails and Toenails, revised on 10/21/2021, the P&P indicated, Purpose: Nail care is given to clean the nail bed and keep the nails trimmed. Policy: I. Fingernails are trimmed by Certified Nursing Assistants (CNAs), except for Residents with diabetes or circulatory impairments, this includes all toenails except for high-risk Residents. NOTE: A Licensed Nurse will trim those Residents' nails .Procedure: XVII. Report any changes in skin color around the nail or nail bed to the Charge Nurse. XVIII. Document the procedure in the Resident's medical record and update the Resident's Care Plan as needed.During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living, dated on 6/9/2026, the P&P indicated, Policy: The Facility ensures each Resident receives appropriate assistance with Activities of Daily Living (AD Ls) to maintain or improve their highest practicable level of function, while promoting dignity, independence, and safety . Staff will encourage Residents to perform ADL to the highest level of their ability. ADL assistance will be documented.

Based on observation, interview, and record review, the facility failed to ensure:a. Resident 6 was wearing a smoking apron (a flame retardant protective garment) while smoking.b. the facility's designated smoking area was free of clutter and flammable items during designated smoking times. These failures resulted in increased risk of fire, burn injuries, and smoking-related accidents to Resident 6 and other residents who were smoking during designated smoking times.Findings:a. During an observation on 7/22/2026 at 9:04 a.m., in the smoking patio, Resident 6 was observed smoking without a smoking apron.During an observation on 7/22/2026 at 9:04 a.m. in the smoking patio, Resident 6 was observed smoking without a smoking apron.During a review of Resident 6's admission Record dated 7/24/2026, the admission Record indicated the facility admitted Resident 6 on 5/4/2024 and was readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). During a review of Resident 6's History and Physical (H&P) dated 5/22/2026, the H&P indicated Resident 6 had the capacity to understand and make medical decisions.During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 2/6/2026, the MDS indicated Resident 6's cognition (ability to think or make decisions) was intact. The MDS indicated Resident 6 needed set-up assistance by staff with eating and oral hygiene, maximum staff assistance (helper does more than half the effort to complete activity) with showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 6 was dependent on staff for toileting hygiene. The MDS indicated Resident 6 was a tobacco user.During a review of Resident 6's Care Plan dated 5/20/2026, the Care Plan indicated Resident 6 was a smoker. The Care Plan indicated goals including resident would not smoke without supervision, resident would smoke safely in accordance with facility protocols, and resident would not suffer injury from unsafe smoking practices. The Care Plan interventions indicated Resident 6 required a smoking apron (a flame retardant protective garment) while smoking. The Care Plan did not address Resident 6's refusal or preference not to wear a smoking apron while smoking.During a concurrent observation and interview on 7/22/2026 at 9:09 a.m., with the Activities Director (AD) in the designated smoking area, Resident 6 was observed. The AD stated Resident 6 does not wear a smoking apron while smoking.During an interview on 7/24/2026 at 2:01 p.m., with the DON, the DON stated the importance of making sure Resident 6 was wearing a smoking apron while smoking was to ensure Resident 6 was smoking safely, to avoid burns or injuries. b. During a concurrent observation and interview on 7/22/2026 at 9:09 a.m., with the AD in the designated smoking area, residents were observed smoking with cardboard supply boxes surrounding the designated smoking area. The AD stated normally there would be no boxes around the smoking area. The AD stated it was important to have a clean and clutter-free area for staff to be able to manage residents and ensure residents were not at risk for smoking-related accidents and injuries. The AD stated there would be potential for the supply boxes to catch fire and the residents would be at risk for burns or injuries.During an interview on 7/24/2026 at 1:59 p.m., with the Director of Nursing (DON), the DON stated the importance of keeping the designated smoking area clean and free of flammable items was to prevent incidents of the boxes catching on fire. The DON stated there was increased risk of residents sustaining burns or other smoking-related injuries.During a review of the facility's policy and procedure (P&P) titled P-NP132 Smoking Residents revised 7/27/2023, the P&P indicated 9. The resident and/or Responsible Party will be educated regarding the risks of smoking and the smoking safety measures recommended by the IDT . The P&P did not indicate procedures for residents regarding the use of smoking aprons while smoking.During a review of the facility's P&P titled P-AP12 Unusual Occurrence Reporting revised 5/30/2024, the P&P did not indicate procedures specific to smoking-related accidents.

Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV -a small, flexible tube placed into a small vein) midline (a thin, flexible tube placed in an upper arm vein to give fluids or medicines) access site was properly cared for, monitored, assessed, documented, and discontinued when IV therapy had been completed for 1 of 3 sampled residents (Resident 49) by:A. Failing to place caps at the end of the IV fluid tubing and Resident 49's midline IV saline lock (an IV-catheter placed in a vein, flushed with salt water, and capped off so a resident can move freely without a continuous fluid bag), leaving the venous access point exposed.B. Failing to assess, monitor, and document the measurement of arm circumference and external lumen of midline catheter every Monday.C. Failing to discontinue/remove Resident 49's IV saline lock after IV hydration therapy was completed.This failure placed Resident 49 at risk for infection at the IV saline lock site, as improper protection and unnecessary continuation of IV access increase the risk of catheter related infections.Findings:A. During a review of Resident 49's admission Record (Face sheet- front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 49 on 5/4/ 2023, and the most recent re-admission was on 6/11/2026 with diagnoses included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), urinary tract infection (UTI- an infection in the bladder/urinary tract), sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), bacteriuria (the presence of bacteria in the urine), and paraplegia (loss of movement and/or sensation, to some degree, of the legs).During a review of Resident 49's History and Physical (H&P), dated 6/14/2026, the H&P indicated Resident 49 had the capacity (ability) to understand and make decisions.During a review of Resident 49's Minimum Data Set (MDS - resident assessment tool), dated 7/10/2026, the MDS indicated Resident 49 required dependent assistance (Helper does all of the effort) from two or more staff for toilet hygiene, shower, lower body dressing, transfer, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, upper body dressing, and independent (Resident completes the actively by himself/herself with no assistance from a helper) from one staff for eating, oral hygiene, personal hygiene.During a concurrent observation and interview on 7/21/2026 at 10:33 a.m., with Resident 49 in her room, Resident 49's IV midline saline lock on the left upper arm was noted without a cap. An IV fluid bag and tubing were hung on the IV-pole next to Resident 49's bed, and the end of the tubing also had no cap. Resident 49 stated the staff forgot to put green caps on her IV saline lock and the end of the IV tubing where it connected with the IV-midline saline lock port after the infusion. Resident 49 stated she was a little worried, because without caps, the port of her IV-saline lock which is directly connected to her vein and the end of the IV tubing could become contaminated, and she might get an infection again.During an interview on 7/21/2026 at 10:37 a.m., with Registered Nurse Supervisor (RNS) 1 in Resident 49's room, RNS 1 stated caps were supposed to be placed on the end of the IV fluid tubing and on Resident 49's midline saline lock port to prevent infection and contamination, because bacteria could have been introduced if a cap was not in place.During a review of Resident 49's Order Summary Report (OSR) dated 7/23/2026, the OSR indicated to change dressing and cap as needed for midline care was ordered on 7/21/2026.B. During a concurrent interview and record review on 7/23/2026 at 9:19 a.m., with RNS 1, Resident 49's Medication Administration Record (MAR), dated from 7/1/2026 to 7/23/2026, was reviewed. The MAR indicated there was no documentation regarding IV site assessment and monitoring. RNS 1 stated the staff should monitor, assess, and document arm circumference to monitor IV infiltration (occurs when intravenous fluid or medication leaks into the tissue surrounding a vein instead of entering the bloodstream), the length of the external IV catheter lumen to assess for any dislodgement, and signs and symptoms of infection at the IV-access site as part of midline IV access care.During a review of Resident 49's Order Summary Report (OSR) dated 7/23/2026, the OSR indicated that measure arm circumference and external lumen catheter every Monday and check the midline site dressing and monitor signs and symptoms of infection every shift was ordered on 7/21/2026.C. During a concurrent interview and record review on 7/23/2026 at 9:23 a.m., with RNS 1, Resident 49's Progress Notes (PN), dated from 7/20/2026 to 7/23/2026, were reviewed. The PN indicated a midline was inserted on 7/20/2026 with an external lumen of 16 centimeters (cm) and an arm circumference of 32 cm for one liter of normal saline (a simple mixture of salt and water that matches the natural salt level inside your body) IV fluid for hydration. RNS 1 stated the IV fluid was completed on 7/21/2026 and it should have been removed or discontinued as soon as the IV therapy was completed, but the midline was not removed until 7/23/2026. RNS 1 stated there was no documentation explaining the reason for the delay. RNS 1 stated any invasive access should be removed as soon as possible to prevent infection and catheter related complications.During a concurrent interview and record review on 7/24/2026 at 9:29 a.m., with The Director of Staff Development (DSD), Resident 49's Care Plan (CP) titled Midline insertion to left upper arm for hydration with normal saline one liter (100 milliliter [ml] per hour), initiated 7/21/2026 was reviewed. The CP Goal indicated Resident 49 would not develop complications until the target date of 10/8/2026. The CP Interventions indicated midline care as ordered and monitoring for signs and symptoms of infection and midline complications. The DSD stated the staff should have knowledge of how to care for a midline. The DSD stated the staff should have assessed, monitored, and documented signs and symptoms of infection, measurement of arm circumference, and the length of the external lumen as the physician ordered and as care planned. The DSD stated the IV port and connector should have had green caps to prevent infection and contamination as ordered. The DSD stated the midline was inserted on 7/20/2026, which was Sunday, and the staff should have assessed and documented the measurement of arm circumference and the length of the external lumen on 7/21/2026, which was Monday, as ordered. The DSD stated if the midline was not removed as soon as IV therapy was completed on 7/21/2026, there should have been documentation of the reason for not removing the midline. The DSD stated she found some documentation indicating no signs and symptoms of infection, but it was not documented every shift as ordered in the progress notes. The DSD stated it should be documented in the MAR.During an interview on 7/24/2026 at 1:20 p.m., with The Director of Nursing (DON), The DON stated staff should have followed and provided midline care as ordered and care planned. The DON stated the midline was an invasive line and infection control should be strictly followed to prevent avoidable infection. The DON stated she agreed the midline should have been discontinued/removed on 7/21/2026 when IV therapy was completed. The DON stated she wanted to check the lab results first before the removal in case Resident 49 required additional IV fluid, but she did not document the reason.During a review of the facility's Policy and Procedure (P&P) titled, General Policies for IV Therapy, dated 3/2023, the P&P indicated, General Policies: M. Documentation of IV therapy should include but is not limited to: Intake and output, Vital signs every shift, IV medication administration, Response to therapy, IV site assessment .X. Disinfecting caps are intended for use on needleless connectors only as a disinfecting cleaner prior to access and to act as a cover between line access. A new cap must be replaced on the needleless connector after each use, do not reuse cap.During a review of the facility's Policy and Procedure (P&P) titled, Intravenous Therapy and Central line management, undated, the P&P indicated, Disinfectant caps: Always place a new disinfecting cap on needleless connector after each use. Dispose of the disinfecting cap after every use .IV administration: Intravenous sites will be evaluated every shift for evidence of IV site-related complications. The IV site will be inspected for signs and symptoms of infection, infiltration, and blockage or leaking of the tube or needle.

Based on observation, interview and record review, the facility failed to:Ensure one of one residents with a gastrostomy tube (G-tube - a tube placed directly into the stomach for long-term feeding) observed during medication administration observation (Resident 1)'s enteral (food delivered directly to stomach through the G-tube) feeding was turned off prior to administration of pantoprazole (medication used to treat gastroesophageal reflux disease [GERD-when stomach acid flows back into the throat]),Follow pharmacy instructions and manufacturer's guidelines when administering pantoprazole for one of seven residents observed during medication administration observation (Resident 1), andEnsure the controlled substance (medications with a high potential for abuse) disposition log had signatures of two licensed staffThis failure had the potential to result in Resident 1's unrelieved acid reflux and increased risk of diversion (transfer of a medication from a legal to an illegal use) of medications.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/9/2026 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and GERD.During a review of Resident 1's History and Physical (H&P), dated 5/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/21/2026, the MDS indicated Resident 1 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment and was dependent on facility staff for oral hygiene, toileting hygiene, bathing, and dressing. During a review of Resident 1's Physician Order Summary, the Order Summary indicated an order for:Enteral feed order every shift: Jevity (fiber fortified balanced liquid nutrition) 1.5 at 60 milliliter (mL - a unit of measurement)/hour (hr) for 20 hours started on 5/27/2026, andPantoprazole Sodium oral packet 40 milligrams (MG - a unit of measurement) to be given via g-tube one time a day for GERD started 5/26/2026.During an observation on 7/21/2026 at 11:37 a.m., in Resident 1's room, Licensed Vocational Nurse (LVN) 4 paused Resident 1's enteral feeding and administered pantoprazole to Resident 1 through Resident 1's g-tube. After administration of the pantoprazole, LVN 4 restarted Resident 1's enteral feeding.During a concurrent interview and record review on 7/21/2026 at 12:29 p.m., with LVN 4, Resident 1's pantoprazole medication packaging was reviewed. LVN 4 stated the pantoprazole medication packaging indicated to give medication a half hour (30 minutes) before meal. LVN 4 stated the instructions were not followed because Resident 1's enteral feeding was running late today. LVN 4 stated they (LVN 4) should have called the doctor and clarified if the medication could have been rescheduled.During an interview on 7/21/2026 at 4:00 p.m., with the Director of Nursing (DON), the DON stated pantoprazole should be administered without food for best absorption.During an interview on 7/22/2026 at 9:33 a.m., with the DON, the DON stated LVN 4 should have called the doctor to get an order before administering the pantoprazole. The DON stated the pantoprazole should not have been administered when the enteral feeding was running.During a review of the facility's policy and procedure (P&P), titled Preparation and General Guidelines - Enteral Tube Medication Administration, dated August 2014, the P&P indicated interactions between medications and feeding formulas, and interactions of multiple medications, are considered before administering medications through the enteral tube. If necessary, information is obtained from the provider pharmacy or consultant pharmacist.if on an intermittent feeding it may be necessary to delay feeding up to two hours to avoid medication interaction with enteral solutions.During a review of the facility's job description titled LVN Staff Nurse, undated, the job description indicated the LVN prepares/administers medications as ordered by the physician and within the legal scope of practice.During a concurrent interview and record review on 7/21/2026 at 3:15 p.m. with the DON, the Controlled Substance Disposition Log for May 2026 and June 2026 were reviewed. The DON stated upon completion of destruction of the controlled substances, the pharmacist and the DON sign the Controlled Substance Disposition Log. The Controlled Substance Disposition Log for May 2026 and June 2026 indicated the DON did not sign the Controlled Substance Disposition Log on 7/6/2026. The DON stated that controlled medications are highly regulated substances and require proper document and verification during the destruction process. The DON stated documentation and witness signatures are important because it helps prevent drug diversion. During a review of the facility's P&P, titled Medication Storage in the Facility, dated August 2014, the P&P indicated controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely double locked area with restricted access until destroyed by the facility's director of nursing or a registered nurse employed y the facility and and pharmacist.

Based on interview and record review, the facility failed to ensure the binding arbitration agreement (legally binding contract in which parties agree to resolve any future or current disputes out of court) was explained to one of three sampled residents (Resident 32), in a language that the resident understood.This failure had the potential to result in Resident 32 or responsible party to unknowingly giving up their right to settle disputes with the facility through a legal process.Findings:During a review of Resident 32's admission Record, the admission Record indicated the facility initially admitted Resident 32 on 12/13/2023 and readmitted on [DATE] with diagnosis including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). The admission Record indicated Resident 32's primary language was not the dominant language of the facility.During a review of Resident 32's Minimum Data Set (MDS - resident assessment tool) dated 6/16/2026, the MDS indicated Resident 32 had moderately impaired cognitive skill (a person has decline with memory, attention, learning and reasoning).During a review of Resident 32's History and Physical (H&P) dated 6/2/2026, the H&P indicated Resident 32 had fluctuating capacity to understand and make decisions.During an interview with Resident 32 on 7/23/26 at 3:30 p.m., Resident 32 stated she does not understand English. Resident 32 stated she does not know what binding arbitration was nor recall signing agreements during admission. Resident 32 stated her family member (FM 1) advised against signing any documents.During a concurrent interview and record review on 7/23/2026 at 4:00 p.m. with the admission Coordinator (AC), Resident 32's binding arbitration agreement was reviewed. The binding arbitration document indicated Resident 32 signed the agreement in English on 1/3/2024. The AC stated the facility hired her on 6/2026 and that there was no documentation in Resident 32's admission records that the binding arbitration was explained to Resident 32 in a language she would understand. The AC stated presenting binding arbitration agreement in a manner that residents understood can support their decision-making process; without such comprehension they are unable to make informed choices.During an interview with the Administrator (ADM) on 7/24/2026 at 3:31 p.m., the ADM stated binding arbitration agreement was an alternative to litigation in resolving disputes between residents and the facility. The ADM stated if the facility presented binding arbitration agreement in a language other than what Resident 32 understood, the resident might unintentionally waive her right to legal action in settling any disputes with the facility.During a review of facility's policy and procedure (P&P) titled, AD 17 Arbitration Agreement, revised 5/25/2023, the P&P indicated .the person presenting the arbitration agreement will: A. Explain the agreement to the Resident in a form and manner that they understand, including in a language the Resident understand.During a review of facility's policy and procedure (P&P) titled SS 04 Translation or Interpretation Services revised 6/27/2024, the P&P indicated The facility provides assistance to residents with limited English proficiency and/or hearing and speech deficits through translation and interpretation services.

Based on interview and record review, the facility failed to: Initiate a care plan for Resident 1's impulsive behavior that was identified in the first fall dated 1/22/2026.Implement a recommendation that was addressed during the Interdisciplinary Team (IDT: Resident's healthcare team consisting of various specialties that share and combine their knowledge and information to create the best possible care plan for the resident) meeting on 3/1/2026.Implement a care plan for Resident 1's known diagnosis of osteopenia (condition where bone mineral density if lower than normal). This deficient practice increased the potential risk of additional falls for the residents. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and was re-admitted to the facility on [DATE] with diagnoses including osteoarthritis (loss of protective cartilage that cushions the ends of your bones) of hip, left knee, left shoulder, dementia (group of thinking and social symptoms that interfere with daily functioning), and other specified disorders of bone density and structure. During a review of Resident 1's IDT Progress Notes - Falls dated 1/24/2026 at 8:39 a.m. the IDT Progress Notes indicated the contributing factors for Resident 1's fall included impulsivity. During a review of Resident 1's care plan titled, Resident 1 has had an actual fall with no injury related to poor balance, poor communication/comprehension, and unsteady gate, the care plan goals included Resident 1 would resume usual activities without further incident. The care plan interventions were to ensure the bed had low sides and floor mats dated 2/26/2026. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/20/2026, the MDS indicated Resident 1 was moderately cognitively (ability to make decisions of daily living) impaired. The MDS indicated Resident 1 was dependent on staff for bathing, required substantial assistance (Helper does more than half the effort) from staff for toileting hygiene, required partial assistance (Helper does less than half the effort) from staff for upper body (waist above) and lower body (below waist) dressing, personal hygiene, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, shower transfer, walk 10 feet, required supervision for oral hygiene, roll left to right, sit to lying, and required set up for eating. The MDS indicated Resident 1 had impairments for the upper extremity (arms/shoulders) bilaterally and utilized a walker and wheelchair. During a review of Resident 1's Change of Condition (COC) dated 5/13/2026 at 7:52 p.m., the COC indicated Resident 1 was found sitting on the floor facing his bed and was assisted back to bed with a two person assist. The COC indicated Resident 1 reported he was attempting to get up from the bed prior to falling. During a review of Resident 1's history and physical (H&P) dated 5/21/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During an interview on 6/2/2026 at 1:18 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated if a resident (general) had a tendency to try and get out of bed without calling for assistance, facility staff would care plan it. RNS 1 stated care plans are the focal point of an individualized care and have to follow interventions for the safety and wellbeing of the residents. RNS 1 stated if care plans are not followed, incidents may occur. During a concurrent interview and record review on 6/2/2026 at 3:49 p.m., with the Director of Nursing (DON), the IDT progress note dated 1/24/2026 was reviewed. The DON stated the IDT progress note indicated, Resident 1 was impulsive as he tried to get out of bed on his own (without calling for assistance) and had poor safety awareness. The DON stated the fall risk intervention of floor mats means floor mats are placed on both sides of the bed. The DON stated on 5/13/2025 after dinner, Resident 1 had a habit of sitting at the side of the bed and attempted to transfer on his own and was found sitting on the floor attempting to self-transfer from the bed to the wheelchair. The DON stated Resident 1's impulsive behavior contributed to his falls. The DON stated Resident 1 was supposed to have floor mats on each side of the bed incase he tried to get out of bed on the left side or the right side. The DON stated a care plan was a guide to provide the appropriate care, and without a care plan, they would not have a guide and would not be able to identify problems, have goals, and interventions. The DON stated Resident 1 was identified as having osteopenia, facility staff should create a care plan to alert the staff that Resident 1 has osteopenia and less bone density and even repositioning Resident 1 could break his bones. During a review of the facility's policy and procedures (P&P), Comprehensive Person-Centered Care Planning, effective date 9/7/2023, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest, physical, mental, and psychosocial well-being. During a review of the facility's P&P titled, Person-Centered Care Planning, effective date 5/22/2025, the P&P indicated person-centered care plan means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what is important to each resident with regard to daily routines and preferred activities and having an understanding of the resident's life before coming to reside in nursing facility. Interventions are actions, treatments, procedures, or activities designed to meet an objective. It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her needs. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. Comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. During a review of the facility's P&P titled, FA01 Fall Management Program, effective date 11/11/2025, the P&P indicated the facility will maintain an environment free of accident hazards, provide adequate supervision and assistive devices to prevent avoidable accidents, and implement an interdisciplinary fall prevention program that includes risk screening, individualized care planning, targeted interventions, and robust post-fall management. Falls: an event in which a person inadvertently comes to rest on the ground, floor, or lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). Avoidable accident: occurs when a facility fails to properly identify and address resident risks of environment hazards, implement and monitor appropriate interventions (such as supervision and assistive devices), and adjust the care plan as needed to reduce or eliminate risks in line with professional standards of practice. Purpose is to reduce the risk of avoidable falls and fall-related injuries and to ensure timely, evidence-based post-fall evaluation and management consistent with best practices, federal and state guidance requirements for resident safety, supervision, and quality of care. During a review of the facility's P&P titled, P-FA01 Fall Management Program, effective date 11/11/2025, the P&P indicated the Interdisciplinary Team (IDT) and/or licensed nurse will develop a care plan according to the identified risk factors. The licensed nurse will evaluate the Resident's response to the interviews weekly and update the Resident's care plan as necessary. Once the Post -Fall Evaluation is completed the licensed nurse will update the care plan with recommendations. The Post-Fall Evaluation form and documentation of the post-fall investigation will go to the IDT meeting for review and updating of the care plan, as appropriate. The IDT will review the circumstances surrounding the fall then summarize their conclusions in an IDT note. The IDT will review and revise the care plan, as necessary.

Based on interview and record review, the facility failed to ensure a Notice of Transfer/Discharge (a written notification to the resident or responsible party which includes the reason for transfer or discharge, where the resident will be transferred to, how to contact the Long-Term Care (LTC) Ombudsman (patient advocate), and how to appeal the transfer or discharge if necessary) was sent to the LTC Ombudsman upon transfer to a General Acute Care Hospital (GACH) for two of three sampled residents (Residents 1 and 2).This failure had the potential to result in an unsafe discharge and/or deny Resident 1 the right to appeal the discharge.Findings:a. During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis including acute kidney failure (sudden and rapid decline in kidney function).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and was dependent (helper does all the effort) on facility staff to complete her activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Transfer Form dated 3/1/2026, the Transfer Form indicated Resident 1 was transferred to the GACH for new or worsening edema (swelling).During a review of Resident 1's Notice of Transfer/discharge date d 3/1/2026, the Notice of Transfer/Discharge did not indicate a copy was sent to the State LTC Ombudsman office.b. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnosis including unstageable pressure ulcer (a severe wound with full thickness skin and tissue loss, where the true depth and severity cannot be determined) of the sacral region (triangular section at the base of the spine, sitting just below the lower back and directly above the tailbone).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was severely impaired and was dependent on facility staff to complete her ADLs.During a review of Resident 2's Physician Order dated 5/10/2026, the Physician Order indicated Resident 2 was to be transferred to the GACH due to shortness of breath and low blood pressure.During a review of Resident 2's Notice of Transfer/discharge date d 5/10/2026, the Notice of Transfer/Discharge did not indicate a copy was sent to the State LTC Ombudsman.During an interview on 5/21/2026 at 12:34 p.m., the Social Services Director (SSD) stated Residents 1 and 2 were transferred to the GACH on the weekend. The SSD stated she does not work on weekends and was not aware of who is responsible for sending the Notice of Transfer/Discharge to the Ombudsman office when she is off.During an interview on 5/21/2026 at 1:11 p.m., the Director of Nursing (DON) stated the nursing staff is responsible for sending a copy of the Notice of Transfer/discharge on the weekends because the social services department does not work on the weekends. The DON stated the Ombudsman needs the proper information to follow up on the residents so they can advocate for residents if needed.During a review of the facility's policy and procedure (P&P) titled Discharge and Transfer of Residents, dated 3/21/2025, the P&P indicated a copy of the Notice of Proposed Transfer and Discharge will be faxed to the ombudsman.

Based on interview and record review, the facility failed to ensure the Director of Nursing (DON) documented the reason for transfer/discharge and the residents (Resident 1) refusal to sign the Notice of Transfer/Discharge (a written notification to the resident or responsible party which includes the reason for transfer or discharge, where the resident will be transferred to, how to contact the Long-Term Care (LTC) Ombudsman (patient advocate), and how to appeal the transfer or discharge if necessary)upon transfer to the General Acute Care Hospital (GACH) for one of three sampled residents (Resident 1). These failures had the potential to prevent Resident 1 from being properly informed of the basis for the transfer/discharge, which could impede her ability to understand and exercise her right to appeal the discharge.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnosis including acute kidney failure (sudden and rapid decline in kidney function).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and was dependent (helper does all the effort) on facility staff to complete her activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Transfer Form dated 3/1/2026, the Transfer Form indicated Resident 1 was transferred to the GACH for new or worsening edema (swelling).During a review of Resident 1's Notice of Transfer/discharge date d 3/1/2026, there was no documentation indicating a reason for the transfer/discharge, and the section designated for the resident's signature was left blank. During an interview on 5/22/2026 at 1:11 p.m., the DON stated Resident 1's Notice of Transfer/Discharge was incomplete and should have indicated a reason for transfer. The DON stated she should have documented that Resident 1 refused to sign the Notice of Transfer/Discharge and had two nurses witness and sign the document. The DON stated on 3/1/2026, the facility was busy and it was a crazy day which is why the document was incomplete.During a review of the facility's policy and procedure (P&P) titled Completion & Correction, dated 3/25/2026, the P&P indicated the facility works to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation.

Based on observation, interview and record review, the facility failed to administer intravenous fluids (IVF - fluids administered through the vein) as ordered by the physician for one of one sampled resident (Resident 1). This failure had the potential to result in Resident 1 experiencing hypovolemic shock (not enough blood in the body to support organ function) and decreased urine output. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including fracture of left tibia (long bone in the lower leg) and acute (sudden onset) kidney failure. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/26/2025, the MDS indicated Resident 1 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, and was dependent for oral hygiene, toileting hygiene, bathing, and upper and lower body dressing. During an observation on 12/23/2025 at 12:24 p.m., Resident 1 was observed receiving IVF 0.45% Sodium Chloride (fluid administered for hydration) at a rate of 50 milliliters (mL - a unit of measurement)/hour. During a concurrent observation and interview on 12/23/2025 at 12:38 p.m., the Director of Nursing (DON) was observed changing the IVF rate from 50 mL/hour to 100 mL/hour. During a concurrent interview and record review on 12/23/2025 at 2:36 p.m., with Registered Nurse (RN) 1, Resident 1's physician's orders were reviewed. Resident 1's orders indicated to start Resident 1 on Intravenous Fluid (IVF) 0.45% Normal Saline at 100 mL/ hour for 24 hours for hydration to start on 12/23/2025. RN 1 stated the IVF were initially administered at a rate of 50 mL/hour, but the order stated to administer the IVF at 100mL/hour. During an interview on 12/23/2025 at 3:30 p.m., with the DON, the DON stated it was important that facility staff administered medications according to the physician's order or it could negatively affect Resident 1. The DON stated the IVF for Resident 1 was incorrectly running at a rate of 50 mL/hour. The DON stated she corrected the IVF rate to 100ml/hour. During a review of the facility's policy and procedure (P&P), titled Medication Administration, dated January 2012, the P&P indicated to ensure the accurate administration of medications for residents in the facility, medications and treatments will be administered as prescribed to ensure compliance with dose guidelines.

Based on interview and record review, the facility failed to provide medical records within two working days of a written request from an authorized representative ([AR] a person who is legally authorized to act on behalf of) per the facility's policy and procedure (P&P) titled, Resident Access to Protected Health Information (PHI), for two of three sampled residents (Residents 1 and 2). Findings: a. During a review of Resident 1's admission Record (Face sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including muscle weakness (a lack of muscle strength), type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Face Sheet indicated Resident 1 was discharged on 10/2/2024. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 9/11/2024, the MDS indicated Resident 1 had moderate cognitive (thought process) impairment. During a review of the request for medical records from the LA dated 7/28/2025, the request indicated the LA was requesting a copy of Resident 1's complete medical records including all records and documents that may be stored physically, digitally, and/or electronically, including but not limited to nonmedical records from 1/1/2024 to the present date. During a telephone interview on 8/21/2025 at 9:53 a.m., with the LA, the LA stated she hand delivered Resident 1's medical records request in writing to the facility on 7/30/2025. LA stated that Resident 1's medical records were received on 8/15/2025, 12 days after she requested Resident 1's documents. During a review of the facility's Log Resident Requests for Access to Protected Health Information (PHI] any information about your health or healthcare that can identify you. This includes your medical history, test results, and even payment information for healthcare services, whether in a paper record, electronic file, or even an email), dated 8/2025, the Log indicated Resident 1's AR requested Resident 1's medical records on 7/30/2025, and the medical records were sent to AR 1 on 8/19/2025. b. During a review of Resident 2's admission Record (Face Sheet), the Face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including muscle weakness, type 2 diabetes mellitus, and gastro-esophageal reflux disease ([GERD] a chronic condition that occurs when stomach contents move up into the esophagus, causing irritation). During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/22/2025, the MDS indicated Resident 2's had moderate cognitive impairment. During a review of the request for medical records from the AR dated 7/22/2025, the request indicated the AR was requesting a copy of Resident 2's complete medical records including all non-privileged physical, digital, and hand-written medical records including records from 7/17/2025 to present. During a review of the facilities Log of Resident Requests for Access to PHI, dated 7/2025, the Log indicated Resident 2's AR 2 requested Resident 2's medical records on 7/22/2025 and the medical records were submitted to Resident 2's representative on 8/15/2025, 16 days after the request date. During an interview on 8/21/2025 at 11:21 a.m., with medical records (MR), MR stated some of her job functions are to gather, file and retain medical records in chronological order. Maintain medical records, release health information records and maintain medical records in the active charts. MR stated to be unaware of how long the process of submitting medical records when they are requested in writing should be. During a concurrent interview and record review on 8/21/2025 at 12:07 p.m., with Medical Records (MR), the facility's P&P titled, Resident Access to Protected Health Information (PHI), revised 11/1/2025 was reviewed. The P&P indicated the facilities MR will provide the residents representatives with a copy of the medical records within two working days after receiving a written request. MR stated that it is her responsibility to ensure that this process is done in a timely manner. MR stated Resident 1's and 2's medical records request process was not done within the two working days because she needed to wait until she received the ok from legal services and facility consultant prior to releasing the records and when she was notified it was ok to release the records, it was already past the two working days. During a concurrent interview and record review on 8/21/2025 at 2:27 p.m., with the Director of Nursing (DON), the Logs of Resident Requests for Access to Protected Health Information dated 7/2025 and 8/2025 were reviewed. The DON stated the process of releasing medical records is to be submitted immediately and it should not take more than 24 hours for the residents or their AR to receive the requested documents. The DON stated that it took the facility over two working days to have Resident 1's and Resident 2's medical records submitted to their representatives. The DON stated this process was not done in a timely manner and resulted in a delay in services. The DON stated that usually whoever is requesting these documents needs them within 24 to 48 hours of them being requested. The DON stated that it is the MR's, DON and the Administrators (ADM) responsibility to ensure this process is done in a timely manner. During a review of the facility's P&P titled, Resident Access to PHI, and revised 11/1/2015, the P&P indicated the purpose of this P&P is to establish guidelines for reviewing resident or resident's personal representative's requests for access to PHI. The time and manner of access is for the resident's representative to request a copy of the resident's medical record. The MR will provide the representative with a copy of the medical record within two working days after receiving the written request.

Based on observations, interview, and record review the facility failed to:A. Document one dose of Acetaminophen in the July 2025 Medication Administration Record ([MAR] - a record of mediations administered to residents) for Resident 1B. Maintain accurate accountability records for controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence), Tramadol on 7/16/2025 and 7/17/2025 for Resident 4 in one of two inspected medication carts (East Station Medication Cart)C. Ensure one of one resident (Resident 44) received lactulose (medication to treat constipation) as needed for no bowel movement in 48 hours. These failures increased the risk of medication errors for Residents 1, 4, and 44 to receive more or less medications than prescribed, adverse reactions (harmful or unpleasant reaction, resulting from an intervention related to the use of a medication) such as: uncontrolled pain, constipation, harm, and inability to readily identify the loss or drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications.Findings: A. During a review of Resident 1's admission record (facesheet), the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pneumonia (an infection/inflammation in the lungs) and sepsis (a life-threatening blood infection). During a review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 1’s cognition (ability to learn reason, remember, understand, and make decisions) was moderately impaired and was dependent (helper does all of the effort) when eating, toileting, bathing, and dressing. During a review of Resident 1’s Physician Order [NAME], the Order Summary indicated an order starting 5/5/2025 for Acetaminophen (medication to relieve pain or fever) tablet 325 milligram (mg- a unit of measurement), give 2 tablets every six hours as needed for fever, temperature greater than 100.4, not to exceed over 3 grams (G-a unit of measurement) in 24 hours. During a review of Resident 1’s Nursing Progress Note dated 7/16/2025 at 2:24 p.m., the Progress Note indicated Resident 1 had a fever of 101.7 degrees Fahrenheit (F), and was given an as needed (PRN) medication that decreased Resident 1’s temperature to 98.1 degrees F. During a concurrent interview and record review on 7/17/2025 at 2:45 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 1’s July 2025 Medication Administration Record (MAR) was reviewed. The MAR did not indicate acetaminophen was administered to Resident 4 on 7/16/2025. LVN 4 stated they administered the acetaminophen and forgot to document it. During an interview on 7/18/2025 at 3:30 p.m. with the Director of Nursing (DON), the DON stated it is important to document medication administration to prevent duplicate administration of any medication. The DON stated not documenting the acetaminophen puts Resident 1 at risk for adverse reactions due to excessive acetaminophen. B. During a review of an admission Record (face sheet), the admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including dysphagia (difficulty swallowing), contractures (the abnormal shortening of muscles, tendons, ligaments, or skin, which restricts the normal range of motion of a joint or body part) of right and both elbows, both knees, and both ankles. During a review of Resident 4’s MDS, dated [DATE], the MDS indicated Resident 4’s cognitive skills for daily decisions making were severely impaired (ability to think and reason). The MDS indicated Resident 4 was dependent and required two or more staff physical assistance for all activities of daily living (ADL, include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). During a review of Resident 4’s History and Physical (H&P) dated 5/19/2025, the H&P indicated Resident 4 does not have the capacity to understand and make decisions. During a review of Resident 4’s Order Summary with active orders as of 7/16/2025 included the following orders for: -Tramadol (treat moderate to severe pain) Oral Tablet 50 mg, give 0.5 tablet (25 mg) by mouth two times a day for pain management r/t (related to) osteoarthritis (a form of arthritis in which cartilage that cushions the ends of bones in a joint gradually wears away, causing pain, stiffness, and reduced movement) of left hand and fingers, order date 5/17/2025 During a review of Resident 4’s Care Plan (CP) titled, “High Risk for Pain/Discomfort related to generalized body aches and osteoarthritis”, dated 8/9/2024 and revised 7/16/2025, the CP goals and interventions indicated the following: Order: Tramadol Oral Tablet 50 mg, Black Box Warning: Risk of medication errors. Ensure accuracy when prescribing, dispensing, and administering tramadol … Because the use of tramadol exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death…Accidental ingestion of even one dose of Tramadol, especially by children, can result in a fatal overdose of Tramadol.” During an observation on 7/17/2025 at 2:42 p.m., with a LVN 5, at the East Station Medication Cart, there was a discrepancy in the Individual Narcotic Record or Controlled Drug Record (inventory and accountability record for CM) form and the prescription label on the two bubble packs (a medication packaging system that contains individual doses of medication per bubble) for Resident 4 and the physician order for Tramadol as follow: Resident 4’s first pharmacy prescription label indicated the bubble pack contained Tramadol 50 mg tablets, with an order to administer one-half (1/2 = 25 mg) tablet by mouth 2 (two) times a day, with a fill date of 7/15/25 with a sticker that indicated ‘MORNING’ Resident 4’s first corresponding ‘Individual Narcotic Record,’ which was handwritten indicated, “Tramadol 75 mg,” with instructions to administer 1 (one) tab (tablet) PO (by mouth) “2X/Day,” and documented that Resident 4 was administered a dose of 50 mg twice on 7/16/25 at 9:00 a.m. and on 7/17/2025 at 8:00 a.m. Resident 4’s second pharmacy prescription label indicated the bubble pack contained Tramadol 50 mg tablets, with an order to administer one-half (1/2 = 25 mg) tablet by mouth 2 (two) times a day, with a fill date of 7/15/25 with a sticker that indicated ‘P.M.’ (evening) Resident 4’s second corresponding ‘Individual Narcotic Record,’ which was handwritten indicated, “Tramadol 25 mg,” with instructions to administer 1 tab PO 2X/Day, and documented that Resident 4 was administered a dose of 25 mg once on 7/16/25 at 4:00 p.m. During a concurrent interview and record review on 7/17/2025 at 2:42 p.m., with LVN 5, Resident 4’s records dated 7/16/2025 and 7/17/2025 were reviewed that include a review of the resident’s Individual Narcotic Record, Bubble Packs containing Tramadol, physician order for Tramadol, and the resident’s Administration Details for the administration on of Tramadol to the resident that included discrepancies between the prescribed dose, prescription label and the hand written Individual Narcotic Record. LVN 5 stated that a different nurse transcribed from the pharmacy label onto Resident 4’s Individual Narcotic Record Tramadol 25 mg because the facility was administering one-half tablet of Tramadol 50 mg even though the prescription label indicated “Tramadol 50 mg” and to give one-half tablet. During an interview on 7/17/2025 at 4:19 p.m., with the Director of Nursing (DON), the DON stated what is on the Narcotic Count Sheet (Individual Narcotic/Controlled Drug Record) received from the facility’s pharmacy should be exactly the same as it is written when transcribed or rewritten on each resident’s Individual Narcotic Record inside of the book. The DON stated whoever is transcribing must include the exact same information from the pharmacy label. The DON stated using the Narcotic Count Sheet provided by the pharmacy would be more accurate and having nurses transcribe the information increases the risk for medication errors and potential for controlled medication misuse. During a review of the facility’s P&P titled, “Ordering and Receiving Controlled Medications”, dated 4/2008, the P&P indicated Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. The director of nursing and the consultant pharmacist maintain the facility’s compliance with federal and state laws and regulations in the handling of controlled medications… The pharmacy dispenses medications listed in Schedules II, III, IV, and V in readily accountable quantities and containers designed for easy counting of contents… An individual resident’s-controlled substance record is prepared by the pharmacy or the facility for each controlled substance medication prescribed for a resident. The following information is completed: 1) Name of resident 2) Prescription number 3) Drug name, strength (if designated), and dosage form of medication 4) Date received 5) Name of person receiving the medication supply 6) Dispensing pharmacy information C. During a review of Resident 44’s admission Record, the admission Record indicated Resident 44 was readmitted to the facility on [DATE] with diagnoses including Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (mental health condition characterized by excessive fear and worry). During a review of Resident 44’s MDS 6/25/2025, the MDS indicated Resident 44’s cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making was intact. The MDS indicated Resident 44 needed moderate assistance (helper does less than half the effort to complete the task) with toileting hygiene. During a review of Resident 44’s Order Summary as of 7/17/2025, the order summary indicated, starting 6/28/2025, Lactulose 30 milliliters by mouth every 12 hours as needed for no Bowel movement in 48 hours. During an interview on 7/15/2025 at 9:52 a.m., with Resident 44, Resident 44 stated she has not had a bowel movement in days and does not remember the last one, but it was more than a week. During a concurrent interview and record review on 7/17/2025 at 2:18 p.m. with Registered Nurse (RN)2, Resident 44’s Documentation Survey Report, for bowel elimination, 7/2025 and Medication Administration Records for 7/2025 were reviewed. RN 2 stated Resident 44’s last bowel movement was on 7/9/2025 and 5 days later 7/14/2025. RN 2 stated Resident 44 should have been offered lactulose at least once between 7/9/2025 and 7/14/2025 to promote comfort. During an interview on 7/18/2025 at 3:30 p.m., with the Director of Nursing (DON), the DON stated medications should be administered as ordered. During a review of the facility’s policy and procedure (P&P) titled, “Medication - Administration”, revised 1/1/2012, the P&P indicated medication will be administered.

Based on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent or greater, as evidence by the identification of three medication errors out of 25 opportunities, to yield a facility error rate of 12 percent (%) for two of two Residents (Resident 4 and Resident 28) by failing to: 1. Ensure for Resident 4, Licensed Vocational Nurse (LVN) 2, LVN 3, and Registered Nurse (RN) 2 failed to follow facility's policies and procedures (P&P) titled, Medication - Administration, by failing to ensure the same nurse that prepared Resident 4's Tylenol (Acetaminophen [APAP], treat mild to moderate pain) Extra Strength Oral Tablet 500 milligrams (mg, unit of measurement by weight) administered the medication, and documented the administration of the medication to ensure the correct resident was administered the correct dose. 2. Ensure for Resident 28, Losartan (a blood pressure medication) was administered to the resident prior to checking the resident's blood pressure. Resident 28's physician's order indicated to hold (not administer) if systolic blood pressure ([SBP] top number in blood pressure; pressure during active contraction of the heart) is less than 110 millimeters of mercury ([mm Hg] unit used to measure BP) or heart rate (HR, beats per minute [BPM]) is less than 60 BPM. 3. Ensure for Resident 28, LVN 2 failed to follow facility's P&P titled, Feeding Tube - Administration of Medication, by failing to check gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition and/or medication directly to the stomach) placement by aspiration (assessing the contents withdrawn from the GT to help confirm its location in the stomach rather than the lungs or other unintended locations) and failing to flush the GT with 15 milliliters (ml, unit of measurement by volume) of water before administering and/or attempting to administer two medications, Losartan and Oxcarbazepine (a medication to treat and prevent seizures) to Resident 28. These deficient practices of failing to administer medications in accordance with the physician orders and the facility's P&Ps, titled, Medication - Administration, and Feeding Tube - Administration of Medication, increased the risk for Resident 4 and Resident 28 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) related to their medication therapy. (Cross Reference F726, F760)Findings:A. During a review of an admission Record (face sheet), the admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including dysphagia (difficulty swallowing), Type 2 diabetes mellitus (DM II, when the body cannot use insulin correctly and sugar/glucose builds up in the blood), contractures (the abnormal shortening of muscles, tendons, ligaments, or skin, which restricts the normal range of motion of a joint or body part) of right and both elbows, both knees, and both ankles. During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 7/2/2025, the MDS indicated Resident 4's cognitive skills for daily decisions making were severely impaired (ability to think and reason). The MDS indicated Resident 4 was dependent and required two or more staff physical assistance for all activities of daily living (ADL, include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). During a review of Resident 4's History and Physical (H&P) dated 5/19/2025, the resident does not have the capacity to understand and make decisions.During a review of Resident 4's Order Summary with active orders as of 7/16/2025 included the following orders for:-Tylenol (Acetaminophen, treat mild to moderate pain) Extra Strength Oral Tablet 500 mg, give two tablets (1000 mg) by mouth every day shift for pain give prior to treatment, order date 5/28/2025-May crush all crushable medications, order date 7/12/2025-Sacral Pressure Injury, monitor for pain using scale 0-10 before, during and after treatment every day shift for 14 days, order date 7/12/2025, with an end date of 7/26/2025.During a review of Resident 4's Care Plan (CP) titled, High Risk for Pain/Discomfort, dated 8/9/2024 and revised 7/16/2025, the CP goals and interventions indicated the following: Tylenol Extra Strength Oral Tablet 500 mg (Acetaminophen) instruction indicated, give 2 (two) tablets by mouth every 6 (six) hours as needed for moderate pain 5-7/10 (pain scale zero to 10, 0 indicates no pain, while 10 represents the worst pain imaginable) not to exceed 3 (three) grams (g, unit of measurement by weight) of APAP in 24 hours from all sources and give 1 (one) tablet by mouth every day shift for pain, give prior to treatment, revision on 7/16/2025.During a concurrent medication pass observation and interview, on 7/16/2025 at 9:12 a.m., with LVN 2, at the East Station Medication Cart, LVN 2 stated Resident 4 needed pain medication before the resident's wound treatment. LVN 2 prepared for Resident 4 - two, 500 mg tablets of Acetaminophen, crushed the tablets, placed the crushed powder into a medication cup and added applesauce to the crushed tablets and mixed them together. LVN 2 stated that Resident 4 has an order to crush the medications. LVN 2 stated she added one-fourth teaspoonful of applesauce to the crushed the Acetaminophen tablets for Resident 4. LVN 2 stated another LVN (LVN 3) will administer the prepared medication (Acetaminophen 500 mg, two tablets = 1000 mg) to Resident 4. LVN 2 handed the cup of medication to LVN 3 as LVN 3 walked up to the East Station Medication Cart after the medication had been prepared by LVN 2. LVN 3 asked LVN 2 which room the resident was in. LVN 2 stated the resident's room number and LVN 3 left with the medication cup to administer the medication to Resident 4.During an interview on 7/16/2025 at 2:38 p.m. with LVN 3, LVN 3 stated, Resident 4 has a routine pain medication order to be administered before wound treatment. LVN 3 stated that LVN 2 gave LVN 3 a cup with crushed medication mixed with applesauce for Resident 4. LVN 3 stated he administered to Resident 4 two tablets of Acetaminophen 325 mg (650 mg), that was given to him crushed and mixed in applesauce by LVN 2. LVN 3 stated, I gave the crushed medication to the resident (Resident 4). LVN 3 stated that he documented the administration of Acetaminophen to Resident 4 on the resident's MAR (an organized record of each medication administered to a resident) on 7/16/2025 after the morning administration. During a concurrent interview and record review on 7/16/2025 at 2:56 p.m., with LVN 3, at the [NAME] Station, Resident 4's MAR for 7/16/2025 was reviewed. LVN 3 stated Resident 4 was documented to have been administered two tablets of Acetaminophen 500 mg (1000 mg) and not two tablets of Acetaminophen 325 mg (650 mg) on 7/16/2025 at 9:08 a.m., by a Registered Nurse (RN) 2. LVN 3 stated RN 2 did not administer the Acetaminophen to Resident 4, he did. LVN 3 stated that usually the licensed nurse that prepares the medication is the one to verify the identity of the resident and ensure the right medication is given to the right resident and to document after the medication has been administered. During an interview on 7/16/2025 with LVN 2, LVN 2 stated, LVN 3 was not present when LVN 2 prepared Resident 4's medication, Acetaminophen. LVN 2 stated it was wrong to give the prepared medication, Acetaminophen for Resident 4 to another licensed nurse, LVN 3, to administer to the resident when LVN 3 was not present during the medication preparation.During an interview on 7/16/2025 with LVN 2 and RN 2, RN 2 stated, she was going to be the one originally to administer Acetaminophen to Resident 4 and signed the MAR prior to the medication being administered to the resident. RN 2 stated, I did not see the resident take the medication. LVN 2 stated, she did not see Resident 4 take the medication. LVN 2 stated having different nurse prepare, administered, and documented the administration increases the risk that the wrong resident may be administered the medication, and/or the correct resident (Resident 4) may not have been administered the medication at all. RN 2 stated the licensed nurse that prepares the medication should be the same nurse that administers the medication to the resident and then document the administration on the resident's MAR.During a review of the facility's policy and procedure (P&P) titled, Medication Administered, revised on 1/1/2012, the P&P indicated: 1.Medications must be given to the resident by the Licensed Nurse preparing the medication.2.The Licensed Nurse will verify the resident's identity before administering the medication.3.The licensed nurse will chart the drug, time administered, and initial his/her name with each medication administered.4.The time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug or treatment. B. During a review of Resident 28's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including dysphagia (difficulty swallowing), DM II, epilepsy (is a neurological condition that causes unprovoked, recurrent seizures [is a sudden rush of abnormal electrical activity in the brain]), hypertension (HTN, high blood pressure), blindness, right eye, and gastrotomy status (GT). During a review of a MDS, dated [DATE], the MDS indicated Resident 28's cognitive skills for daily decisions making was severely impaired (ability to think and reason). The MDS indicated Resident 28 was dependent and required two or more staff physical assistance for all ADL.During a review of Resident 28's History and Physical (H&P) dated 6/6/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.During a review of Resident 28's Order Summary with active orders as of 7/16/2025 included the following orders for:1. Enteral Feed Order every shift check for placement (ensures the tube is correctly placed into the stomach), patency (involves verifying the GT's ability to drain stomach contents, flush with water, and assessing for any signs of blockage or dislodgement, where the GT comes out of the stomach) and residual (measuring the amount of stomach contents remaining in the stomach before a feeding or medication administration). If residual is more than 60 milliliters (ml, unit of measurement by volume) or reaches an amount indicated by the physician hold feeding until residual diminishes, order date 6/6/2025.2. Enteral Feed Order every shift flush tube (GT) with 50 ml water, order date 6/6/2025.3. Enteral Feed Order every shift flush GT with 10 ml to 15 ml water between medications.4. Clopidogrel (used to prevent blood clots) Oral Tablet 75 mg, give one tablet via GT one time a day for cerebrovascular accidents (CVA or stroke), order date 6/6/2025.5. Gabapentin Capsule 300 mg, give one capsule via GT three times a day for Neuropathic pain (nerve pain), order date 6/6/2025.6. Losartan Potassium Tablet 50 mg, one tablet via GT one time a day for HTN. Hold if SBP is less than 110 mmHg, or HR is less than 60 bpm, order date 6/6/2025.7. Oxcarbazepine Oral Suspension 300 mg/ 5ml, give 15 ml via GT two times a day for seizures (900 mg = 15 ml), order date 6/6/2025.8. Keppra (Levetiracetam) Oral Solution 100 mg.ml, give 15 ml via GT two times a day for seizure, order date 6/6/2025.9. Dilantin (Phenytoin) Oral Tablet Chewable 50 mg, give four (4) tablets (200 mg) via GT two times a day for seizure disorder, order date 6/24/2025.10. Aspirin 81 mg Oral Tablet Chewable, give one tablet via GT one time a day for CVA prophylaxis (preventative treatment), order date 6/6/2025.During a review of Resident 28's CP titled, Hypertension, related to inappropriate diet and lifestyle choices, dated 5/23/2025, the CP indicated the following:-The resident has hypertension (HTN) related to inappropriate diet and lifestyle choices. Medication use: Losartan Potassium Tablet 50 mg. Give one tablet by mouth one time a day for HTN hold if systolic blood pressure less than 110 mmhg (unit of pressure). To give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension a sudden drop in blood pressure that occurs upon standing from a sitting or lying down position) and increased heart rate (Tachycardia) and effectiveness. Date initiated: 5/23/2025.-The resident requires GT feeding r/t Dysphagia, chewing problem.The resident needs the head of the bed (HOB) elevated 45 degrees during and thirty minutes after GT feed. Check for GT placement and gastric contents/residual volume per facility protocol and record.Monitor/document/report as needed (PRN) and signs and symptoms of aspiration, fever, shortness of breath (SOB), GT dislodged, infection at GT site, self-extubation (removal of a GT by a patient/resident), GT dysfunction or malfunction, abnormal breath/lung sounds, abnormal laboratory (lab) values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, or dehydration. The resident is dependent with GT feeding and water flushes.date initiated 5/23/2025. -The resident has a seizure disorder r/t epilepsy, stroke. Medication prophylaxis, Levetiracetam Oral Solution, Oxcarbazepine Oral Suspension, and Phenytoin Oral Tablet Chewable, interventions indicated, give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness, date initiated 5/23/2025.During a concurrent medication pass observation and interview, on 7/16/2025 at 9:17 a.m., with LVN 2, at the East Station Medication Cart, LVN 2 was observed preparing the following medications for Resident 28:a. Clopidogrel 75 mg, one tabletb. Gabapentin 300 mg, one capsulec. Losartan 50 mg, one tabletd. Oxcarbazepine 300 mg/ 5 ml, 15 ml (900 mg)e. Aspirin 81 mg chewable, one tabletf. Levetiracetam Oral Solution 100 mg/ml, 15 ml (1500 mg)g. Phenytoin 50 mg chewable, four tablets (200 mg)LVN 2 stated Resident 28's BP was 120/80 (mmHg) and HR 74 (bpm). LVN 2 was not observed checking Resident 28's BP or HR. LVN 2 was observed reviewing a piece of paper with a list that included resident's by room number and bed assign and listed corresponding vital signs (measures temperature, pulse/heart rate, respiration rate [rate of breathing], and blood pressure) documented next to the room numbers, The document reviewed by LVN 2 was undated and did not include residents names or indicate the date and time the vital signs were recorded or by whom. LVN 2 stated another nurse, LVN 3, residents on East Nursing Station vital signs, which included Resident 28's BP and HR. LVN 2 stated that she did not know what time LVN 3 had checked Resident 28's BP or HR. During a concurrent medication pass observation and interview, on 7/16/2025 between 9:32 a.m. through 10:01 a.m., with LVN 2, at the East Station Medication Cart for Resident 28, the following was observed:-On 7/16/2025 at 9:32 a.m., LVN 2 stated she had prepared a total of seven morning medications for Resident 28. LVN 2 crushed each tablet individually and placed them into separate medication cups.-On 7/16/2025 at 9:38 a.m., LVN 2 entered Resident 28's room without sanitizing hands with alcohol-based hand sanitizer or washing with soap and water, put on gown and gloves-On 7/16/2025 at 9:40 a.m., LVN 2 stated she poured 15 ml of water into each medication cup that contained crushed medication and mixed. LVN 2 then stated she pushed 20 cc (cc unit of measurement) of air to check GT placement and stated she was unable to hear gurgle sound to confirm the GT was in the correct location, the stomach. LVN 2 tried pushing air two more times with 30 cc and again with 40 cc of air and stated, I cannot hear it. -On 7/16/2025 at 9:47 a.m., LVN 2 called for LVN 3 assistance. LVN 3 entered Resident 28's room and stated he pushed 10 cc of air through the GT to check placement. LVN 3 stated he could not hear gurgling, or stomach sounds after pushing air into Resident 28's stomach and could not confirm GT placement and left the room.-On 7/16/2025 at 9:51 a.m., LVN 2 requested a Registered Nurse Supervisor (RN) 1 to assist with confirming GT placement.-On 7/16/2025 at 9:45 a.m., RN 1 entered Resident 28's room placed a stethoscope on Resident 28's stomach LVN 2 stated she pushed 45 cc of air, while RN 1 listened through the stethoscope. RN 1 stated, I can hear the gurgling sound, and confirmed GT placement, then left Resident 28's room. RN 1 was not observed checking Resident 28 for aspiration and amount of residual. -On 7/16/2025 at 9:58 a.m., LVN 2 was not observed aspirating or checking Resident 28 for amount of residual. LVN 2 stated she was administering Resident 28's BP medication Losartan. LVN 2 poured Resident 28's BP medication, Losartan into the GT syringe connected to the GT tubing and used a plunger to push the medication into Resident 28's stomach. LVN 2 poured 10 ml of water into the GT syringe and again use the plunger and push the water into Resident 28's stomach. LVN 2 was not observed providing an initial water flush prior to administering the first medication, Losartan.-On 7/16/2025 at 9:59 a.m., it stated that Resident 28 residual was not checked prior to medication administration via GT. LVN 2 checked Resident 28 for residual and stated, she pulled out medication about 0.5 ml and then used the plunger inside of the syringe and pushed the medication back into Resident 28's stomach.-On 7/16/2024 at 10:01 a.m., LVN 2 poured the second medication Oxcarbazepine into Resident 28's GT syringe, the medication was observed remaining inside of the GT syringe and not passing through the GT tubbing into Resident 28's stomach. LVN 2 stated she knows that she was supposed to administer Resident 28's medication by gravity (utilizing the natural downward pull of gravity to deliver the medication into the stomach through the GT/feeding tube). LVN 2 stated at this point she will notify RN 1 because the medication is not going down. During an interview on 7/16/2025 at 10:05 a.m., with LVN 3, LVN 3 stated, I took all the vitals for the residents at 8 a.m., on 7/16/2025. LVN 3 acknowledged providing handwritten paper with multiple resident room numbers and vital signs written down to LVN 2. During a concurrent medication pass and observation on 7/16/2025 at 10:10 a.m., at Resident 28's bedside, with LVN 2, RN 1, and the Director of Nursing (DON), LVN 2 stated for Resident 28, I did not check residual. I pushed the first medication and water flush. The DON checked GT placement for Resident 28 by pushing air into the resident's stomach twice and stated she used 15 cc of air the first time and 30 cc of air the second time and confirmed the GT was in place. The DON stated that Resident 28's stomach was hyper tympanic (belly that sounds hollow or drum-like due to excessive gas buildup), the resident's abdominal wall was distended (noticeable outward swelling or enlargement of the abdomen). The DON stated will call Resident 28's doctor and daughter and to hold feeding and all medications. During an interview on 7/16/2025 at 10:20 a.m., with LVN 2, LVN 2 stated, I was doing everything myself yesterday (7/15/2025) and today (7/16/2025) the DON wanted LVN 3 to tag team and to do the vitals that makes everything confusing and frustrating now.During an interview on 7/16/2025 at 10:30 a.m., with RN 1, RN 1 reviewed the handwritten paper used by LVN 2 to determine when to administer Resident 28's BP medication Losartan. RN 1 stated the paper did not include a date or time to indicate when the vital signs were taken for each resident. RN 1 stated residents BP can fluctuate, and it is better to recheck BP just prior to medication administration for an accurate reading before giving the BP medication that has a parameter to determine when to give or not give the medication.During a concurrent interview and review of the facility's P&P titled, Feeding Tube - Administration of Medication, dated 6/12/2024, the P&P indicated to, Verify tube placement via aspiration method. Return aspirate to stomach. DON stated, the facility's policy did not indicate checking GT placement by introducing air into the resident's stomach. DON stated the licensed nurses are supposed to check GT placement by aspiration. DON stated the facility's practice does not correspond to the facility, Feeding Tube - Administration of Medication, policy. During a review of the facility's P&P titled, Feeding Tube - Medication Administered, effective date 6/12/2024, the P&P indicated to:-Verify tube placement via aspiration method. Return aspirate to stomach.-Flush tube with 15 cc (unless a different amount is specified by the Physician/Prescriber) of water before administering medication.-Between each medication, the tube (GT) is flushed with 15 ml of water, keeping in mind the patient's fluid volume status (unless a different amount is specified by the Physician/Prescriber).-Administer medication by syringe via gravity into the feeding tube.-Flush tube with 15 ml of water (unless a different amount is specified by the Physician/Prescriber) after administering the medications.-After administering medication reestablish feeding as prescribed.Bottom of Form

Based on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) titled, Medication - Administration, to prevent significant medication errors (medication errors that causes the resident discomfort or jeopardizes the resident health and safety) for two of five sampled residents (Residents 28 and Resident 4), by failing to: (Cross Reference F759) 1. Ensure LVN 2, LVN 3 and RN 1 followed facility's P&P titled, Medication - Administration, to ensure accurate administration of medications by making sure the same nurse preparing Resident 4's Tylenol medication for pretreatment for wound care was the same nurse that administered the medication and documented the administration. 2. Ensure LVN 2 followed Resident 28's Physician/Medical Doctor (MD) 1's orders to check the resident's blood pressure (BP) and heart rate (HR) prior to the administration of Losartan (a medication used to treat high blood pressure), as an ordered parameter (used to assess, monitor, and guide treatment decisions) to determine whether to give or not give the medication. These deficient practices resulted in Residents 28 and 4 not receiving medications in accordance with the physicians' orders, and the facility's P&Ps. These failures placed Residents 28 and 4 at risk for significant medical complications including pain, delayed wound healing, uncontrolled blood pressure creating a change of condition, discomfort, and hospitalization.Findings:1. During a review of an admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including dysphagia (difficulty swallowing), and contractures (the abnormal shortening of muscles, tendons, ligaments, or skin, which restricts the normal range of motion of a joint or body part) of right and both elbows, both knees, and both ankles.During a review of a Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 7/2/2025, the MDS indicated Resident 4's cognitive skills for daily decisions making was severely impaired (ability to think and reason). The MDS indicated Resident 4 was dependent and required two or more staff physical assistance for all activities of daily living (ADL, include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). During a review of Resident 4's History and Physical (H&P) dated 5/19/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of an Order Summary with active orders as of 7/16/2025 included the following orders for:Tylenol (Acetaminophen, treat mild to moderate pain) Extra Strength Oral Tablet 500 mg, give two tablets (1000 mg) by mouth everyday shift for pain give prior to treatment, order date 5/28/2025During a review of Resident 4's Care Plan titled, High risk for pain/discomfort, dated 8/9/2024 and revised on 7/16/2025, the CP interventions indicated, Tylenol Extra Strength Oral Tablet 500 mg (Acetaminophen) instruction indicated, give 2 (two) tablets by mouth every 6 (six) hours as needed for moderate pain 5-7/10 (pain scale zero to 10, 0 indicates no pain, while 10 represents the worst pain imaginable) not to exceed 3 (three) grams (g, unit of measurement by weight) of APAP in 24 hours from all sources and give 1 (one) tablet by mouth every day shift for pain, give prior to treatment, revision on 7/16/2025.During a concurrent medication pass observation and interview, on 7/16/2025 at 9:12 a.m., with LVN 2, at the East Station Medication Cart, LVN 2 stated Resident 4 needed pain medication before the resident's wound treatment. LVN 2 prepared for Resident 4 - two, 500 mg tablets of Acetaminophen, crushed the tablets, placed the crushed powder into a medication cup and added applesauce to the crushed tablets and mixed them together. LVN 2 handed the cup of medication to LVN 3 as LVN 3 walked up to the East Station Medication Cart after the medication had been prepared by LVN 2. LVN 3 asked LVN 2 which room the resident was in. LVN 2 stated the resident's room number and LVN 3 left with the medication cup to administer the medication to Resident 4.During an interview on 7/16/2025 at 2:38 p.m. with LVN 3, LVN 3 stated he administered to Resident 4 two tablets of Acetaminophen 325 mg (650 mg), that was given to him crushed and mixed in applesauce by LVN 2. LVN 3 stated, he administered the crushed Acetaminophen medication to the resident (Resident 4), on 7/16/2025 during the 9 a.m., morning medication pass.During a concurrent interview and record review on 7/16/2025 at 2:56 p.m., with LVN 3, at the [NAME] Station, Resident 4's MAR for 7/16/2025 was reviewed. LVN 3 stated Resident 4 was documented to have been administered two tablets of Acetaminophen 500 mg (1000 mg) and not two tablets of Acetaminophen 325 mg (650 mg) on 7/16/2025 at 9:08 a.m., and Resident 4's MAR was initialed to indicate a Registered Nurse (RN) 2 had administered the medication to the resident. LVN 3 stated RN 2 did not administer the Acetaminophen to Resident 4, he did (LVN 3).During an interview on 7/16/2025 with LVN 2 and RN 2, RN 2 stated, she was going to be the one nurse to administer Acetaminophen to Resident 4 and signed the MAR prior to the medication being administered to the resident. RN 2 stated, I did not see the resident take the medication. LVN 2 stated, she did not see Resident 4 take the medication. LVN 2 stated having different nurses prepare, administered, and documented the administration increases the risk that the wrong resident may be administered the medication. RN 2 stated the licensed nurse that prepares the medication should be the same nurse that administers the medication to the resident and then document the administration on the resident's MAR.During a review of the facility's policy and procedure (P&P) titled, Medication Administered, revised on 1/1/2012, the P&P indicated:-To ensure the accurate administration of medications for residents in the Facility.-Medication must be given to the residents by the Licensed Nurse preparing the medication.-The Licensed Nurse will verify the resident's identity before administering the medication.-The licensed nurse will chart the drug, time administered, and initial his/her name with each medication administered.-The time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug or treatment. 2. During a review of Resident 28's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included dysphagia (difficulty swallowing) and hypertension (HTN, high blood pressure), and gastrotomy status (GT, a tube inserted through the abdomen that delivers nutrition and/or medication directly to the stomach).During a review of a MDS, dated [DATE], the MDS indicated Resident 28's cognitive skills for daily decisions making was severely impaired (ability to think and reason). The MDS indicated Resident 28 was dependent and required two or more staff physical assistance for all ADL.During a review of Resident 28's History and Physical (H&P) dated 6/6/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.During a review of an Order Summary with active orders as of 7/16/2025 included but was not limited to:Losartan Potassium Tablet 50 mg, one tablet via GT one time a day for HTN. Hold systolic blood pressure ([SBP] top number in blood pressure; pressure during active contraction of the heart) is less than 110 millimeters of mercury ([mm Hg] unit used to measure BP) or heart rate (HR, beats per minute [BPM]) is less than 60 BPM, order date 6/6/2025During a review of Resident 28's CP titled Hypertension, related to inappropriate diet and lifestyle choices, goals and interventions indicated:The resident has hypertension (HTN) related to inappropriate diet and lifestyle choices. Medication use: Losartan Potassium Tablet 50 mg. Give one tablet by mouth one time a day for HTN hold if systolic blood pressure less than 110 mmhg. To give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension a sudden drop in blood pressure that occurs upon standing from a sitting or lying down position) and increased heart rate (Tachycardia) and effectiveness. Date initiated: 5/23/2025.During a concurrent medication pass observation and interview, on 7/16/2025 at 9:17 a.m., with LVN 2, at the East Station Medication Cart, LVN 2 was observed preparing the following medications for Resident 28, a. Clopidogrel 75 mg, one tabletb. Gabapentin 300 mg, one capsulec. Losartan 50 mg, one tabletd. Oxcarbazepine 300 mg/ 5 ml, 15 ml (900 mg)e. Aspirin 81 mg chewable, one tabletf. Levetiracetam Oral Solution 100 mg/ml, 15 ml (1500 mg)g. Phenytoin 50 mg chewable, four tablets (200 mg)LVN 2 stated Resident 28's BP was 120/80 (mmHg) and HR 74 (bpm). LVN 2 was not observed checking Resident 28's BP or HR. LVN 2 was observed reviewing a piece of paper with a list that included resident's by room number and bed assign and listed corresponding vital signs (measures temperature, pulse/heart rate, respiration rate [rate of breathing], and blood pressure) documented next to the room numbers, The document reviewed by LVN 2 was undated and did not include residents names or indicate the date and time the vital signs were recorded or by whom. LVN 2 stated another nurse, LVN 3, residents on East Nursing Station vital signs, which included Resident 28's BP and HR. LVN 2 stated that she did not know what time LVN 3 had checked Resident 28's BP or HR. During on observation on 7/16/2025 at 9:58 a.m., LVN 2 was not observed checking aspiration (assessing the contents withdrawn from the GT to help confirm its location in the stomach rather than the lungs or other unintended locations) or checking Resident 28 for amount of residual (measuring the amount of stomach contents remaining in the stomach before a feeding or medication administration). LVN 2 stated she was administering Resident 28's BP medication Losartan. LVN 2 poured Resident 28's BP medication, Losartan into the GT syringe connected to the GT tubing and used a plunger to push the medication into Resident 28's stomach. LVN 2 poured 10 ml of water into the GT syringe and again use the plunger and push the water into Resident 28's stomach. LVN 2 was not observed providing an initial water flush prior to administering the first medication, Losartan.During an interview on 7/16/2025 at 10:05 a.m., with LVN 3, LVN 3 stated, I took all the vitals for the residents at 8 a.m., on 7/16/2025. LVN 3 acknowledged providing handwritten paper with multiple resident room numbers and vital signs written down to LVN 2. During an interview on 7/16/2025 at 10:20 a.m., with LVN 2, LVN 2 stated, I was doing everything myself yesterday (7/15/2025) and today (7/16/2025) the DON wanted LVN 3 to tag team and to do the vitals that makes everything confusing and frustrating now.During an interview on 7/16/2025 at 10:30 a.m., with RN 1, RN 1 reviewed the handwritten paper used by LVN 2 to determine when to administer Resident 28's BP medication Losartan. RN 1 stated the paper did not include a date or time to indicate when the vital signs were taken for each resident. RN 1 stated residents BP can fluctuate, and it is better to recheck BP just prior to medication administration for an accurate reading before giving the BP medication that has a parameter to determine when to give or not give the medication. RN 1 stated there were between 31 to 32 Residents on East Station that LVN 2 was scheduled to pass morning medicationsDuring a review of the facility's P&P titled, Medication Administered, revised on 1/1/2012, the P&P indicated, Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required and the results recorded. When administering of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record i.e. BP, pulse, finger stick blood glucose monitoring etc. During a review of the facility's P&P titled, Feeding Tube - Medication Administered, dated 6/12/2024, the P&P indicated to:-Verify tube placement via aspiration method. Return aspirate to stomach.-Flush tube with 15 cc (unless a different amount is specified by the Physician/Prescriber) of water before administering medication.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of infectious organisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food) for 81 of the facility's residents who eat food prepared in the kitchen by failing to: 1. Ensure the store prepared 18 cups of juice with a prepared-on date.2. Ensure to place an open-date on a Residents juice that was placed in the fridge. These deficient practices had the potential to result in residents developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization. Findings: During an initial visit to the kitchen on 7/15/2025 at 8:15 a.m., with the Dietary supervisor (DS) , there were six glasses of cranberry juice, 5 glasses of apple juice, 3 glasses of milk, and 3 glasses of orange juice without a prepare-on date inside the walk-in refrigerator. During an observation on 7/15/2025 at 08:30 a.m., with the DS, there was 1 large container of juice in the resident's refrigerator with no opened-on date. During an interview on 7/16/2025 at 8:47 a.m., with the DS, the DS stated it is the dietary staff's responsibility to label foods and drinks with prepared-on and opened-on dates. The DS stated it was important to label and date foods and drinks so that we can know when to throw them out. The DS stated juices last for 72 hours then you must throw it out. The DS stated if the juice is kept beyond the 72 hours the juice can be hazardous, and the resident can become sick if they drink it. During a review of the facility's P&P titled Food Storage and Handling revised on 2/9/2024, the P&P indicated label and date all food items.

Based on interview and record review the facility failed to ensure two of three sampled residents' (Resident 2 and Resident 44) informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for psychotropics (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) was obtained prior to administration.This deficient practice violated Resident 2 and 44's rights to receive all information, in advance, of risks and benefits of proposed care, treatment, treatment alterative, and choose the alterative of choice which includes information for administration of psychotropic drugs.Findings: A. During a review of Resident 2's admission record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 2’s Minimum Data Set (MDS – a resident assessment tool), 6/24/2025, the MDS indicated was able to understand and be understood by others and was dependent (helper does all of the effort) for eating, toileting, bathing, and dressing. During a review of Resident 2’s Physician Order Summary, the Order Summary indicated the following: 1. Starting 3/20/2024, Resident 2 is incapable of making healthcare decisions. 2. Starting 2/5/2025, Apripiprazole (medication for bipolar disorder) five milligrams (mg- unit of measurement), every other evening for sudden shifts in mood from pleasant to extreme anger. 3. Starting 3/28/2025, Valporic Acid (medication for bipolar disorder) 250 mg/5 milliliters (ml unit of measurement for liquids), two times a day for extreme mood swings. During a concurrent interview and record review on 7/18/2025 at 11:40 a.m. with the Director of Nursing (DON), the DON stated the most recent informed consent for psychotropics for Resident 2 was dated 7/23/2024. The DON stated informed consents for psychotropics should be signed and updated every six months. The DON stated if informed consents for psychotropics are not obtained, there is a risk for unnecessary medication use and violating residents’ right to refuse. B. During a review of Resident 44’s admission Record, the admission Record indicated Resident 44 was readmitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (mental health condition characterized by excessive fear and worry). During a review of Resident 44’s MDS, dated [DATE], the MDS indicated Resident 44’s cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making was intact. During a review of Resident 44’s Order Summary Report as of 7/11/2025, the Summary report indicated the following: 1. Starting on 7/8/2025, Ativan (medication for anxiety) on mg, by mouth, every 12 hours as needed for verbalization of feeling anxious.2. Starting on 5/16/2025, Trazadone (medication for depression) 125 mg by mouth, at bedtime. During a concurrent interview and record review on 7/17/2025 at 3 p.m. with Registered Nurse (RN) 2, Resident 5's Informed consents for Ativan and Trazadone were reviewed. RN 2 stated both informed consents were incomplete and therefore not valid. RN 2 stated Ativan consent was missing the date and physician signature. RN 2 stated the Trazadone consent was also missing the date and physician signature. During an interview on 7/18/2025 at 3:30 p.m., with the DON, the DON stated informed consents should be obtained prior to the first dose of medication and need to be obtained by the medical provider who orders the medication. During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent”, revised 6/27/2024, the P&P indicated It was the healthcare provider’s responsibility to obtain informed consent. During a review of the facility’s policy and procedure (P&P) titled, “Behavior/Psychoactive Medication Management”, revised 4/24/2025, the P&P indicated the residents written informed consent for treatment will be obtained and renewed every six months.

Based on interview and record review, the facility failed to conduct Interdisciplinary Team (IDT- a group of medical professionals from different disciplines who work together to help a resident achieve their goals) meetings quarterly and as needed for one of three sampled residents (Resident 32).This failure resulted in Resident 32 and Resident 32's Responsible Party (RP) to be unaware of the plan of care and experience worry while waiting for mammogram (x-ray of the breast to detect signs of breast cancer) results for three months. Findings: During a review of Resident 32's admission record, the admission record indicated Resident 32 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and kidney failure (condition where kidneys lose the ability to filter waste and fluid from the body). During a review of Resident 32's History and Physical (H&P), dated 6/1/2025, the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated 6/18/2025, the MDS indicated Resident 32's cognition (ability to learn reason, remember, understand, and make decisions) was intact, required set-up assistance when eating, required maximal assistance (helper does more than half of the effort) for bathing and dressing, and was dependent (helper does all of the effort) for toileting. During a review of Resident 32's Physician Order Summary dated 7/18/2025, the Order Summary indicated on 3/6/2025, Resident 3 had an order for a diagnostic bilateral mammogram. During an interview on 7/15/2025 at 10:07 a.m. with Resident 32, Resident 32 stated she had a mammogram a few months ago, but has been worried because she has not received any results. During an interview on 7/15/2025 at 12:41 p.m. with Resident 32's Responsible Party (RP), the RP stated Resident 32 had a mammogram around May 2025 and has not heard any updates or results. The RP stated the last IDT meeting was over three months ago.During a concurrent interview and record review on 7/17/2025 at 1:57 p.m. with the Social Services Director (SSD), Resident 32's medical record was reviewed. The SSD stated Resident 32 had mammogram on 4/14/2025, and did not see results in Resident 32's medical record. The SSD stated the last IDT meeting was 3/19/2025. The SSD stated there should have been an IDT meeting in June 2025. The SSD stated it is important to have quarterly IDT meetings to update residents and their RP's of the plan of care. The SSD stated if there was an IDT meeting in June 2025, the mammogram results would have been discussed. During an interview on 7/18/2025 at 3:30 p.m. with the Director of Nursing (DON), the DON stated IDT meetings are completed on admission, quarterly, and as needed. The DON stated IDTs are important to update residents and their families of the plan of care and give an opportunity for them to voice their concerns. During a review of the facility's policy and procedure (P&P), titled Comprehensive Person-Centered Care Planning, revised 8/24/2023, the P&P indicated the facility must provide the resident and representative, if applicable, reasonable notice of car planning conferences to enable resident and representative participation. The P&P indicated the care planning meeting will be documented in the clinical record.

Based on interview and record review, the facility failed to ensure a resident, who had diagnosis of self-harm, did not inflict self-injury by spraying oven-cleaner (degreaser) over his arms, for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure staff followed Resident 1's untitled Care Plan dated 7/8/2025, for ideations of self-harm to provide the resident with a one-on-one sitter (a caregiver who provides continuous, dedicated support to an individual patient when a patient requires close supervision due to safety concerns such as potential for self-harm) after Resident 1 was readmitted back to the facility on 7/7/2025 from a general acute care hospital (GACH) 1 where he had been admitted for ideations of self-harm. 2. Implement the facility's procedure and policy titled, Resident Safety, dated 04/15/2021, indicated the facility would provide a safe and hazard free environment where residents would be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the residents. 3. Ensure staff followed the facility's P&P titled, Person-Centered Care Planning, dated 5/22/2025, which indicated the facility must develop and implement a comprehensive person-centered care plan for each resident. The facility failed to implement Resident 1's untitled care plan dated 7/8/2025, for the resident's ideations of self-harm to provide the resident with a one-on-one sitter monitoring to prevent Resident 1 from self-harm on 7/8/2025. This failure resulted in Resident 1 spraying oven cleaner over both of his arms causing second degree (damage to both the outer and underlying layer of skin) chemical burns on 7/8/2025 and getting transferred to GACH 2 on 7/8/2025 and then to a burn center ([GACH 3] (a specialized facility dedicated to treating severe burn injuries, equipped with advanced resources and a multi-disciplinary team) on 7/10/2025 for surgical interventions. On 7/15/2025, at GACH 3 Resident 1 underwent surgical debridement (a medical procedure involving the removal of damaged, dead, or infected tissue from a wound to promote healing) of areas that were chemically injured on both arms on 7/15/2025.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), suicidal/self-harm ideations (preoccupation of causing harm or death to self), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension ([HTN]-high blood pressure) and morbid obesity (significantly excessive body weight that present health risks).During a review of Resident 1's Psychology (medical specialty in human mind and behavior) Note dated 5/27/2025, the Psychology Note indicated Resident 1 complained of feeling depressed, and verbalized frustration with being physically impaired due to morbid obesity, muscle weakness, and abnormal gait and mobility. The Psychology Note indicated Resident 1 had a history of self-harm behaviors. The psychology note indicated Resident 1 reported he would self-harm by burning himself to relieve his feelings of depression.During a review of Resident 1's History and Physical (H&P) dated 7/7/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions.During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/24/2025, the MDS indicated Resident 1 had moderately impaired cognitive (thought process) skills for daily decision making and required set up assistance (helper sets up while resident completes the activity) with self-care abilities such as eating, and supervision (helper provides verbal cues as resident completes the activity) with oral hygiene, upper body dressing and personal hygiene, moderate assistance (helper does less than half the effort) with lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1's mood severity score (a measure used to gauge the overall severity of depressive symptoms [a cluster of emotional, cognitive, and behavioral changes that characterize depression]) was 10, which indicated moderate depression (a level of depression that is in the middle of mild and severe which persist for at least two weeks such as persistent low mood or sadness, sleep disturbances, feeling of guilt of worthlessness).During a review of Resident 1's untitled Care Plan dated 7/8/2025, the Care Plan indicated Resident 1 was having ideations of self-harm. The Care Plan indicated Resident 1 felt frustrated with being physically impaired because of morbid obesity. The Care Plan goal was for Resident 1 to remain safe, evaluate the risk of depression and manage undesirable behaviors (such as thoughts of self-harm). The Care Plan interventions included calmly listening to the resident's storytelling without judgement, asking directly if any chance to hurt himself, frequent visual checks, provide one-on-one sitter, engaging Resident 1 in conversation to distract him from thoughts of self-harm and ensure the safety of Resident 1 and others.During a review of Resident 1's medical records including Nursing Progress Notes for July 2025, admission Notes dated 7/7/2025, and Social Services assessment dated [DATE], the medical records did not indicate the facility staff assessed Resident 1 regarding thoughts of self-harm or harm to others when he was admitted back to the facility on 7/7/2025.During a review of Resident 1's Change of Condition form dated 7/8/2025, the Change of Condition form indicated Resident 1 told Registered Nurse Supervisor (RNS) 1 that he wanted to go to a psychiatric (things related to mental illness and its treatment) hospital for further evaluation. The Change of Condition form indicated Resident 1 stated he sprayed oven cleaner on his forearms (to cause pain). The Change of Condition form indicated Resident 1 showed RNS 1 both of his forearms that had scattered pinpoint redness. The Change of Condition form indicated the back of Resident 1's right hand had a brown patch measuring 8.0 by 9.0 centimeters ([cm], a unit of measurement) and the back of his left hand had scattered brown patches. The Change of Condition form indicated Resident 1 stated he needed to go to a psychiatric hospital that has therapy to stabilize him and to help him stop hurting himself. The Change of Condition form indicated 911 was called and Resident 1 was brought to GACH 2 for further evaluation and management due to the appearance of his forearms.During a review of Resident 1's Physician's Orders Summary Report, the Physician's Orders Summary Report indicated an order dated 7/8/2025to transfer the resident to GACH 2 due to threatening to hurt self, for evaluation and treatment.During a review of Resident 1's Skilled Nursing Facility (SNF) to GACH Transfer Form dated 7/8/2025, the SNF to GACH 2 Transfer Form indicated Resident 1 was transferred out to GACH at 7:12 p.m., with flat tan to brownish discoloration on the back of his right hand and left arm noted with flat tan-brownish scattered discoloration. The SNF to GACH 2 Transfer Form indicated Resident 1 had symptoms of agitation with risk to harm self or others.During a review of Resident 1's GACH 2 Records dated 7/8/2025 at 7:22 p.m., the GACH 2 Records indicated Resident 1 was admitted to GACH 2 with diagnoses including second-degree chemical burns to both forearms. The GACH 2 records indicated poison control (a specialized unit that advises on and assists in the prevention, diagnosis and management of poisoning) was called and Resident 1 received a surgical consultation for the burns on both forearms. The GACH 2 records indicated Resident 2 was in distress (emotional or psychological difficulty that is noticeable and impactful).During a review of Resident 1's GACH 2 records dated 7/9/2025 at 8:55 a.m., the GACH 2 records indicated Resident 1 had a pain level of 9 out of 10 on a pain rating scale (a tool used to help people describe and quantify their pain, allowing healthcare professionals to better understand and manage it, ranging from 0 [no pain] to 10 [worst pain imaginable]) due to the chemical burns on both of his arms.During a review of Resident 1's GACH 2 records dated 7/9/2025 at 11:17 a.m., the GACH 2 records indicated a physician's order for:-Hydrocodone-Acetaminophen (medication used for moderate to severe pain), with not specified dosage, one tablet every six hours for pain (severity of pain not specified).-Morphine Sulfate intravenous ([IV] into a vein]) medication used for severe pain) 2.0 milligram (mg-unit of measurement)/1.0 milliliter (mL-unit of measurement) intravenously (IV [into or within a vein]) every six hours.During a review of Resident 1's GACH 2 records dated 7/9/2025 at 9:05 p.m., the GACH 2 Records indicated Resident 1 had a surgical consultation.During a review of Surgical Consultation note, the Surgical Consultation note indicated both of Resident 1 arms were necrotic (tissue that is dead or dying) and the resident would need debridement and possible skin grafting to an area on the back of the left hand. The Surgical Consultation Note indicated Resident 1 would need a transfer to a higher level of care/burn center for treatment.During a review of Resident 1's GACH 3 Records, the GACH 3 Records indicated Resident 1 did have a history of a prior self-harm and was admitted to GACH 2 and then transferred to GACH 3 for management of both upper extremity (arm) burns. The GACH 3 records indicated Resident 1 was on one-on-one sitter for self-harm precautions and psychiatric evaluation.During a telephone interview on 7/11/2025 at 10:15 a.m., with RNS 1, RNS 1 stated Resident 1 was admitted back to the facility on 7/7/2025 around 12:40 p.m., with a diagnosis of ideations of harm to self or others. RNS 1 stated Resident 1 did not have a one-on-one sitter to keep him safe. RNS 1 stated Resident 1 should have had a one-on-one sitter to keep him safe from self-harm and should have had a psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) consultation regarding his ideations of self-harm when admitted back to the facility on 7/7/2025.During an interview on 7/11/2025 at 1:37 p.m., with the Administrator (ADM), the ADM stated the facility does not have a screening and assessment process for residents that are admitted to their facility with diagnoses of thoughts of self-harm. The ADM stated the facility did not screen Resident 1 for thoughts of self-harm, but the facility should have implemented a screening assessment for residents who had diagnoses of ideation of harm to self or others.During an interview on 7/11/2025 at 2:20 p.m., with the Director of Nursing (DON), the DON stated there was no screening assessment done for Resident 1 who was admitted to their facility after discharge from GACH 1 on 7/7/2025, with diagnoses of ideations of harm to self or others. The DON stated there was no specific screening assessment implemented for residents (general) with diagnoses of harm to self or others but there should have been a screening done for Resident 1 to screen for thoughts of harm to self or others.During a concurrent interview and record review on 7/11/2025 at 3:26 p.m., with the Director of Nursing (DON), the untitled Care Plan initiated on 7/8/2025 and Nurse Progress Note dated 7/7/2025 were reviewed. The DON stated Resident 1's care plan interventions such as one-on-one sitter were not implemented when Resident 1 was readmitted back to the facility on 7/7/2025. The DON stated Resident 1 was not with a one-to-one sitter because Resident 1 did not express he had any thoughts or feelings of harming self or others. The DON stated there was no documentation of any assessment or screening done upon admission. The DON stated Resident 1 was on visual and verbal hourly monitoring/rounding where staff would check on the resident every hour. The DON stated t Resident 1 would have benefitted from the one-on-one sitter because there would be continuous monitoring with eyes on the resident.During a telephone interview on 7/11/2025 at 4:01 p.m. with Resident 1, Resident 1 stated he had thoughts of self-harm when he was admitted back to the facility on 7/7/2025. Resident 1 stated the facility staff did not ask him if he had any thoughts of hurting himself when he was admitted back to the facility on 7/7/2025. Resident 1 stated he ordered the oven-cleaner online and had it delivered to him on 7/8/2025 at the facility. Resident 1 stated he did not tell anyone he wanted to hurt himself but wished the staff had asked him if he had thoughts of self-harm. Resident 1 stated he wished he received help from the facility staff about his thoughts of self-harm. During a telephone interview on 7/14/2025 at 10:27 a.m., with the RN that took care of Resident 1 at the GACH 3 burn center (RNGACH 3), RNGACH 3 stated Resident 1 was transferred to their facility on 7/10/2025. RNGACH 3 stated Resident 1 had a one-to-one sitter for self-harm precautions because Resident 1 had wounds from the self-harm he inflicted on himself from the facility he was at. RNGACH 3 stated Resident 1 needed treatment for second degree chemical burn injuries and surgery was planned for 7/15/2025. RNGACH 3 stated Resident 1 was scheduled for surgery for debridement on his bilateral (both) arms for the second-degree burns. During a concurrent interview and record review on 7/14/2025 at 1:25 p.m. with RNS 1, RNS 1 stated Resident 1 had a one-on-one sitter before he was transferred out on 6/24/2025 but he did not have a one-on-one sitter when he was readmitted back on 7/7/2025. Resident 1 was on hourly rounding where a CNA kept an eye on him every hour, to have visuals on him every hour but Resident 1 would have benefitted from one-on-one sitter to prevent him from harming himself. RNS 1 stated a one-on-one sitter would always keep eyes on the residents. During a review of the facility's policy and procedures (P&P), titled, Resident Safety, dated 4/14/2021, indicated, the purpose was to provide a safe and hazard free environment .residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident during the comprehensive assessment period, the interdisciplinary team ([IDT], a collaborative meeting where professionals from various healthcare disciplines come together to discuss and coordinate patient care) members will assess the resident's safety risk as well as any other resident specific safety risks .the IDT will establish a person centered observation or monitoring systems for residents to address the identified risk factors identified .the person centered care plan may require more frequent checks.During a review of the facility's P&P titled, Resident Initial admission Assessment, dated 3/23/2023, indicated upon admission to the facility, licensed nursing staff will complete an initial admission assessment to identify the resident's needs and develop plans of care . the assessment will be documented in the medical records.During a review of the facility's P&P titled Person-Centered Care Planning, dated 5/22/2025, indicated the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial wellbeing .comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation, interview and record review, the facility failed to ensure the resident, who was transferred by a mechanical lift (a device used to transfer residents from a bed to a chair or between surfaces), did not fall from the lift during transfer and sustained injuries for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 1) did not transfer Resident 1 by herself from a bed to a shower chair (a movable or permanently installed seat for the tub or shower) by using a mechanical lift (a device used to transfer residents from a bed to a chair or between surfaces). 2. Ensure CNA 1 did not use a mechanical lift sling (accessory attached to a mechanical lift [device used to transfer residents from one surface to another]) with worn out straps to transfer Resident 1 from bed to shower chair. 3. Ensure staff followed the mechanical lift Manufacturer ' s User Manual guide dated 2016 and 10/1/2018 which indicated after each laundering the sling must be inspected for wear, tears, and loose stitching. Slings that have been bleached, torn, cut, frayed, or broken are unsafe and could result in injury and should be discarded immediately. These failures resulted in Resident 1 falling from the mechanical lift to the floor and sustaining a bump (swelling) on the right parietal (located near the back and top of the head) area of the head, a right frontal (front) scalp hematoma (discoloration of skin, due to bleeding under the skin) and soft tissue swelling (inflammation and fluid buildup, that can potentially feel tender or painful) in her right elbow. Resident 1 was admitted to the General Acute Care Hospital (GACH) for three days for evaluation and treatment. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including morbid obesity (having too much body fat), dementia (a progressive state of decline in mental abilities) and chronic kidney disease (a long-term condition that occurs when the kidney are damaged and can ' t filter blood properly). During a review of Resident 1 ' s History and Physical (H&P) dated 5/10/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Sheet (MDS- a resident assessment tool), dated 8/30/2024, the MDS indicated Resident 1 had moderately impaired cognitive (thought process) skills for daily decision making and was dependent (helper does all of the effort to complete activities, the assistance of two or more helpers is required) on self-care abilities such as oral hygiene, toileting, shower/bathing, upper and lower body dressing and mobility such as rolling left and right, sitting to lying, lying to sitting and bed to chair transfers. During a review of Resident 1 ' s untitled Comprehensive Care Plan dated 10/5/2022, the Comprehensive Care plan indicated Resident 1 was able to transfer from bed to chair with extensive assistance, requiring two persons assistance. During a review of Resident 1 ' s untitled Comprehensive Care Plan dated 5/16/2023, the Comprehensive Care Plan Indicated Resident 1 was dependent on staff and needed physical assistance with mobility (ability to move freely) and with completion of physical activities such as eating, bathing, and transfers. The Care Plan indicated to use a mechanical lift as indicated for transfer. During a review of the Nurses Progress Notes, dated 10/15/2024, and timed at 10:55 a.m., the Nurses Progress Notes indicated Resident 1 had a fall in her room on 10/15/2024. The Nurses Progress notes indicated Resident 1 had a pain level of 6 on a pain scale (a tool for pain rating as follows: 1-4 mild pain, 5-7 moderate pain, 8-10 severe pain) to the occipital (back of the head) area. The Nurses Progress Notes indicated Resident 1 was being transferred from bed to shower chair, and as she was being lowered with the mechanical lift at about two feet from the ground, the resident moved, the sling hook broke, and Resident 1 fell to the floor. During a review of Resident 1 ' s Change of Condition (COC), dated 10/15/2024 and timed at 10:40 a.m., the COC indicated Resident 1 had a fall in the resident ' s room on 10/15/2024. The COC indicated Resident 1 was complaining of a pain level of 6 out of 10 (pain scale 0-no pain - 10 excruciating pain) at the back of her head. During a record review of Resident 1 ' s Order Summary Report (Physician ' s orders) dated 10/15/2024, the Order Summary Report indicated a physician ' s order dated 10/15/2024 to transfer Resident 1 to the GACH via 911 (by emergency transportation services) due to a fall. During a record review of Resident 1 ' s GACH H&P Note dated 10/15/2024 and timed at 3:54 p.m., the GACH H&P Notes indicated Resident 1 was admitted for further management due to a mechanical fall with imaging results indicating a mild subarachnoid (brain tissue) hemorrhage and a right frontal scalp hematoma. During a review of Resident 1 ' s Nurses Progress Notes dated 10/18/2024 and timed at 3:03 p.m., the Nurses Progress Notes indicated Resident 1 was admitted back to the facility. The Nurses Progress Notes indicated that Resident 1 stated her right arm and the right side of her face were tender. The Nurses Progress Notes indicated Resident 1 had discoloration on the right shoulder, right upper arm, right elbow, and a bump with discoloration on the right parietal area of the head. Resident 1 complained of a headache pain level rated 3 out of 10. During a review of Resident 1 ' s Investigation Conclusion Letter, dated 10/19/2024, the Facility Investigation Conclusion Letter indicated CNA 1 was backing up the mechanical lift, with Resident 1 on it, from the bed to place Resident 1 on the shower chair, the upper right side of the sling ripped, and the resident fell on the floor. During a telephone interview on 11/25/2024 at 4:06 p.m., CNA 1 stated on 10/5/2024 she was transferring Resident 1 from the bed to the shower chair by herself with the mechanical lift but halfway to the shower chair, the right upper side of the sling hook latch ripped, and Resident 1 fell to the floor. CNA 1 stated the sling had a blue with green rim and was the correct color sling for the resident ' s body size according to what she was told during in-service education she received. CNA 1 stated she did not check the sling for damage such as wear and tear, or threadbare areas of the sling, because the laundry staff checked the slings for damage before they made them available for use to transfer residents. During a concurrent observation and interview on 11/26/2024 at 9:58 a.m., with Resident 1, in her room, Resident 1 stated on the day of the fall, CNA 1 put her on the mechanical lift and did the transfer by herself. Resident 1 stated she fell from the mechanical lift during the transfer and hit her head and arm. Resident 1 pointed to the right side of her head near her forehead where there was a bump. Resident 1 stated her head still hurts sometimes and that her right arm has been hurting after the fall. Resident 1 stated she used to eat independently but now it is harder because of the pain in her right arm. Resident 1 stated she was unable to elevate her right arm up since the fall. During an interview on 11/26/2024 at 11:43 a.m., CNA 2 stated he was the CNA that was helping CNA 1 with transferring residents from bed to shower chair using the mechanical lift on that day. CNA 2 stated he was helping CNA 3 transfer Resident 2 from bed to shower chair with the mechanical lift while CNA 1 was getting ready with the supplies needed to transfer Resident 1 from bed to a shower chair. CNA 2 stated he went back to Resident 1 ' s room and saw Resident 1 lying on the floor next to the bed. CNA 2 stated Resident 1 verbalized that her head and right shoulder were hurting. CNA 2 stated when using the mechanical lift to transfer residents, there should be two persons assisting with the mechanical lift. CNA 2 stated the old slings were defective and the facility ordered new slings. The old slings were worn out and ripped. During an interview on 11/26/2024 at 1:00 p.m., with the House Keeping Supervisor (HKS) stated that he has worked in the facility for over [AGE] years, and this was the first time they have replaced the slings in the facility. During an interview on 11/26/2024 at 1:16 p.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 required a total care (residents who need help with all their daily activities such as bathing, toileting, eating). LVN 1 stated there could be severe injury when Resident 1 fell from the sling and hit her head on 10/15/2024. LVN 1 stated the situation could have been prevented if the transfer with a mechanical lift was done with two persons assistance and the sling was inspected prior to using it to transfer Resident 1. During an interview on 11/26/2024 at 1:40 p.m., Registered Nurse Supervisor (RNS 1) stated Resident 1 was totally dependent on staff for shower and bathing. RNS 1 stated on the day of the fall (10/15/2024), she found Resident 1 on the floor and Resident 1 told her the back of her head was hurting. RNS 1 stated Resident 1 complained that her pain level was a 7 or 8 out of 10 on the pain scale. RNS 1 stated the incident could have been prevented if staff had inspected the sling to make sure it was in good condition. RNS 1 stated before CNA 1 transferred Resident 1, CNA 1should have been made sure there was another staff member to assist her transfer Resident 1 with the mechanical lift. RNS 1 stated that if CNA 1 had called for some help, it might have helped to prevent the fall. During an interview on 11/26/2024 at 2:05 p.m., the Director of Staff Development (DSD) stated staff were in-serviced (trained) on the use of a mechanical lift to use two or three persons transfer assistance. The DSD stated the slings were based on height and weight of the residents and staff were to use the slings associated with the residents ' height and weight. The DSD stated the correct size sling for Resident 1 was a large, which was the sling with the green and blue rim. The DSD stated the slings should be checked prior to using it to transfer the resident to make sure it was in good working condition. The DSD stated new slings were ordered after the incident that happened with Resident 1. The sling used to transfer Resident 1 was worn out and ripped indicating it was old, and the color was faded from multiple washes. The DSD stated the Administrator (ADM) and Central Supply staff ordered new slings after this fall incident. During an interview on 11/26/2024 at 4:03 p.m., the Director of Nursing (DON) stated on 10/15/2024, Resident 1 fell on the floor from the mechanical lift during transfer. The DON stated Resident 1 was transferred to the GACH because the resident fell with a head injury and the resident complained of pain to the back of her head. The DON stated the incident could have been avoidable if CNA 1 waited for another CNA to help her with Resident 1 ' s transfer via mechanical lift. The DON stated any transfer with the mechanical lifts must be done by two to three persons assistance. The DON stated the sling ripped on the hook that was attached to the black strap that was attached to the sling. The DON stated CNA 1 should have checked the sling before using it to transfer Resident 1. The DON stated all slings used to transfer residents with the mechanical lift were replaced on 10/22/2024 after Resident 1 ' s fall. The DON stated that slings were replaced if there were noted wear and tear, and the nursing staff should have checked to make sure all slings were intact. During an observation and interview on 11/27/2024 at 9:15 a.m., with the Occupational Therapist (OT) in Resident 1 ' s room, Resident 1 ' s OT treatment session was observed. The OT stated Resident 1 was dependent on staff for activities of daily living but was able to eat on her own. The OT stated Resident 1 did have pain with movement in her right arm. Resident 1 stated she was in pain in her head and right arm , and the OT told Resident 1 it was expected for someone who fell . During a record review of the facility's policy and procedure (P/P), titled Total Mechanical Lift, revised 4/27/23, indicated mechanical lifts are devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by nursing staff alone .nursing staff will receive training on how to use the mechanical lift .at least two people are present while resident is being transferred with the mechanical lift. During a record review of the mechanical lift Manufacturer ' s User Manual dated 10/1/2018, the Manufacturer User Manual guide indicated recommends included that two assistants be used for all lifting preparation, transferring from, and transferring to procedures. After each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears, and loose stitching. Slings that have been bleached, torn, cut, frayed, or broken are unsafe and could result in injury and should be discard immediately. During a record review of the mechanical lift Manufacturer ' s User Manual dated 2016, the Manufacturer User Manual instructions indicated to not lift a resident unless you are trained and competent to do so, plan your lifting operations before commencing, familiarize yourself with the operating control and safety features of a lift before lifting a patient, do not use a sling unless it is recommended for use with the lift, check the sling is suitable for the particular patient and is of the correct size and capacity and, never use a sling, which is frayed or damaged.

Based on interview and record review, the facility failed to ensure the resident, who had diagnosis of depression (mental health disorder characterized by persistently low mood or loss of interest in activities, causing significant impairment in daily life ) and a history of suicidal ideation (thinking about or formulating plans for suicide [the act or an instance of ending one's own life voluntarily and intentionally) did not commit suicide for one of three sampled residents out of 38 residents with a diagnosis of depression (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN 1) initiated continuous Resident 1's assessment and closed monitoring of Resident 1's change in behavior, mood, cognition (ability to think, understand, learn, and remember), presence of hallucinations (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real), and delusions (believing things that are not true), and suicidal ideation, when Certified Nursing Assistant (CNA 1) reported to LVN 1 that Resident 1 was observed sobbing (crying spells) and accusing CNA 1 of putting poison in his water pitcher on [DATE] @ 12:15 a.m. 2. Ensure a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status) assessment was completed when Resident 1 was having crying spells, shaking hands, anxious (uneasy or worried), and verbalizing being scared and that someone was trying to kill him. 3. Ensure staff followed Resident 1's care plan titled Resident uses antidepressant (Lexapro- medication for depression) related to depression initiated on [DATE], indicated interventions to monitor, document, and report as necessary changes in Resident 1's behavior, mood, cognition, hallucinations, delusions, and suicidal thoughts, withdrawal (removes themselves from interactions with others), and notify the physician of COC. 4. Ensure Resident 1 primary care physician was notified when Resident 1 experienced a COC, when Resident 1 was observed sobbing (crying) and accusing CNA 1 of putting poison in his water pitcher on [DATE] at 12:15 a.m. 5. Ensure Social Services Director (SSD) reviewed and assessed Resident 1's history of wanting to die on [DATE] as documented in Resident 1's medical record from Resident 1's previous admissions to the facility. 6. Ensure SSD assessed Resident 1 upon admission and gather information to complete Resident 1's Patient Health Questionnaire ([PHQ 9- a validated interview that screens for symptoms of depression) on the 7th day after admission 7. Ensure nursing staff followed the facility's policy and procedure (P&P) titled, Resident Safety, which indicated the residents will be evaluated whenever there is a change in condition, to identify circumstances that pose a risk for the safety and wellbeing of the resident. As a result of these failures, Resident 1 was found hanging in the bathroom with a phone charging cord around his neck, on [DATE] at 4:40 a.m. The resident was lowered to the floor, cardiopulmonary resuscitation ([CPR]-an emergency procedure that can save a person life if their breathing or heart stops) was initiated and 911 (emergency services) was called. The Emergency Medical Services ([EMS]- medical professionals providing emergency medical care) arrived at the facility and pronounced Resident 1 dead on [DATE] at approximately 5:25 a.m. On [DATE] at 6:16 p.m., the Immediate Jeopardy ([IJ] a situation in which the facility'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) was called in the presence of Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to assess, monitor and inform Resident 1's primary physician when Resident 1 exhibited changes in behavior. On [DATE] at 6:55 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP implementation through observation, interview, and record review, the IJ was removed on [DATE] at 7:07 p.m., in the presence of the ADM and the DON. The IJRP included the following immediate actions: 1.On [DATE]-[DATE], the DON provided a 1:1 (individualized instruction) education to LVN 1, CNA 1, Registered Nurse Supervisor (RNS), LVNs and CNAs that worked on [DATE] on 11 p.m. to 7 p.m. shift regarding COC process, with emphasis on the following: a. Assessment and close monitoring of residents with change in behavior, mood, cognition, hallucinations, delusions, and suicidal thoughts, disruptive vocalizations (verbal noises [screaming, yelling, nonsense talking, cursing] which are generally considered unusual, inappropriate or are upsetting to others, and difficulty sleeping. b. Ensuring a COC assessment was completed for residents having a change in behavior; paranoid behavior (distrust and suspicion of others), verbalization of hurting self, hallucinations, delusions, that is disruptive vocalizations, yelling, difficulty sleeping. c. Monitoring, documenting, and reporting as necessary any change in resident's behavior, mood, cognition, hallucinations, delusions, and suicidal thoughts, and notifying the physician of the COC. d. Non-Pharmacological Interventions ( healthcare interventions that do not primarily rely on medication) to care for residents with depression; include removing stressors, offering food and beverages, increasing therapeutic activities of choice/routine, psychosocial (mind and emotions) support, encouraging family involvement, other non-pharmacological interventions to include but not limited to physical comfort (food, activities of daily living (ADL) assistance), environmental (offer soothing activities such as, TV, reading book, music, getting fresh air, offer a walk). Continuously monitoring the resident's mood and adjusting interventions as necessary to ensure the environment is maintained safe. e. Informing physician and responsible party when resident had COC in behavior, mood, delusions, hallucinations, and suicidal thoughts, and recognition of residents who were depressed and have a history of suicidal ideation. f. Behavior management. g. Suicide prevention. 2. On [DATE], the Administrator provided a 1:1 in - service education to SSD regarding completion of Assessments, including PHQ-9 following the Resident Assessment Instrument (RAI-standardized assessment tool) Manual guidelines. 3. On [DATE], the DON/designee conducted an audit of current residents with diagnosis of serious mental illness such as schizophrenia (a serious mental disorder in which people interpret reality abnormally), major depression, bipolar disorders (a mental health condition that causes extreme mood swings that include emotional highs [mania] and lows[depression] that make it difficult to carry out day-to-day tasks and activities), mood disorders, psychotic disorders (severe mental illnesses that cause people to lose touch with reality and have an abnormal thinking) and other psychiatric (mental) diagnoses to determine residents who have had a change in behavior, mood, cognition, hallucinations, delusions, within the last 30 days, and current or history of suicidal ideations or suicide attempt, to ensure that: a. Residents are assessed and closely monitored for changes in mood (that is disruptive vocalizations, yelling, difficulty sleeping, mood, cognition, hallucinations, delusions, and suicidal thoughts). b. A COC is completed as indicated for changes in behavior such as disruptive vocalizations, yelling, difficulty sleeping, mood, cognition, hallucinations, delusions, and suicidal thoughts, i.e. disruptive vocalizations, yelling, difficulty sleeping. c. Care plan initiated, and interventions are implemented to be followed. d. Primary Care Physician is notified of COC, and e. SSD Assessments are completed within 7 days of the resident's admission,quarterly/annually, and based on significant change of condition. PHQ-9 Assessment is completed per assessment reference date schedule following admission, quarterly, and for significant change of condition assessments. 4. On [DATE], SSD conducted an audit of current residents with diagnosis of serious mental illness such as schizophrenia, major depression, bipolar disorders, mood disorders, psychotic disorders, and other psychiatric diagnoses. Out of 99 residents there were 38 residents identified to have a diagnosis of depression. One resident was identified to have exhibited a change in mood and was assessed by licensed nurse, COC was competed, and the attending physician was notified. A PHQ-9 Assessment of other 37 identified residents with diagnosis of depression were completed by the SSD on [DATE] through [DATE]. 5. On [DATE], the DON/Designees conducted interviews of current interviewable residents to identify any potential changes in behavior or mood. 6.On [DATE], the DON/Designee provided an in-service education to the staff on Behavior Management/Suicide Management. 7. On [DATE], the DON/Designee initiated an in - service education to the Department heads which consist of Director of Staff Development, Case Manager, Activity Director, Director of Rehab, Infection Preventionist, Dietary Manager, Minimum Data Set Coordinators (MDSC), Maintenance Supervisor, Housekeeping Supervisor, Social Services Director, Social Service Aide, Social Services Assistant, Medical Records Director, Business Office Manager, Business Office Assistant, and Admission Coordinator, licensed nurses and CNAs regarding the policies and procedures for: Behavior/Psychoactive (affective the mind or behavior) Medication Management, Change of Condition Notification, Behavior - Threats to Harm Self, and Comprehensive Care Planning. 8. On [DATE], the Regional Social Service Consultant provided an in-service education to the Social Service Designee on the Policy and Procedure titled Social Service Assessment and Policy and Procedure titled Social Service Program, emphasizing the importance of completing required Social Service Assessments, including the PHQ-9 within the required timeframe, per regulatory guidelines. 9. The ADM and the DON will present the results of the Admission/Readmission, and Change in Condition Audits, and Resident Interviews to the Quality Assurance and Performance Improvement Committee for monthly review and recommendations for three months or until substantial compliance is achieved. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE]. On [DATE] Resident 1 was discharged home and readmitted back to the facility on [DATE] with diagnoses including depression, cerebral infarction (damage to the brain from interruption of its blood supply) with right sided hemiplegia (paralysis of one side of the body and right hemiparesis( weakness of one side of the body), and failure to thrive (a syndrome that describes a decline in an older adult's health that can include weight loss, poor nutrition, and inactivity). During a review of Resident 1's History & Physical (H&P) dated [DATE], the H& P indicated Resident 1 had the capacity to understand and make decisions. During a review of Minimum Data Set ([MDS] a standardized assessment and care screening stool) dated [DATE], the MDS indicated Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment for daily decision making and required supervision or touching assistance (helper provides verbal cues) with bed mobility, transfer from chair/bed-to-chair transfer (ability to transfer to and from a bed to chair or wheelchair), walking 10 feet (ability to walk at least 10 feet in a room, corridor or similar space once standing) and personal hygiene. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had an active diagnosis of depression and was taking anti-depressant (prescription medications that can help treat depression and other mental health conditions) medication. During a review of Resident 1's baseline care plan (a document that provides instructions for a resident's care in a nursing home), dated [DATE], the baseline care plan indicated, under Social Services, Resident 1 was being monitored for depression, and SSD to complete PHQ-9 assessment. During a review of Resident 1's Informed Consent (the process in which a healthcare provider educated a patient about the risks, benefits, and alternatives of a given procedure, treatment, or intervention), dated [DATE], the Informed Consent indicated Resident 1 was prescribed Lexapro (medication used to treat depression) for depression and persistent verbalization of sadness. During a review of Resident 1's Care Plan titled Resident 1 uses antidepressant medication Lexapro related to depression initiated on [DATE], the Care Plan indicated a goal for Resident 1 was to decrease resident's episodes of signs and symptoms of depression. The Care Plan's interventions included to administer antidepressant medications as ordered by the physician, monitoring, documenting, reporting as needed change in behavior/mood/cognition (mental process involved in knowing, learning, and understanding things), hallucinations (false perception of reality), delusions, social isolation (no relationships with other), suicidal thoughts, and withdrawal. During a review of Resident 1's initial Psychiatric Evaluation (a comprehensive examination of a person's mental, emotional, and behavioral health), dated [DATE], the initial Psychiatric Evaluation indicated Resident 1 was oriented to person, place, and time. The initial Psychiatric Evaluation, under the treatment plan, indicated to observe the resident for deterioration in function, resident was educated to report worsening of symptoms and to report if noted with changes in mood and behavior. Gradual dose reduction ([GDR] a step in tapering a dose of a medication) for Lexapro was contraindicated at this time as it may exacerbate (to make something worse) resident symptoms (not specified). During a review of Resident 1's Nurses Progress Notes, dated [DATE], the Nurses Progress Notes indicated Resident 1 was on monitoring due to hallucination episode. The Nurses Progress Notes indicated Resident 1 could not sleep because he was experiencing strange things in the room during the night such as pages of a book in his closet flipping by themselves. During a review of Resident 1's PHQ-,d+[DATE] questionnaire, dated [DATE], the PHQ ,d+[DATE] indicated a score of 10 (a score of ,d+[DATE] is moderate depression). During a review of Resident 1's Nurses Progress Notes, dated [DATE], the Nurses Progress Notes indicated a Social Worker met with Resident 1 for verbalization of wanting to die and Lexapro was increased to 20 milligrams ([mg]-unit of measurement). During a review of Resident 1's Nurses Progress Notes, dated [DATE], the Nurses Progress Notes indicated Resident 1 was being monitored for episodes of verbalization of wanting to die. During a review of Resident 1's Nurses Progress Notes, dated [DATE], the Nurses Progress Notes indicated Resident 1 was being monitored for panic attacks (a sudden episode of intense fear or discomfort that can cause physical and mental symptoms) and tachycardia (a heart rate that is faster than 100 beats per minute). During a review of Resident 1's Nurses Progress Notes dated [DATE] timed at 12:51 a.m., the Nurses Progress Notes indicated on [DATE] at around 12:15 a.m., CNA 1 called Resident 1's assigned charge nurse (LVN 1) to resident's room. The Nurses Progress Notes indicated LVN 1 entered Resident 1's room and found Resident 1 sitting on the side of his bed appeared worried and stated someone was trying to poison him pointing to his water pitcher/cup. The Nurses Progress Notes indicated Resident 1's blood pressure ([BP] force of blood pushing against artery [blood vessel] walls when the heart pumps blood throughout the body) was ,d+[DATE] millimeters of mercury (mm/Hg unit of measurement [reference range for normal blood pressure is less than ,d+[DATE]], the resident had a headache rated four out of 10 on a pain scale (tool to measure pain intensity by asking patient to rate their pain on a scale of 0 to 10, where zero is no pain and 10 is the worse pain possible ). The Nurses Progress Notes indicated at 12:18 a.m., Resident 1 received Tylenol (medicine used to relieve pain) and at 12:38 a.m. Resident 1 received Clonidine (medicine used to lower blood pressure) for high BP. The Nurses Progress Notes indicated on [DATE], at around 4:40 a.m., CNA 3 entered the Resident 1's bathroom and found Resident 1 kneeling on the floor facing the wall with a red cord around his neck, and the cord was tied around the handrail. The Nurses Progress Notes indicated Resident 1 was unresponsive, not breathing and the staff was unable to obtain a blood pressure reading. The Nurses Progress Notes indicated Resident 1's pulse rate was 186 beats per minute (reference range for adult pulse is 60 to 90 beats per minute). The Nurses Progress Notes indicated a facility staff (unknown) called 911 (emergency services) and initiated CPR. At 5:01 a.m., paramedics (Emergency Medical Services) arrived and continued CPR. Resident 1 was pronounced dead at around 5:25 a.m. During an interview on [DATE] at 2:50 p.m., with Resident 1's roommate (Resident 2), Resident 2 stated on the night of [DATE], he could not sleep well as Resident 1 was not sleeping and crying a lot. Resident 2 stated a staff member (unknown) came into the room to calm Resident 1 down on [DATE] at 3:00 a.m., and after staff member left Resident 1 began crying again. Resident 2 stated around 4 am. he heard Resident 1 struggling to walk to the bathroom, as he was holding onto the walls while walking. Resident 2 stated after that he went back to sleep and did not hear anything until someone told him the next day what happened to Resident 1 (committed suicide). During an interview on [DATE], at 6:25 a.m., CNA 1 stated on [DATE] at 12:00 a.m., Resident 1 was restless standing next to his (Resident 1) bed crying. CNA 1 stated she informed LVN 1 that Resident 1 was restless and crying. CNA 1 stated Resident 1 continues to cry when he was assisted back to bed. CNA 1 stated it was important to report to the charge nurse any changes in a resident's behavior so the charge nurse can check on the resident and assess the behavior. CNA 1 stated she returned to check on Resident 1 at 1:00 a.m. and observed Resident 1 was awake lying in bed. CNA 1 stated at 4 a.m., she saw Resident 1 standing up next to his bed talking with CNA 3 and LVN 1. CNA 1 stated when Resident 1 saw her he pointed at her and stated, that was her, she was trying to kill me, you poisoned the water, while pointing to his water pitcher. During an interview on [DATE], at 6:45 a.m., LVN 1 stated CNA 3 informed her that Resident 1 appeared worried and concerned and was telling CNA 3 someone was trying to poison him. LVN 1 stated she went to assess him, and Resident 1 was alert and oriented and did not appear to be confused. LVN 1 stated Resident 1 calmed down after she explained to him that the CNAs were delivering the new water pitchers and offered to get him a new CNA but Resident 1 declined. LVN 1 stated she felt there was a misunderstanding between her (LVN 1) and Resident 1 and not a change of condition, and that was the reason she did not call Resident 1's doctor to inform of the resident's behavior. During an interview on [DATE], at 7 a.m., with CNA 3 stated when she was passing out water pitchers at approximately 12:00 a.m. on [DATE], Resident 1 verbalized to CNA 3 that another CNA (unknown) was trying to poison him. CNA 3 stated Resident 1 appeared nervous, scared, his hands were shaking, and verbalized repeatedly that a lady was trying to poison him. CNA 3 stated she stayed with Resident 1 to listen to his concerns and then reported his behavior to LVN 1. During a concurrent interview and record review on [DATE], at 7:25 a.m., with LVN 1, Resident 1's medication administration record (MAR) was reviewed. LVN 3 stated she gave Resident 1 Tylenol for his headache at 12:18 a.m., and Clonidine at 12:30 a.m. LVN 1 stated it was difficult to obtain Resident 1's blood pressure because he was moving a lot and was pointing at his water pitcher. LVN 1 stated Resident 1 had depression and high blood pressure, and when Resident 1 was stating someone was trying to poison him it could have been related to his depression. LVN 1 stated Resident 1 was taking Lexapro for his depression for targeted behaviors of persistent verbalization of sadness. LVN 1 stated when she saw Resident 1, he appeared anxious, worried, and had a lot of concerns (not specified). LVN 1 stated she should have done a COC when Resident 1 had changes in his behavior so they could have better monitored him. LVN 1 stated she failed to inform Resident 1's physician when Resident 1 had changes in his behavior. LVN 1 stated they (facility staff) did not do any monitoring but visually checked on him more frequently but did not document it was done. LVN 1 stated Resident 1 was exhibiting delusions when he continued to think that someone was trying to poison him. LVN 1 stated Resident 1 suicide could have been prevented if she would have stayed with Resident 1, called his doctor, and placed the resident on 1:1 (a type of care where a patient is constantly observed by a healthcare professional to ensure patient safety) observation/monitoring but because he calmed down, she did not think she needed to do so. During a phone interview on [DATE], at 10:05 a.m., LVN 3 stated on [DATE] approximately 4:40 a.m., she was called by CNA 3 to Resident 1's room and found Resident 1 in the bathroom of his room, on his knees, facing the wall on the right side of the toilet, with a cord around his neck. LVN 3 stated she used scissors to cut the cord around Resident 1's neck. LVN 3 stated Resident 1 was still warm to touch and thought he had a faint carotid (neck) pulse. LVN 3 stated Resident 1 was not breathing so she initiated CPR with CNA 5. During an interview on [DATE], at 11:05 a.m., the Social Services Director (SSD) stated Resident 1 was admitted on [DATE] and she only saw him once on [DATE]. The SSD stated she did not complete Resident 1's required screenings (Brief Interview for Mental Status [BIMS], PHQ9, depression screening, social determinants of health, social service assessments, because she had seven days to complete from the time of Resident 1's admission on [DATE]. During a phone interview on [DATE], at 11:45 a.m., the Psychiatric Nurse Practitioner ([PNP] a registered nurse with advanced training who provides mental health care to residents), stated Resident 1's doctor should have been notified immediately of Resident 1's new behavior when he was observed crying and stating someone was trying to poison him. The PNP stated possible interventions to prevent the resident's suicide would have been closed monitoring of the resident for behavioral symptoms. The PNP stated Resident 1's behavior could have been a delusion when he verbalized somebody was putting poison in his water, a symptom of mental illness, or a symptom of another medical illness. During an interview on [DATE], at 12:24 p.m., Registered Nurse Supervisor (RNS 2) stated when CNA 1 informed her that Resident 1 verbalized someone was trying to poison him, she thought it was because Resident 1 was confused. RNS 2 stated she failed to do a COC as she thought Resident 1's delusion was because he was confused. RNS 2 stated she was not aware of Resident 1's behavior of crying spells, having hands tremor (shaking), feeling scared, and being anxious. RNS 2 stated she was not told by LVN 1 about Resident 1's change in behavior and if she would have known, she would have placed Resident 1 on 1:1 monitoring to keep him safe, call Resident 1's primary physician, complete a COC, and transfer Resident 1 to a higher level of care. During an interview on [DATE], at 10:10 a.m., the Minimum Data Set Coordinator (MDSC) stated the SSD was responsible for completing Section D (Mood) of the MDS and should be continuously assessing residents (through observation, interview, and record review) during the Assessment Reference Date ([ARD] marks the end of a seven-day period during which a resident is observed and assessed) from admission. The MDSC stated the SSD should have started Resident 1's assessments upon admission and to have an ongoing resident's assessments during the seven days following admission and not just one visit with the resident. The MDSC stated psychosocial assessments (an evaluation of a resident's mental health, and social well-being) was a part of the residents needs so it was important to conduct the assessments continuously from the time of admission. During an interview on [DATE], at 11:05 a.m., SSD stated knowing a resident's (in general) past medical history was important so you can develop a person-centered care plan. The SSD stated she does not review previous notes for those that were previously admitted to the facility because she prefers to do her own assessment of the resident. The SSD stated she was made aware by staff that Resident 1 was admitted to the facility in the past but did not review his previous records. The SSD stated she did not complete the PHQ9 or BIMS for Resident 1 because she was busy and did not have time to complete her assessment after seeing him on [DATE]. The SSD stated her progress notes and Resident 1's assessment that she completed on [DATE] was based on one-time interaction with the resident (on [DATE]). The SSD stated she started to write a note for Resident 1 assessment on [DATE] but did not submit it until [DATE] because she wanted to include her conversation with Resident 1's son. The SSD stated, she should have reviewed Resident 1's progress notes from previous admission to the facility. The SSD stated moving forward she will incorporate review of records in her assessment. The SSD stated, if she would have reviewed Resident 1's previous SSD notes from previous admission, she would have completed her assessments right away when he was admitted , would initiate plans for monitoring and assessing, and would push for the psychologist (mental health professional who help resident cope with mental health conditions) to see him. During an interview on [DATE], at 12:00 p.m., RNS 3 stated if he had observed Resident 1 crying and stating someone was poisoning his water, he would have done a COC and let the resident's primary care physician know. RNS 3 stated this behavior could have been due to infection or depression. RNS 3 stated a COC was an important monitoring and communication tool to let other staff members aware of what was going on with a resident. RNS 3 stated if he had been Resident 1's nurse, he would have provided 1:1 monitoring for the resident's safety, called the resident's doctor, and completed a COC because the resident's behavior was not his usual/normal behavior for him. During a concurrent interview and record review on [DATE], at 12:30 p.m., the DON stated it was important to review the residents (in general) past medical history and past admissions records from the facility prior to seeing the residents upon their admission. The DON stated LVN 1 should have done a COC, notified resident 1's doctor, and maybe transferred Resident 1 to a higher level of care when he was exhibiting behavior manifested by crying spells, shaking his hands, feeling scared anxious, and verbalized that someone was trying to kill him. The DON stated there was no COC completed for Resident 1, but one should have been done because Resident 1 was not at his baseline and his behavior indicated there was a medical problem occurring. The DON stated the COC was a tool to inform the nurses for what to assess, monitor and plan Resident 1's care. The DON stated LVN 1 should have assessed and monitored Resident 1 after he exhibited change in behavior because one time look at the resident does not provide enough information. The DON stated LVN 1 should have read previous admission notes and evaluated more in depth as to why Resident 1 was taking Lexapro. The DON reviewed Resident 1 care plan for Lexapro dated [DATE] and stated one of the interventions was to monitor the resident for changes in behavior, mood, and other adverse reactions to the medication, and Resident 1's change in behavior should have been reported to the doctor but was not done. During an interview on [DATE], at 9:55 a.m., the SSD stated when she assessed Resident 1 on [DATE], Resident 1 was not very talkative, giving brief one-word responses. The SSD stated if she had engaged in more conversation with Resident 1, he might have opened up more and she would have learned more about him. The SSD stated a single interaction was insufficient for her to conduct a thorough behavioral assessment. During a concurrent interview and record review on [DATE], at 10:43 a.m., LVN 5 stated the importance of the care plan was to serve as a guideline for caring for Resident 1 and monitoring his progress towards meeting the objectives of the care plan. LVN 5 stated Resident 1 had a personalized care plan reflecting the resident's treatment of his depression with Lexapro. LVN 5 stated staff should adhere with the interventions and to report any changes in the resident's behavior. LVN 5 stated should any changes in the resident's behavior occur including hallucination or delusion, or mood changes like increased crying or expressing fears of being harmed, these signs must be documented and reported to Resident 1's doctor, completed a COC assessment, provide closed monitoring, and transferred to higher level of care. During a review of the facility's Assessment Tool, updated [DATE], the Assessment Tool indicated The purpose of the facility assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain the highest practicable physical, mental, and psychosocial well-being. Services we offer and care we are able to provide is based on the needs of the resident include mental health and behavior: manage the medical conditions and medication, related issues, causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues, such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post-traumatic stress disorder (PTSD- a mental and behavioral disorder that can develop after experiencing a traumatic event), other psychiatric (mental) diagnosis, intellectual and developmental disabilities. During a review of the facility's Charge Nurse Job Description, undated, the Charge Nurse Job Description indicated, Qualifications: Ability to provide patient care in accordance with applicable standards, policies, and procedures; Possess critical thinking skills to analyze, synthesize, and evaluate clinical data and observations in developing a nursing plan of care; Comprehensive knowledge of applicable nursing principles, practices, and standards of care. Duties: Makes daily rounds to interview physical and emotional status and to implement any requires nursing interventions. During a review of the facility's RN Supervisor Job Description, undated, the RN Supervisor Job Description indicated, Duties: Assure that residents have a clean, safe, orderly, and comfortable environment; Ensure that notification is given to the resident's attending physician, as well as the resident's representative, when the resident has a significant change in condition. [NAME][TRUNCATED]

Based on interview and record review, the facility failed to ensure the licensed nurses notified the physician when a resident with diagnosis of depression (mental health disorder characterized by persistently low mood or loss of interest in activities, causing significant impairment in daily life ) experienced a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive behavioral, or functional status) manifested by sobbing (crying spells) and verbalization that someone wants to kill him by putting poison in his water pitcher for one of three sampled residents (Resident 1). This failure resulted in Resident 1 committing suicide (the act or an instance of ending one's own life voluntarily and intentionally). On [DATE] at 4:40 a.m. Resident 1 was found hanging in the bathroom with a phone charging cord around his neck. The resident was lowered to the floor, cardiopulmonary resuscitation ([CPR]-an emergency procedure that can save a person life if their breathing or heart stops) was initiated and 911 (emergency services) was called. The Emergency Medical Services ([EMS]- medical professionals providing emergency medical care) arrived at the facility and Resident 1 was pronounced dead on [DATE] at approximately 5:25 a.m. Findings During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE]. On [DATE] Resident 1 was discharged home and readmitted back to the facility on [DATE] with diagnoses including depression, cerebral infarction (damage to the brain from interruption of its blood supply) with right sided hemiplegia (paralysis of one side of the body and right hemiparesis( weakness of one side of the body) , and failure to thrive (a syndrome that describes a decline in an older adult's health that can include weight loss, poor nutrition, and inactivity). During a review of Resident 1's History & Physical (H&P) dated [DATE], the H& P indicated Resident 1 had the capacity to understand and make decisions. During a review of Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated [DATE], the MDS indicated Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment for daily decision making and required supervision or touching assistance with bed mobility, transfer from chair/bed-to-chair transfer (ability to transfer to and from a bed to chair or wheelchair), walking 10 feet ( ability to walk at least 10 feet in a room, corridor or similar space once standing) and personal hygiene. During a review of Resident 1's Care Plan titled Resident 1 uses antidepressant medication Lexapro (medication used to treat depression and anxiety) related to depression initiated on [DATE], the Care Plan indicated a goal for Resident 1 was to decrease resident's episodes of signs and symptoms of depression. The Care Plan's interventions included to administering antidepressant medications as ordered by the physician, monitoring, documenting, reporting as needed change in behavior/mood/cognition (mental process involved in knowing, learning, and understanding things), hallucinations (false perception of reality), delusions (having false or unrealistic beliefs), social isolation, suicidal thoughts, and withdrawal (removes themselves from interactions with others). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had an active diagnosis of depression and was taking anti-depressant (prescription medications that can help treat depression and other mental health conditions) medication. During an interview on [DATE], at 6:25 a.m., CNA 1 stated on [DATE] at 12:00 a.m., Resident 1 was restless standing up next to his bed crying. CNA 1 stated she informed Licensed Vocational Nurse (LVN 1) in charge that Resident 1 was restless and crying. CNA 1 stated Resident 1 continues to cry when he was assisted back to bed. CNA 1 stated it was important to report to the charge nurse any changes in a resident's behavior so the charge nurse can check on the resident and assess the behavior. CNA 1 stated she returned to check on Resident 1 at 1:00 a.m. and observed Resident 1 was awake in bed. CNA 1 stated at 4 a.m. she saw Resident 1 standing up next to his bed talking with CNA 3 and LVN 1. CNA 1 stated when Resident 1 saw her he pointed at her and stated, that was her, she was trying to kill me, you poisoned the water while pointing to his water pitcher. During an interview on [DATE], at 6:45 a.m., LVN 1 stated CNA 3 informed her that Resident 1 appeared worried and concerned and was telling CNA 3 someone was trying to poison him. LVN 1 stated she went to assess him, and Resident 1 was alert and oriented and did not appear to be confused. LVN 1 stated Resident 1 calmed down after she explained to him that CNAs were delivering water pitchers with fresh water and offered to get him another, but Resident 1 declined. LVN 1 stated she felt there was a misunderstanding between her and Resident 1 and not a change in the resident's condition that was the reason she did not call Resident 1's doctor about the resident's worried/anxious behavior and his statement that someone was trying to poison him. During a concurrent interview and record review on [DATE], at 7:25 a.m., LVN 1 stated she did not informed Resident 1's physician when Resident 1 had change in his behavior. LVN 1 stated Resident 1 was exhibiting delusions when he and repeatedly was saying that someone was trying to poison him. LVN 1 stated Resident 1 suicide could have been prevented if she would have stayed with Resident 1, called his doctor, and had done 1:1 monitoring (a type of care where a patient is constantly observed by a healthcare professional to ensure patient safety) but because he calmed down, she did not think she needed to. During a phone interview on [DATE], at 11:45 a.m., with the Psychiatric Nurse Practitioner ([PNP] a registered nurse with advanced training who provides mental health care to residents) stated Resident 1's doctor should have been notified immediately of Resident 1's new behavior when he was observed crying and stating someone was trying to poison him. The PNP stated nursing staff should have been closely monitoring Resident 1 for behavioral symptoms. The PNP stated Resident 1's behavior could have been a delusion when he verbalized somebody was putting poison in his water, a symptom of mental illness, or a symptom of another medical illness. During an interview on [DATE], at 12:00 p.m., Registered Nurse Supervisor (RNS 3) stated if he had observed Resident 1 crying and stating someone was poisoning his water, he would have done a COC and let the doctor know. RNS 3 stated this behavior could have been due to infection or the resident's depression. RNS 3 stated a COC was an important monitoring and communication tool to let other staff members aware of what was going on with a resident. RNS 3 stated if he had been Resident 1's nurse, he would have provided the resident with 1:1 monitoring for the resident's safety, called the resident's doctor, and done a COC because the resident's behavior was not normal for him. During a concurrent interview and record review on [DATE], at 12:30 p.m., with the Director of Nursing (DON) stated LVN 1 should have done a COC, notified Resident 1's doctor, and probably transferred Resident 1 to a higher level of care (an acute general hospital) when the resident was exhibiting behavior manifested by crying spells, shaking his hands, scared, anxious, and verbalizing someone was trying to kill him. Reviewed Resident 1's medical record, the DON stated there was no COC completed for Resident 1, but one should have been done because Resident 1 was not at his baseline and his behavior indicated there was a medical problem occurring. After reviewing Resident 1's care plan for Lexapro, the DON stated one of the care plan interventions was to monitor for changes in Resident 1's behavior and mood and report to the doctor, but it was not done. During a review of the facility's RN Supervisor Job Description, undated, the job description indicated, Duties: Ensure that notification is given to the resident's attending physician, as well as the resident's representative, when the resident has a significant change in condition. During a review of the facility's P&P titled, Change in Condition Notification, revised [DATE], the P&P indicated, The facility will promptly inform the resident's Attending Physician and notify the resident's legal representative when the resident endures a significant change in their condition caused by a significant change in the resident's physical, mental, or psychosocial status. Change of Condition related to Attending Physician notification is defined as when the Attending Physician must be notified when any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem, complication, or permanent change in status and require a medical assessment, coordination, and consultation with the Attending Physician and a change in the treatment plan. The Licensed Nurse will notify the resident's Attending Physician and an appropriate family member when there is a significant change in the resident's physical, mental, or psychosocial status. Cross Reference F740 and F656

Based on interview and record review, the facility failed to ensure the licensed nurses (Licensed Vocational Nurse [LVN 1] Registered Nurse Supervisor [RNS 2] ) implemented the resident's care plan interventions related to the use of Lexapro (prescription medicine that treats depression [a mental health condition that involves a persistent feeling of sadness and loss of interest in activities, along with other symptoms that affect daily life] and anxiety ( feeling of worry, nervousness or unease) to prevent the resident from committing suicide (the act or an instance of ending one's own life voluntarily and intentionally) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN 1) implemented interventions of Resident 1's care plan titled, Resident 1 uses antidepressant medication Lexapro including assessment, monitoring, and documentation related to Resident 1's change in behavior and mood. On ,d+[DATE]/ 2024 at 12:15 a.m. Resident 1 was observed having crying spells, shaking his hands, appeared scared, anxious, and verbalized that someone was trying to kill him by poisoning his water pitcher. 2. Ensure the licensed nurses (Licensed Vocational Nurse [LVN 1] Registered Nurse Supervisor [RNS 2]) followed the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning which indicated to address resident specific health and safety concerns to prevent decline or injury and identify needs for supervision, behavioral interventions. These failures resulted in Resident 1 committing suicide on [DATE]. Resident 1, who had diagnosis of depression and a history of suicidal ideation (thinking about or formulating plans for suicide) on [DATE] at 4:40 a.m. was found hanging in the bathroom with a phone charging cord around his neck. The resident was lowered to the floor, cardiopulmonary resuscitation ([CPR]-an emergency procedure that can save a person life if their breathing or heart stops) was initiated and 911 (emergency services) was called. The Emergency Medical Services ([EMS]- medical professionals providing emergency medical care) arrived at the facility and Resident 1 was pronounced dead on [DATE] at approximately 5:25 a.m. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE]. On [DATE] Resident 1 was discharged home and readmitted back to the facility on [DATE] with diagnoses including depression, cerebral infarction (damage to the brain from interruption of its blood supply) with right sided hemiplegia (paralysis of one side of the body) and right hemiparesis (weakness of one side of the body), and failure to thrive (a syndrome that describes a decline in an older adult's health that can include weight loss, poor nutrition, and inactivity). During a review of Resident 1's History & Physical (H&P) dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated [DATE] , the MDS indicated Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment for daily decision making and required supervision or touching assistance with bed mobility, transfer from chair/bed-to-chair transfer (ability to transfer to and from a bed to chair or wheelchair), walking 10 feet ( ability to walk at least 10 feet in a room, corridor or similar space once standing) and personal hygiene. During a review of Resident 1's Care Plan titled Resident 1 uses antidepressant medication Lexapro related to diagnosis of depression, initiated on [DATE], the Care Plan indicated a goal for Resident 1 to decrease the resident's episodes of signs and symptoms of depression. The Care Plan's interventions included to administer antidepressant medications as ordered by the physician, monitor, document, and report a change the resident's behavior/mood/cognition, presence of hallucinations (false perception of reality), and delusions (having false or unrealistic beliefs), social isolation, suicidal thoughts (thinking about or formulating plans for suicide), and withdrawal (removes themselves from interactions with others). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had an active diagnosis of depression and was taking anti-depressant (prescription medications that can help treat depression and other mental health conditions) medication. During a review of Resident 1's Nurses Progress Notes dated [DATE] and timed at 12:51 a.m., the Nurses Progress Notes indicated that on [DATE] at around 12:15 a.m., Certified Nursing Assistant (CNA 1) called Licensed Vocational Nurse (LVN 1) in charge to Resident 1's room. The Nurses Progress Notes indicated LVN 1 entered Resident 1's room and found Resident 1 sitting on the side of his bed. Resident 1 appeared worried and stated someone was trying to kill him by poisoning his water pitcher or cup, pointing at his water pitcher. The Nurses Progress Notes indicated Resident 1's blood pressure ([BP] a force of blood pushing against artery walls when the heart pumps blood throughout the body) was ,d+[DATE] millimeters of mercury (mm/Hg unit of measurement, BP reference range is ,d+[DATE] mm/Hg) Resident 1's had a headache rated four out of 10 on a pain scale rating (a tool to measure pain intensity by asking patient to rate their pain on a scale of 0 to10, where a zero represents no pain and 10 represents the worse pain possible). The Nurses Progress Notes indicated at 12:18 a.m. Resident 1 received Tylenol (medicine used to relieve pain) and at 12:38 a.m. Resident 1 received Clonidine (medicine used to lower blood pressure) for high BP. The Nurses Progress Notes indicated on [DATE], at around 4:40 a.m. CNA 3 entered Resident 1's bathroom and found Resident 1 kneeling on the floor facing the wall with a red cord around his neck and tied around the handrail of the bathroom. The Nurses Progress Notes indicated Resident 1 was unresponsive, not breathing, and staff was unable to obtain his BP reading. The Nurses Progress Notes indicated the facility staff (unknown) called 911 (emergency services) and CPR was initiated The Emergency Medical Services ([EMS]- medical professionals providing emergency medical care) arrived at the facility and pronounced Resident 1 dead on [DATE] at approximately 5:25 a.m. During a phone interview on [DATE], at 11:45 a.m., the Psychiatric Nurse Practitioner ([PNP] a registered nurse with advanced training who provides mental health care to residents), stated the licensed nurses should have monitored Resident 1's behavioral symptoms. The PNP stated Resident 1's crying spells and statement of someone wanted to kill him by placing poison in his water pitcher, could have been manifestation of Resident 1 was experiencing a delusion. During a review of Resident 1's initial Psychiatric Evaluation (a comprehensive examination of a person's mental, emotional, and behavioral health), dated [DATE], the initial Psychiatric Evaluation indicated Resident 1 was oriented to person, place, and time. The initial Psychiatric Evaluation indicated, under the treatment plan, to observe the resident for deterioration in function, resident was educated to report worsening of symptoms and to report, if noted, changes in mood and behavior. Gradual dose reduction ([GDR] a step in tapering a dose of a medication) for Lexapro (medication to treat depression) was contraindicated at this time as it may exacerbate (to make something worse) resident symptoms (not specified). During an interview on [DATE] at 2:50 p.m., with Resident 1's roommate (Resident 2), Resident 2 stated on the night of [DATE], he could not sleep well as Resident 1 was crying a lot. Resident 2 stated a staff member (unknown) came in the room to calm Resident 1 down on [DATE] at 3:00 a.m., and after the staff member left, Resident 1 began crying again. Resident 2 stated on the same night, around 4 a.m., he heard Resident 1 struggling to walk to the bathroom, as he (Resident 1) was holding onto the walls while walking to the restroom. Resident 2 stated after that he went back to sleep and did not hear anything until someone told him the next day what happened to Resident 1 (committed suicide). During an interview on [DATE], at 6:25 a.m., CNA 1 stated on [DATE] at 12:00 a.m., Resident 1 was restless standing up next to his bed crying. CNA 1 stated she informed LVN 1 that Resident 1 was restless and crying. CNA 1 stated Resident 1 continues to cry when he was assisted back to bed on [DATE] (unknown time). During an interview on [DATE], at 7 a.m., CNA 3 stated when she was passing out water pitchers at approximately 12:00 a.m. on [DATE], Resident 1 verbalized to CNA 3 that another CNA (unknown) was trying to poison him. CNA 3 stated Resident 1 appeared nervous, scared, his hands were shaking, and verbalized repeatedly that a lady was trying to poison him. CNA 3 stated she reported Resident' 1s behavior to LVN 1. During an interview on [DATE], at 7:23 a.m. LVN 1 stated she gave Resident 1 Tylenol (medication to treat pain) for his headache on [DATE] at 12:18 a.m. and Clonidine (medication to treat high BP) at 12:30 a.m. LVN 1 stated it was difficult to obtain Resident 1's BP because he was moving a lot and was pointing at his water pitcher. LVN 1 stated Resident 1 had depression and a high BP. LVN 1 stated when Resident 1 stated someone was trying to poison him on it could have been related to his depression. LVN 1 stated on [DATE] she observed Resident 1 being anxious, worried, with a lot of concerns (not specified). LVN 1 stated she should have done a COC when Resident 1 had changes in his behavior so nurses could better monitor him. LVN 1 stated after CNA 3's report of Resident 1 change in behavior on [DATE] at approximately 12:00 a.m. they (facility staff) visually checked on him more frequently but did not document it was done. LVN 1 stated Resident 1 was exhibiting delusions when he repeatedly verbalized that someone was trying to poison him on [DATE]. LVN 1 stated Resident 1 suicide could have been prevented if she would have called his doctor and placed the resident on 1:1 monitoring (a type of care where a patient is assigned a staff member to provide constant observation and assistance to ensure a patient safety) on [DATE] but because he calmed down, she did not think she needed to do so. During an interview on [DATE], at 12:24 p.m., Registered Nurse Supervisor (RNS 2) stated when CNA 1 informed her on [DATE] that Resident 1 verbalized someone was trying to poison him, she thought it was because Resident 1 was confused. RNS 2 stated she failed to do a COC as she thought Resident 1's delusion was due to his confusion. RNS 2 stated she was not aware of Resident 1 having behavior of crying spells, shaking hands, feeling scared and anxious. RNS 2 stated LVN 1 did not inform her about Resident 1's change in behavior and if she has known, she would have placed Resident 1 on 1:1 monitoring/observation to keep him safe, call Resident 1's doctor and family member, complete a COC, and transfer Resident 1 to a higher level of care (a general acute care hospital). During an interview on [DATE], at 10:42 a.m. LVN 5 stated it was important to follow and implement plan of care interventions. LVN 5 stated care plan enables nursing staff to monitor, assess, and inform the doctor when Resident 1 was exhibiting behavioral changes including crying spells and delusions. During a concurrent interview and record review on [DATE] at 1:06 p.m. with RNS 3, Resident 1's Care Plan for the administration of Lexapro dated [DATE] was reviewed. RNS 3 stated licensed nurses were responsible to initiate, modify and implement the comprehensive care plan of a resident (in general). RNS 3 stated Resident 1's Care Plan for Lexapro required monitoring for any adverse side effects (undesired effect of a drug) of the medication, documenting them, and reporting any changes in Resident 1's behavior, mood, cognition, including delusion and suicidal ideation to Resident 1's doctor. RNS 3 stated the care plan serves as guidelines to address and implement interventions for a particular Resident 1's health condition. RNS 3 stated licensed nurses (LVN 1 and RNS 2) failed to follow a care plan and implement Resident 1's plan of care when he exhibited changes in behavior including crying spells and verbalization of somebody was putting poison in his water and was trying to kill him on [DATE]. During a concurrent interview and record review on [DATE], at 2:35 p.m. the Director of Nursing (DON) stated the care plan provides a detailed outline of the interventions the staff were to perform for a specific identified physical or psychological problem. The DON stated the care plan served as a checklist for necessary staff actions regarding the resident's issue or problem. The DON reviewed Resident 1's care plan dated [DATE] related to the use of Lexapro , and stated that LVN 1 failed to follow and implement Resident 1's care plan interventions including monitoring and/or recognizing changes in the resident's behavior and reporting to the doctor any change in Resident 1's condition when the resident was observed having crying spells, shaking hands, was feeling scared, anxious, and verbalizing someone was trying to kill him. During a review of facility's policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning revised ,d+[DATE], the P&P indicated the facility will provide person-centered, comprehensive, care that reflects the best practice standards for meeting health, safety, psychosocial, behavioral needs of the resident to maintain or obtain the highest physical, mental, and psychosocial being. The P&P indicated the Care Plan should address resident specific health and safety concerns to prevent decline or injury and will identify needs for supervision, behavioral interventions, and assistance with activities of daily living. During a review of facility's P&P titled Change of Condition Notification revised ,d+[DATE], the P&P indicated the facility will notify the attending physician when there is any sudden and marked adverse change in the resident's condition manifested by signs and symptoms different than usual denoting a new problem, complication requiring a medical assessment, coordination and consultation with the Attending Physician or a change in the treatment plan. During a review of facility's P&P titled Behavior /Psychoactive Drug Management revised ,d+[DATE], the P&P indicated if a resident manifests a change in his/her mood for behavior symptoms, the licensed nurse will assess the resident's mood and behavior utilizing the change of condition process. Cross Reference F740 and F580

Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA 1) did not transfer a resident, who required two persons for physical assistance with transfers between surfaces, by using a mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) alone, for one out of two sampled residents (Resident 1). As a result of this deficient practice Resident 1 sustained a nasal (nose) bridge laceration (cut) with a nasal fracture (a break) after being struck in the nose by the bar of the mechanical lift. Resident 1 was transferred to a General Acute Care Hospital (GACH) where he was treated with IV ([intravenous] in the vein) antibiotics (medication to treat bacterial infections) for his nasal laceration and nasal fracture. Findings: During a review of Resident 1 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including Alzheimer ' s disease (a disease which slowly destroys memory and thinking skills) and muscle weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 8/10/2023, the MDS indicated Resident 1 ' s cognitive (thinking) skills for daily decision making were severely impaired, and Resident 1 required extensive assistance from two staff members when transferring from bed to chair. During a review of Resident 1 ' s Change of Condition (COC) progress note, dated 9/12/2023, the COC indicated while Resident 1 was being assisted by CNA 1 to a wheelchair via a mechanical lift, Resident 1 ' s nose came into contact with the mechanical lift bar. The COC indicated Resident 1 sustained a cut to his nasal bridge which measured 1.0 x 0.1 centimeters [(cm) a unit of measurement). During a review of Resident 1 ' s undated Care Plan, the Care Plan indicated Resident 1 had activities of daily living [(ADL) tasks such as eating, bathing, dressing, grooming and toileting] self-care performance deficits and required extensive assistance from two staff members during transfers between surfaces. During a review of the facility ' s Mechanical Lift List ([MLL] a list to indicate which residents require a mechanical lift for transfers), dated 9/2023, the MLL indicated Resident 1 ' s name was not on the list. During a review of the facility ' s Fall Management Program note dated 9/8/2023, the Fall Management Program note indicated the rehabilitation department recommended that Resident 1 use a two wheeled walker along with limited physical assistance from nursing for mobility and completion of physical activities. During a review of Resident 1 ' s Physician order, dated 9/12/2023, the Physician ' s order indicated to obtain an X-ray of Resident 1 ' s nose. During a review of Resident 1 ' s Radiology Report, dated 9/12/2023, the Radiology Report indicated Resident 1 ' s nasal bone was fractured. During a review of Resident 1 ' s Physician ' s Order dated 9/12/2023, the Physician ' s Order indicated to transfer Resident 1 to a GACH due to his nasal bone fracture. During a review of the GACH ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the GACH on 9/13/2023. During a review of the GACH ' s History and Physical (H&P), dated 9/14/2023, the H&P indicated Resident 1 had a nasal contusion (an injury in which the skin is not broken, as in a bruise) on the bridge of his nose with a nasal bone fracture. During a review of the GACH ' s Critical Care Medicine Consultation report dated 9/13/2023, the Critical Care Medicine Consultation report indicated for Resident 1 to receive IV antibiotics for an infection of his nasal laceration. During a review of the GACH ' s Physician ' s Order dated 9/13/2023, the Physician ' s Order indicated Resident 1 to receive Ceftriaxone (a medication to treat bacterial infections) 1000 milligrams ([mg] a unit of measurement) IV daily for a bloodstream infection. During a telephone interview on 9/14/2023 at 11:44 a.m., CNA 1 stated when she transferred Resident 1 on 9/12/2023 to his wheelchair from his bed, using a mechanical lift, Resident 1 grabbed the mechanical lift ' s bar and the bar hit Resident 1 in his nose. CNA 1 stated she did not have assistance from staff when she used the mechanical lift to transfer Resident 1 to his wheelchair. CNA 1 stated she decided to use the mechanical lift to transfer Resident 1 to his wheelchair because Resident 1 was not cooperating with her. CNA 1 stated there is a binder with a list of residents who required the use of a mechanical lift, but she could not recall if Resident 1 ' s name was on the list. CNA 1 stated no other staff members were available to help with the mechanical lift and stated there should be two staff members when using the mechanical lift. During an interview on 9/14/2023 at 12:13 p.m., Licensed Vocational 1 (LVN 1) stated he went into Resident 1 ' s room (9/12/2023) because he heard a squeaky noise coming from the room that caught his attention, that is when he found CNA 1 holding the mechanical lift bar away from Resident 1 ' s face. LVN 1 stated CNA 1 told him the mechanical lift bar hit Resident 1 ' s nose. LVN 1 stated there was some scant (a small amount) bleeding from the top of Resident 1 ' s nose. LVN 1 stated there was no other staff member in Resident 1 ' s room assisting CNA 1 with the mechanical lift. LVN 1 stated there should be two staff members when using the mechanical lift for safety reasons. LVN 1 stated there is a binder at the nurse ' s station with the appropriate transfer methods for each resident. LVN 1 stated Resident 1 was able to stand and transfer to his wheelchair. During an interview on 9/15/2023 at 12:15 p.m., the Director of Staff Development (DSD) stated staff, including CNAs and licensed staff have been in-serviced to have two staff members when using the mechanical lift. The DSD stated for safety reasons one staff member operates the lift while the other staff member ensures the resident is safe and not moving around. The DSD stated there is a binder at every nurse ' s station with a list of residents who require the mechanical lift. The DSD stated Resident 1 ' s name was not on the list. During an interview on 9/15/2023 at 1:14 p.m., the Director of Rehabilitation (DOR) stated the rehabilitation department created the MLL. The DOR stated Resident 1 required partial to moderate assistance with transfers and needed extra time for transfers due to the resident ' s cognitive status. However, Resident 1 did not require the use of a mechanical lift. During an interview on 9/15/2023 at 1:58 p.m., the Director of Nursing (DON) stated when the mechanical lift is used, there should be two staff members transferring the resident for the resident ' s safety. The DON stated Resident 1 ' s care plan intervention indicated the resident required the use of two staff members during transfers and Resident 1 ' s name was not on the MLL for residents who require the use of a mechanical lift. The DON stated CNA 1 was alone when she (CNA 1) used the mechanical lift to transfer Resident 1. The DON stated when interventions for the resident ' s, who requires two persons physical assistance, are not implemented and residents do not receive the appropriate assistance, there is a risk for residents to be injured. During a review of the facility ' s policy and procedure (P/P) titled Total Mechanical Lift revised 4/27/2023, the P/P indicated at least two people are present while resident is being transferred with the mechanical lift. The P/P indicated mechanical lifts are devices used to transfer individuals who require support for mobility which cannot be provided by the nursing staff alone.

Based on interview and record review, the facility failed to ensure the resident, who had a history of falls, did not fall and sustained a fracture (brake in a bone) of the right foot fifth metatarsal bone (the bone connecting a person's ankle to a little toe) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was offered and assisted to go to the bathroom as indicated in Resident 1's untitled Care Plan [(CP) - a document that outlines a resident's health conditions, specific care needs, current treatments, and goals] to prevent the resident from falling again after the resident's first fall on 3/21/2023 at 6:00 a.m. 2. Ensure Resident 1 was accurately assessed for the risk for falls to implement necessary fall preventative measures based on the risk for falls assessment, including placement of a sign on Resident 1's room door indicating 'High Fall Risk' and a soft fall mat by the bed. 3. Implement the Physical Therapist's [(PT 1) a qualified medical professional to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise] recommendation for Resident 1 to use a two-wheels walker (a walking aid with two front wheels and no rear wheels, geared toward users who have more limited mobility and can walk slowly) and physical assistance with mobility. 4. Ensure staff followed PT 1's recommendation to provide Resident 1 with supervision assistance with completing physical activity, including to get out of bed and to go to the bathroom, moving Resident 1 closer to the nursing station, provide Resident 1 with a two-wheeled walker, and assist Resident 1 with toileting. These deficient practices resulted in Resident 1 sustaining a fall with a fracture to the right fifth metatarsal (the bone connecting a person's ankle to the little toe) toe which led to a swelling and discoloration of the resident's right foot with absence of pedal (an arterial [a measurement of the heart's contraction] pulse (which can be felt on top of the foot in front of the ankle) that required a left femoral (related to a thigh) popliteal vein (related to the back of the knee) bypass surgery (a procedure that creates a new route for blood flow to right lower leg by using healthy vein from the left leg). Findings: During a record review of Resident 1's Admission Record (Face Sheet), the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including muscle weakness, anemia (condition in which the blood does not have enough healthy red blood cells), anxiety (a feeling of fear, dread, and uneasiness), disorientation (a state of mental confusion), atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), and diabetes mellitus (a chronic condition where the body is unable to absorb sugar from the blood stream without medication). During a review of Resident 1's History and Physical (H&P), dated 3/28/2023, the H&P indicated, Resident 1 could make needs known but could not make medical decisions. During a record review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/8/2023, the MDS indicated, Resident 1 required supervision from one staff for bed mobility, transfers, walking in room, locomotion on unit, eating, and limited assistance from one staff for personal hygiene, and getting dressed. During a review of Resident 1's Medication Administration Record (MAR), dated from 3/1/2023 to 3/31/2023, the MAR indicated Resident 1 was receiving medications that could increase Resident 1's risk for falls. The MAR indicated Resident 1 was receiving Insulin Lispro (medication for lowering high blood sugar), Metoprolol Tartrate (a medication for lowering high blood pressure), 100 milligrams [(mg)- a unit of measure] one tablet twice a day by mouth, Lisinopril (medication for lowering high blood pressure) 20 mg one tablet once a day by mouth, Furosemide (medication for removal of fluid excess from the body to lowering blood pressure) 40 mg one tablet by mouth two times a day, Spironolactone (a medication to lower blood pressure) 25 mg one tablet by mouth one time a day, and Buspirone HCL (medication to reduce anxiety) 5mg one tablet by mouth twice a day. According to https://www.drugs.com a comprehensive and up-to-date source of drug information, Lispro could cause side effects such as, dizziness, fast heart rate, and feeling anxious or shaky, Metoprolol Tartrate, Lisinopril, Furosemide and Spironolactone have a potential side effect of very low blood pressure and causing dizziness. Buspirone HCL side effects of dizziness, confusion, fatigue, and nervousness. These medications side effects are the contributing factor to a residents falls. During a review of Nursing Progress Note (NPN), dated 3/21/2023 and timed 6:00 a.m., the NPN indicated, Resident 1 was found sitting on the floor on the left side of the bed. The NPN indicated, Resident 1 was alert and denied discomfort or pain. The NPN indicated, Resident 1's skin was intact. The NPN indicated, Resident 1 stated she wanted to go to the bathroom and lost the balance. The NPN indicated, Resident 1 was advised not to rise rapidly, and the resident's physician was notified. During a review of Nursing Progress Note (NPN), dated 3/21/2023 and timed 10:00 a.m., the NPN indicated, Resident 1 was found sitting on the floor while leaning back on the wall of her room near the door. The NPN indicated, Resident 1 stated she was trying to stand up and fell . The NPN indicated, Resident 1's had a right hip skin discoloration and excoriation (lesions on the surface of the skin) and the dressing was applied. The NPN indicated, Nurse Practitioner (NP) ordered an X-ray (a type of medical imaging that creates pictures of bones and soft tissues) of right foot on 3/21/2023 and reviewed the X-ray report which indicated acute fracture of fifth metatarsal bone on 3/21/2023. The NPN indicated, NP ordered to transfer Resident 1 to GACH on 3/21/2023 for further evaluation. During a review of Resident 1's Care Plan (CP), undated, the CP focus indicated status post unwitnessed fall (1st fall incident). The CP interventions included frequent visual checks, attend resident's needs in a timely manner, and offer and assist resident to use bathroom as needed. During an interview on 5/11/2023, at 2:39 p.m., with Certified Nurse Assistant (CNA) 2 via telephone, CNA 2 stated, she worked on 6:30 a.m. to 2:30 p.m. shift on 3/21/2023. CNA 2 stated, she did not witness the first fall, but she received a report from the night shift staff regarding the first fall incident that happened on 3/21/2023 at 6:00 a.m. CNA 2 stated, later that day she heard a loud thud and found Resident 1 on the floor in a sitting position on 3/21/2023, at 10 :00 a.m. CNA 2 stated, there was no floor mat to prevent injury from the fall, and no falling star placed on Resident 1's room to indicate Resident 1 was a fall. CNA 2 stated, she noticed Resident 1 was getting more confused, and repeatedly saying, I need to go to the bathroom now. CNA 2 stated, she notified LVN 3 regarding Resident 1's increased confusion. CNA 2 stated Resident 1 was trying to get up and go to the bathroom unassisted when she fell . During an interview on 5/11/2023, at 4:00 p.m., with ADON, ADON stated, Resident 1 should have been but was not on 1:1 supervision (resident has a staff member assigned to them for constant monitoring and ensuring the resident stays safe) and responsible staff did not place Resident 1 on a Falling STAR program (assessing residents for their risk of falls and then identifying those at high risk with a visible symbol, usually a falling star graphic placed on a resident's door) after the first fall on 3/21/2023 at 6 a.m. ADON stated, Resident 1 was alert and denied any pain after the first fall. ADON stated the second fall on 3/21/2023 at 10:00 a.m. could have been avoided if those interventions (the Falling Star program, and 1:1 monitoring) were implemented right after the first fall. ADON stated, Resident 1 was hospitalized multiple times after the falls due to complications including a right fifth metatarsal fracture, discoloration of the right foot that led to possible amputation, and femoral bypass surgery. ADON stated Resident 1 should have been moved closer to the nursing station if 1:1 supervision was not possible, especially after the first fall on 3/21/2023 at 6 a.m. ADON stated Resident 1 should have been assigned a Yellow Star upon admission since she had a history of multiple falls and should have been assigned a Red Star (indicating that the resident has had multiple fall incidents and a fall with major injury) after the second fall because of the multiple falls with injury. During an interview on 5/9/2023, at 2:45 p.m., with Licensed Vocational Nurse (LVN 2), LVN 2 stated a Fall Risk Assessment [(FRA) - a nursing tool that uses a scoring system to evaluate resident's risk of fall] should be completed accurately because fall prevention interventions for each resident were based on the FRA. LVN 2 stated fall incidents to elderly residents could result in immobility, pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) due to immobility, and fractures. LVN 2 stated a resident's fracture could interfere with normal blood circulation, due to trauma, on the fractured extremity, because immobility which could result in an amputation (the surgical removal of part of the body) due to lack of blood flow to the area past the fracture. During a concurrent interview and record review, on 5/9/2023, at 4:10 p.m., with Assistant Director of Nursing (ADON), Resident 1's FRA, dated 3/2/2023, FRA dated 3/21/2023 and timed at 6:00 a.m., and FRA dated 3/21/2023 and timed at 10 a.m. were reviewed. Resident 1's FRA completed on 3/2/2023, indicated Resident 1 was not at risk for falls, with a score of seven. FRA dated 3/2/2023 indicated, Resident 1 had one to two falls in the past three months, a balance problem while walking and standing, taking one to two medications that increase Resident 1's risk for fall, and no predisposing (to have a tendency toward something) disease to contribute to Resident 1's fall risk. Resident 1's FRA, dated 3/21/2023 and timed at 6:00 a.m., (completed after the first fall on 3/21/2023) indicated Resident 1 was assessed as no risk for the potential for falls, and was scored eight which indicated no fall risk (score 0-9: no risk for fall & 10 or above: high risk for fall). FRA dated 3/21/2023 indicated, Resident 1 had no falls in the past three months, although according to FRA dated 3/2/2023 Resident 1 did have a history of one to two falls in the past three months. FRA dated 3/21/2023 indicated Resident 1 had normal balance and gait (a person's manner of walking) had been taking three to four medications that increased Resident 1's risk for falls and had no predisposing disease that could cause falls. FRA dated 3/21/2023 and timed at 10 a.m., indicated Resident 1 was considered as not being at risk for the potential for falls and scored nine which indicated no fall risk. FRA dated 3/21/2023 and timed at 10 a.m., had inaccurate information because FRA dated 3/2/2023 indicated Resident 1 have had one to two falls in the past three months and according to FRA dated 3/21/2023 and timed at 6 a.m., Resident 1 have had one additional fall at 6:00 a.m. on 3/21/2023. FRA dated 3/21/2023 and timed at 10 a.m., indicated Resident 1 had a balance problem while standing and walking, required use of assistive devices (two-wheels walker) for walking, had been taking three to four medications to increase Resident 1's risk for falls, and had no predisposing disease that could increase risk for fall (cause falls). The FRA dated 3/21/2023 and timed at 10 a.m., instructions included the following: If the total score is 10 or greater, the resident should be considered a High Risk for potential falls, the 'Fall Prevention protocol' should be initiated immediately and documented on the care plan. Gait/Balance: to assess the resident's gait/balance, have the resident stand on both feet without holding onto anything: walk straight forward; walk through a doorway; and make a turn. Medications: Respond based on the following types of medications: antihypertensives (lowering blood pressure), diuretics (getting rid of excess water from body and lowering blood pressure), hypoglycemics (lowering blood sugar). Predisposing Diseases: respond based on the following predisposing conditions: Hypotension (low blood pressure), Vertigo (dizziness), Cerebral Vascular Accident (stroke-a loss of blood flow to part of the brain), Osteoporosis (weakened bones), Fractures. During an interview on 5/9/2023, at 4:10 p.m., the ADON confirmed, all three FRAs had documentation of incorrect Resident 1's assessments for the risk for falls. The ADON stated, the licensed nurses that completed FRAs assessments failed to identify and to evaluate Resident 1 as a high fall risk. The ADON stated, if a resident's scores less than 10 on the FRA then the resident is considered at no risk for falls according to instructions for FRA. The ADON stated, staff could have implemented fall prevention interventions, such as a sign on the resident's room indicating 'High Fall Risk' and a soft fall mat by the bed. The ADON confirmed Resident 1 was considered independent and at no risk for falls because of inaccurate FRA assessments. During a review of Resident 1's Physical Therapy Evaluation & Plan of Treatment (PTEPT), dated on 3/3/2023, the PTEPT indicated, Resident 1 was unable to stand steady without upper extremities supported for more than 10 seconds, required an assistive device for functional mobility and a two-wheeled walker to walk 20 feet. The PTEPT indicated, Resident 1's mobility function scored five out of 12 which was ranged from 0 (no function) to 12 (highest function). During a concurrent interview and record review, on 5/11/2023, at 1:34 p.m., with PT 1, the Berg Balance Scale [(BBS)- an assessment tool to determine a person's balance abilities], dated on 3/8/2023 (within a week of first admission) was reviewed. The BBS indicated, Resident 1's BBS score was 31 out of 56, where a score of less than 45 indicated a greater risk of falling (BBS indicated, 0-20 high fall risk, 23-40 a medium fall risk, and 41-56 a low fall risk). PT 1 stated, she assessed Resident 1 as a high fall risk because Resident 1's family had also told her that Resident 1 have had five falls prior to admission to the facility. PT 1 stated, Resident 1 required supervision or touching assistance requiring a staff member to provide verbal cues, touching, steadying, and contact guard assistance as the resident completes an activity. PT 1 stated, Resident 1 needed supervision to get out of bed and to go to the bathroom. PT 1 stated, she had recommended supervision for Resident 1 to licensed staff for safety. PT 1 stated, she went to the nursing station after finishing her PT evaluation and gave verbal recommendations to the charge nurse since there was no written recommendation form available. PT 1 stated, fall incidents could be reduced if close supervision was provided and staff followed her recommendations. PT 1 stated, she had also recommended moving Resident 1 near the nursing station, providing Resident 1 with a two-wheeled walker, and assisting Resident 1 with toileting. PT 1 stated a fall could lead to many complications such as fractures, immobility, pressure ulcers, and compromising circulation on injured sites. During a review of the facility's Fall Prevention Program Guidelines: Falling STAR Program (FSP), undated, the FSP indicated, the purpose of falling STAR program was to reduce facility's fall percentage, prevent recurrent falls and resulting major injury. Identification of Residents on the Falling STAR Program: The Yellow STAR represents a resident's history of falls and is placed over the headboard of a resident's bed. The Red STAR represents a resident's history of multiple fall incidents and a fall with a major injury. Procedure & Steps on Placing Residents on Falling STAR Program: Prior to admission, the facility's admission staff will identify residents that are at high risk for fall or had a history of falls prior to the admission to the facility and assign a Yellow Star to the inquiry packet to alert the admitting nurse. After a fall incident for a current resident, a Yellow/Red STAR is placed over the headboard of a resident's bed, and the special equipment, such as landing mats by the bed will be placed in the room, and a plan of care will be formulated accordingly. During a review of Resident 1's Right foot X-ray (a type of medical imaging that creates pictures of bones and soft tissues) report, dated on 3/21/2023, the X-ray report indicated, Resident 1 had nondisplaced (not moved out of alignment) fracture distal (away from the center of the body) end of right fifth metatarsal bone. During a review of Resident 1's GACH 1 medical record (GACH1MR), dated 3/24/2023, the GACH1MR X-ray final report of the resident's right foot, indicated, a right foot fifth metatarsal fracture. During a review of Resident 1's GACH 2 medical records (GACH2MR), dated 4/16/2023, the GACH2MR Emergency Department Encounter indicated, Resident 1 was admitted to GACH 2 for further evaluation of swelling and discoloration to right lower extremity associated with absence of pedal pulse. GACH2MR Internal Medicine History and Physical, dated 4/16/2023, indicated Resident 1 had altered cognitive status, had right foot toes cyanosis (a bluish color in the skin caused by a shortage of oxygen in the blood) with no pedal pulse via doppler (a noninvasive device that can be used to estimate the blood flow) examination. GACH2MR Operative Report, dated 4/20/2023, indicated, Resident 1 had a left femoral vein to right femoral bypass surgery. During a review of the facility's P&P titled, Fall Management Program, dated 3/13/2021, the P&P indicated, the facility will implement a Fall Management Program that supports and provides an environment free from fall hazards. The P&P section Fall Risk Evaluation indicated as part of the admission assessment, the licensed nurse will complete a fall risk evaluation. If a fall risk factor is identified, the licensed nurse will document interventions on the resident's care plan and document interventions for every resident regardless of fall risk evaluation score. The interdisciplinary Team (IDT - a health care team from various areas of expertise) will initiate, review, and update the resident's fall risk status and care plan for the following intervals-on admission, quarterly, annually, upon identification of a significant change of condition, post fall and as needed. The P&P under section Recurrent Falls indicated a resident who endures more than one fall in a day, week, or month, will be considered at high risk for falls.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for one of two sampled residents (Resident 1). Resident 1 was rough handled by Certified Nursing Assistant 1 (CNA 1) after the resident refused care resulting in physical injuries and mental abuse. CNA 1 was allowed to continue to care for Resident 1. The facility failed to implement its abuse policy and procedure (P/P) as follows: 1. Report the abuse allegation to the Department of Public Health (DPH) within 24 hours. 2. Remove CNAs 1 and 2 immediately from providing care to Resident 1 during the investigation. 3. Thoroughly investigate the allegation which included interviewing other staff and residents. 4. Ensure Resident 1 was safe and free from further abuse. This deficient practice resulted in Resident 1 sustaining injury to the right eye, mental anguish (suffering that someone experiences as the result of a traumatizing experience) and fear, as CNA 1 was allowed to continue to care for Resident 1 after the abuse allegation. Resident 1 called the police three days after the abuse (3/20/2021) fearing she was going to be killed. This deficient practice resulted in physical and mental harm to Resident 1 and had the potential to affect Resident 2 and other residents in the facility. During an interview on 3/24/2021 at 5:30 p.m., with the facility's administrator (ADM), the director of staff development (DSD), and the Nurse Consultant, they were informed that an Immediate Jeopardy ([IJ], a situation in which the facility'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) was identified and declared under F600 to ensure residents were free of abuse. The facility provided an acceptable plan of action (POA) for correction of the IJ on 3/26/2021 at 4:05 p.m. The IJ was lifted on 3/26/2021 at 4:17 p.m., after the team verified, while onsite, through observation, interview, and record review to ensure the POA was implemented. The POA included the following: 1. Resident 1 no longer resides in the facility. 2. CNA 1 was suspended pending investigation on 3/24/2021. 3. The ADM educated the Social Worker on alleged abuse/unusual occurrence reporting on 3/25/2021. 4. The DSD suspended CNA 2 on 3/25/2021 pending the investigation. 5. The RQMC (regional quality management consultant) counseled the DSD on 3/25/2021 regarding the importance of following the policy and procedure (P/P) regarding suspension and/or removal of the CNA from work when an allegation of abuse incident occurred. 6. The RQMC in-serviced the Administrator, DON, and the Social Services Director on proper communication and adhering to facility's P/P for abuse allegation management, grievances, reporting of unusual occurrences and injury of unknown origin on 3/25/2021. 7. Licensed Nurses were In-serviced immediately on reporting any alleged abuse or grievance by the ADM, DON and DSD (started on 3/24/2021). 8. The ADM and DSD started in-services immediately to all staff regarding P/P of abuse prevention, abuse reporting, screening training; unusual occurrence; grievance; injury of unknown origin started on 3/24/2021. 9. All residents (83) in the facility were interviewed by designated Department Managers, ADM, and DON, initiated on 3/24/2021 with regards to being safe and being treated with respect and dignity. 10. The interdisciplinary team ([IDT] group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) conducted room rounds, which included identification of unusual occurrence, injury of unknown origin and/or any grievance. There were two grievances identified and the SSD acted on it immediately and resolved the issue. 11. The ADM will enhance room round items and assignments with the department manager that includes safety and security of the residents and other concerns/issues including unusual occurrences/grievances and injury of unknown origin starting on 3/24/2021 every day on going. 12. The ADM and department Managers will conduct interview of current staff at random selection of any knowledge of abuse/allegation and any injury of unknown origin, unusual occurrences/grievances; at least 5 staff a day (started on 3/25/2021 for two months and quarterly thereafter). 13. The Licensed nurses under the direction of the DON performed a body check to 83 residents in house to identify any injuries of unknown origin (started on 3/25/2021 and completed on 3/26/2021). None found. 14. The ADM and/or designee will further review daily of grievances, any indication of abuse and will report to the Department of Health Services, Police Department and Ombudsman within the required time frame (started on 3/25/2021 and monthly thereafter). 15. The ADM will schedule a manager of the day on weekends (Saturday and Sunday) to monitor and identify any events that requires reporting to the Department of health, police and/or Ombudsman start 3/25/2021 for three (3) months consecutively, then monthly thereafter. 16. The ADM will ensure that each nursing station will be provided with a binder that includes: policy and procedures for abuse/grievance and unusual occurrence/injury of unknown origin, Fax numbers to the DPH, Police and Ombudsman, Interview forms, Elder Abuse Reporting Form and grievance/complaint forms (started 3/25/2021 and ongoing thereafter). 17. The ADM/Department managers will conduct a question and answer form to at least 10 staff a day on abuse prevention reporting and investigation/policy (started on 3/25/2021) daily for one month then monthly thereafter, regarding the following: 1. Alleged abuse 2. Unusual occurrences 3. Injury of unknown origin 4. Grievances 18. The ADM or designee will conduct weekly compliance of the action plan and will report to the QA committee monthly (started on 3/27/2021 and ongoing). Findings: During an anonymous telephone call to the DPH, received on 3/23/2021 at 9:15 a.m., the caller who was in the facility at the time, stated they wanted to inform the Department that someone should come to the facility that morning to investigate an abuse allegation, in which the facility was trying to cover-up. The caller stated a resident (Resident 1) was abused and sustained a black eye with redness to the sclera (white area layer of the eyeball) and the resident was leaving the state sometime that day. The caller expressed his concern and wanted to be sure the Department sent an evaluator in time to see the injuries Resident 1 suffered prior to Resident 1 leaving the facility. During an unannounced onsite visit to the facility on [DATE] at 10:55 a.m., a record review indicated Resident 1 was discharged in the care of the resident's family member (FM 1) that morning at 9:45 a.m. During a review of Resident 1's Face Sheet (admission record) the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 2/3/2021 indicated Resident 1's cognitive skills (thought process) were intact. According to the MDS, Resident 1 required extensive assistance for bed mobility, dressing, toilet use and personal hygiene and was totally dependent in transferring. During a review of Resident 1's Assessment-Data Collection form, dated 3/17/2021, the Assessment form indicated Resident 1 had no redness or discoloration to either eye upon readmission. During a review of Resident 1's Assessment-Data Collection form, dated 3/18/2021, the Assessment Data form indicated Resident 1 had redness to the right eye area. During a review of Resident 1's change of condition/situational, background, assessment, recommendation (COC/SBAR [internal communication form]) report, dated 3/20/2021 the COC/SBAR indicated Resident 1 called the police on 3/20/2021 and reported she was rough handled during care by a certified nursing assistant (CNA 1) and sustained injury on 3/17/2021. There was no documented evidence in Resident 1's clinical record that an investigation was done and/or how Resident 1 had sustained bluish discoloration on both eyes. During a telephone interview on 3/23/2021 at 12:33 p.m., Resident 1's family member (FM 1) stated that according to Resident 1, CNA 1 was handling her rough during care while turning her and hit both of her eyes on the side rail on 3/17/2021 on the night shift (11 pm-7 am). During an interview on 3/23/2021 at 12:57 p.m., the DON stated she was made aware of the incident on 3/20/2021 by LVN 9 (three days after the incident). The DON stated in the beginning of the COC, Resident 1 had only redness to the right eye which CNA 2 reported to the charge nurse. The DON stated Resident 1 had the tendency to rub her eyes. During a telephone interview on 3/23/21 at 2:37 p.m., CNA 1 stated Resident 1 was asking her if she was a friend of CNA 2, because Resident 1 assumed that she (CNA 1) would be rough with her, as CNA 2. During an interview on 3/23/2021 at 3:45 p.m., the ADM was asked if CNA 1 was working on 3/22/2021 on the night shift (11 pm-7 am) and the ADM stated CNA 1 was still working. The ADM stated she was not initially aware CNA 1 was still working while the investigation was still ongoing. The ADM admitted she would take full accountability of her action of not knowing CNA 1 was allowed to work after an abuse allegation was made against CNA 1. The ADM stated CNA 1 should have been suspended pending investigation as according to the facility's P/P. During an interview on 3/23/2021 at 3:50 p.m., the DSD stated, I was not aware the CNA (CNA 1) should be on suspension. During a subsequent telephone interview on 3/24/2021 at 7:38 a.m., FM 1 stated Resident 1 was discharged on [DATE], it had been planned for her to go home with him to another state, but not this soon. FM 1 stated this abuse incident happened last week and she (Resident 1) felt so disrespected, humiliated (ashamed or embarrassed), and undignified (unworthy) for being handled roughly and sustaining injury. During an interview on 3/24/2021 at 2:15 p.m., the social services director (SSD) stated the ADM and DON came to the facility on [DATE] because Resident 1 called the police stating she was handled roughly during care on 3/17/2021 resulting in injuries. The SSD stated per the resident (Resident 1) she informed two CNAs (CNAs 1 and 4) she did not need to be changed, as she had been changed already. CNA 1 proceeded to change her (Resident 1) anyway and rolled her over and her forehead hit the side rail. The SSD stated Resident 1's right eye was red on the sclera and by the lacrimal (a small bone forming part of the eye socket) and was purple inside the bridge of the nose between the eye and the nose. The SSD stated he did not conduct any other interviews with staff or residents because the ADM conducted the interviews. did it. During an interview on 3/24/2021 at 2:35 p.m., the ADM stated she came to the facility on [DATE] to investigate the abuse allegation after a licensed vocational nurse (LVN 9) told her (the ADM) about the abuse incident and Resident 1 calling the police. The ADM stated she did not see Resident 1 because LVN 9 gave her the information and completed an elderly abuse reporting form. The ADM stated she talked to the nurses and then left the facility. The ADM was asked why she did not interview Resident 1 and the ADM, who was the facility's abuse coordinator (responsible for overseeing the abuse prevention program and ensure that all suspected abuse was reported and all staff are educated on what constitutes abuse), stated she did not have any specific reason why she did not interview Resident 1, she just did not. The ADM agreed that the facility's P/P indicated the resident should be interviewed regarding any allegation of abuse. During a subsequent telephone interview on 3/24/2021 at 3 p.m., FM 1 was very agitated and angry and stated the resident (Resident 1) had a bad bruising to her right eye and redness on the sclera. FM 1 stated, She (Resident 1) made the report and call the cops and the very next day the same staff took care of her. She (Resident 1) was afraid and crying thinking the staff might go into her room and kill her. FM 1 stated Resident 1 suffered physical and mental harm. FM 1 stated he took Resident 1 out of the facility on 3/23/2021 earlier than anticipated and signed her out against medical advice ([AMA] leaving before a physician deems it advisable) because Resident 1 was afraid and did not want to stay in the facility anymore, so he moved her out of state with him. FM 1 stated the resident (Resident 1) thought they were going to kill her, and she did not deserve to be abused. FM 1 was asked to take a picture of Resident 1's eye and send. During an observation of the picture FM 1 sent of Resident 1's right eye, 10 days after the injury occurred, it showed Resident 1's right eye remained swollen with the top eyelid discolored bluish-purple in color and the sclera was red. During a telephone interview on 3/24/2021 at 3:49 p.m., CNA 1 stated on 3/17/2021, on the night shift, both she (CNA 1) and CNA 4 walked into the Resident 1's room and the resident stated, Are you a friend to that other CNA (CNA 2) and are you going to treat me the same way? CNA 1 stated she told Resident 1 she was not CNA 2 and she then proceeded to change Resident 1, while she was laying on a low air loss (LAL) mattress (a flotation mattress designed to prevent and treat pressure wounds). CNA 1 stated both she (CNA 1) and CNA 4 were changing the sheets and cleaning the resident and Resident 1 started yelling and screaming stating, You guys are hitting me and being too rough with me. CNA 1 stated she was not aware of the abuse allegation Resident 1 made against her, as the facility did not investigate nor notify her. CNA 1 stated she had cared for Resident 1 before and never had a problem with her until she found out she (CNA 1) was a friend of CNA 2. CNA 1 stated she worked on 3/18/2021 and was off on 3/19/2021 and 3/20/2021. CNA 1 stated she returned at work on 3/22/2021. During the review of CNA 1 timecard, it indicated she (CNA 1) continued to work on the 11-7 shift on 3/18/2021, 3/19/2021 and 3/22/2021 after the alleged abuse incident on 3/17/2021. During an interview on 3/24/2021 at 4:05 p.m., Registered Nurse 3 (RN 3) stated she readmitted Resident 1 on 3/17/2021 (before the incident) and there was no bluish discoloration to the eye. RN 3 stated Resident 1 was responsive to all the questions needed for re-admission and was calm and cooperative. During an interview on 3/24/2021 at 4:15 p.m., Registered Nurse 1 (RN 1) stated she conducted an IDT meeting on 3/19/2021 and talked to Resident 1 about the incident, but RN 1 stated she was not aware what really happened. During an interview on 3/24/2021 at 4:25 p.m., CNA 3 stated he took care of Resident 1, but he did not have any problems with the resident. CNA 3 stated Resident 1 had mentioned to him about CNA 1 and she (Resident 1) would start crying but he was not sure why, Resident 1 would not complete what she was saying. CNA 3 stated Resident 1 stated, No one believes me. During a telephone interview on 3/24/2021 at 4:38 p.m., CNA 2 stated, I worked with the resident (Resident 1) two months prior and the resident (Resident 1) told the charge nurse I was very mean to her. CNA 2 stated she was interviewed by the SSD back then (no date given) and was asked what happened and the SSD told her not to worry about it and it was okay just leave it alone. CNA 2 stated the facility called her on 3/22/2021 after Resident 1 called the police. CNA 2 stated she continued to take care of Resident 1 even though Resident 1 complained about CNA 2 treatment towards her (Resident 1). During a telephone interview on 3/24/2021 at 5:06 p.m., LVN 7 stated on 3/17/2021, on the night shift, both CNAs 1 and 4 were caring for Resident 1 when the resident started yelling about the bedsheet and not wanting to be changed. Resident 1 was very upset, because she wanted the bedsheet to be removed. LVN 7 stated she heard Resident 1 accusing CNA 1 of abuse and being rough, but the resident was over 300 pounds and of course the staff needed to work harder to clean her and the resident (Resident 1) probably felt like they were rough with her. During an interview on 3/24/2021 at 5:28 p.m., with the Administrator, DSD, Regional Quality Management Consultant, regarding Resident 1's allegation of abuse incident that was reported on 3/17/2021. The DSD stated the DON told her that CNA 1 would probably be suspended due to the allegation of abuse by Resident 1 on 3/19/2021. The DSD stated she called CNA 1 about the abuse allegation and CNA 1 stated she was going to provide a resignation. During a telephone interview on 3/25/2021 at 11:03 a.m., the ADM stated CNA 1 was officially suspended on 3/23/2021 (six days after the incident). The ADM stated I should have started doing the investigation on the same day when I reported the incident to the DPH on 3/20/2021. The ADM stated if it was reported to me as an abuse and the facility should have conducted the investigation immediately. During an interview on 3/25/2021 at 1:57 p.m., regarding the investigation, the DSD stated she could have done something and at least start an investigation. I know it was not specific because the word that was used from Resident 1 was rough handling and I know as the DSD, it could mean a lot of things especially if it resulted to physical injury such as bruising. During a review of facility's P/P titled, Abuse-Reporting & Investigation dated 11/2016, the P/P indicated: it was the facility's policy to report all allegations of abuse as required by law and regulations to the appropriate agencies. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of an unknown source when appropriate. The purpose was to protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation, or injuries of unknown source are promptly and thoroughly investigated, as follow: a. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with facilities policies. b. The Administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation.

Based on interview and record review, the facility failed to follow its policy and procedure and notify the physician when a resident had a change in condition for one of two sampled residents (Resident 1). Resident 1, who had a high risk for falls, complained of pain to the left lower leg with a decline in physical therapy due to pain and the physician was not notified for 13 days. This deficient practice resulted in a delay in [DIAGNOSES REDACTED]. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was originally admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 3/17/18, indicated a Brief Interview for Mental Status (BIMS) score of 15 (13-15= cognition intact (thought process)). The MDS indicated Resident 1 required limited assistance and was dependent in care of a one-person physical assist for walking in the room, transferring and personal hygiene. A review of Resident 1's Fall Risk Assessment, dated 2/17/18, indicated Resident 1 had a high risk for falling. The Assessment indicated a score of 10, a total score above 10 represent High Risk. A review of Resident 1's Care Plan titled, Impaired Activities of Daily Living (ADL)/Physical Functioning/Requiring Extensive one Person Assistance for Ambulation, dated 2/24/18, indicated the staff interventions included to observe and monitor for changes in physical functioning/decline and refer to physical therapy (PT). On 3/30/18 at 3:01 p.m., during an interview, the Physical Therapist (PT) stated that Resident 1 complained of pain to the left lower extremity (LLE) during physical therapy treatment that started on 3/14/18. The PT stated that Resident 1 was able to point to the location of pain, and that he notified the nursing staff of Resident 1's pain to her LLE. A review of Resident 1's PT weekly notes indicated the resident had a decline in ambulation (walking) distances. The note indicated, on 2/19/18, the resident ambulated 200 feet, on 3/19/18 it was 125 feet, and on 3/25/18 it was zero feet. The notes indicated Resident 1 was refusing to ambulate due to pain to LLE. A review of Resident 1's PT notes dated 3/14/18 through 3/27/18, indicated Resident 1 complained of left LLE pain and discomfort during the treatment. The PT's notes indicated the nursing staff was notified. A review a Licensed Personnel Weekly Progress Note, dated 3/14/18, and timed at 8 a.m., indicated Registered Nurse 1 (RN 1) was called by Certified Nurse Assistant 1 (CNA 1) to assess Resident 1's left leg cramps (painful, involuntary contraction of a muscle or muscles). The note indicated Resident 1 was out of bed and sitting on the floor next to the bed. The note indicated that RN 1 called Resident 1's physician and the physician was made aware of the resident's leg cramping episode. The mote did not indicate Resident 1 had sustained a fall. On 3/30/18 at 3:15 p.m., during an interview, RN 1 stated that on 3/14/18, Resident 1 complained of pain to her LLE with generalized body pain. RN 1 stated that the facility did not suspect there was a fracture due to Resident 1's constant complaining of leg cramps. A review of a Licensed Personnel Weekly Progress Note, dated 3/27/18, and timed at 4 p.m., indicated Resident 1 went to the nursing office and complained of LLE pain. The note indicated that Resident 1's physician was notified of the resident's LLE pain after complaining for over 13 days. The note indicated Resident 1's physician ordered a left hip x-ray to rule-out possible fracture. A review of the X-ray result, dated 3/28/18, concluded that there was an acute minimally displaced left femoral (leg bone) neck (top part of the femur (leg bone) is broken, just below the ball and socket joint) fracture. On 6/6/18 at 7:15 a.m., during an interview, Resident 1 stated she did not remember the exact day she fell , but remembered hearing a pop sound and then everything turning dark, and the resident stated she fell to the floor. On 6/6/18 at 8:20 a.m., during an interview, Resident 2, Resident 1's roommate, stated she heard when Resident 1 fell . Resident 2 stated that upon opening the bedside curtain, Resident 1 was observed on the floor facing up next to her bed. Resident 2 stated that after Resident 1 fell she overheard Resident 1 whimpering during the night due to pain. A review of Resident 2's MDS, dated [DATE], indicated the resident had a BIMS score of 15 (13-15= cognition intact (thought process)). The MDS indicated Resident 2 required limited assistance and was dependent in care of a one-person physical assist for walking in the room, transferring and personal hygiene. On 6/6/18 at 10:47 a.m., during an interview, RN 1 stated Resident 1's physician was called and notified regarding the resident's cramping of the left lower leg. RN 1 stated the physician was notified of Resident 1 sitting on the floor, but not of a fall. A review of Resident 1's Medication Administration Sheet (MAR) for the month of 3/2018, indicated the resident received 12 doses (24 tablets) of [MEDICATION NAME] (narcotic pain medication) from 3/14/18 through 3/18/18 (four days) for generalized body pain. A review of Resident 1's Narcotic Record indicated to give [MEDICATION NAME] 50 milligrams (mg) two tablets by mouth, every six hours, as needed for pain management/chronic back pain. The record indicated Resident 1 received 14 doses (28 tablets) from 3/19/18 through 3/28/18. A review of a physician's orders [REDACTED]. A review of the GACH ED (Emergency Department) Provider Note, dated 3/28/18, indicated that Resident 1 presented to the ED complaining of slight left hip with movement. A review of the GACH Discharge Summary, dated 4/3/18, indicated Resident 1 suffered a fall and sustained a left [MEDICAL CONDITION]. The summary indicated Resident 1 underwent open reduction and internal fixation ((ORIF) surgery used to stabilize and heal a broken bone by realigning the bone fracture into the normal position) surgery of the left hip. According to the summary, Resident 1's discharge [DIAGNOSES REDACTED]. On 6/6/18 at 9:18 a.m., during a telephone interview, Resident 1's physician (MD 1) stated that Resident 1 mentioned she had a fall. MD 1 stated that when older residents complain of hip pain, a fracture should be suspected. A review of the facility's undated policy and procedure (P/P) titled, Documenting Physician Notification, indicated that the Licensed nurse in charge of the resident's care shall be responsible for immediate notification of resident's primary care physician for any aspect of resident's care, which may require physician and/or medical interventions including changes in the resident's status or condition.

Based on observation, interview, and record review, the facility failed to provide adequate assistance and supervision, and implement measures to prevent falls for two of 20 sampled residents (Residents 1 and 7) and one randomly selected residents (Resident 21). Resident 1, who required facility staff assistance with transferring and walking and who had a history of [REDACTED]. The resident walked to the bathroom without assistance and fell . The facility staff was aware that the resident walked inside his room and corridor without requesting for assistance but the facility did not put a system in place to supervise the resident when he walked unassisted, and did not provide the appropriate level of assistance (limited assistance) that he required when walking to prevent falls and injury. As a result, Resident 1 sustained a left hip fracture requiring a transfer to a general acute care hospital (GACH), a surgical repair of the fracture, and administration of pain management and blood transfusion. After the fall, Resident 1 experienced a decline in his overall condition, which included the development of pressure sore (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Resident 1's bed was not placed in a low position after re-admission to the facility. This deficient practice had the potential to result in further falls and injury. Resident 7's who was assessed as being at high risk for falls was not placed in the lowest bed position according the plan of care. This deficient practice had the potential to result in further falls and injury. Resident 21, who was assessed as high risk for falls, fell twice in one month. The facility did not implement measures after each fall. This deficient practice had the potential to result in further falls and injury. Findings: a. The facility self-reported an incident to the Department on 9/8/15 that indicated Resident 1 was found sitting on the bathroom floor on 8/30/15, after the resident lost his balance and subsequently fell with resulting pain to the right buttocks. A review of Resident 1's clinical record indicated the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Fall Risk Assessment, dated 6/13/15, indicated the resident had a score of 13. According to the assessment, a total score above 10 represented a high risk for falls. A review of a Fall Risk care plan, dated 6/13/15, indicated Resident 1 was a risk for falls and/or further falls secondary to the resident's history of falls, impaired cognition, impaired vision, impaired mobility and transfer, and having an unsteady gait. The facility staff's approaches included visual checks and monitoring at least every shift, monitoring for the resident's whereabouts at least every shift and as needed, and providing assistance with bed mobility and transferring as indicated. The Fall Risk care plan, revised on 7/13/15, indicated Resident 1 could use the bathroom with supervision. The approaches indicated the facility staff would provide supervision during transfers and ambulation, and check the resident's bathroom needs at close intervals. The care plan did not define the frequency of the close intervals. A review of a physical therapy evaluation and plan of treatment document, dated 6/14/15, indicated Resident 1 was referred for skilled physical therapy (PT) services due to the resident's decline in functional mobility, decreased balance, and poor safety awareness. The treatment plan was for the resident to receive physical therapy from 6/14/15 through 7/11/15. The Rehabilitation Screening Form, dated 6/14/15, indicated Resident 1 required limited assistance (contact guard- therapist in contact with resident via a gait belt (a belt placed around the resident's waist and held by a caregiver in order to help with safe transfers and ambulation), in case physical assistance was needed) with balance activities, such as moving from seated to standing position, turning around and facing opposite direction while walking, surface to surface transfer, and standing balance. A review of the admission Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 6/26/15, indicated Resident 1's cognitive summary score (a determination of a person's mental status) was five out of 15, which indicated the resident was cognitively impaired. According to the MDS, the resident required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with one person physical assist when walking in his room and in the corridor, and required extensive assistance from staff (resident is involved in the activity, staff provide weight-bearing support) during transfers. A review of the 60-Day Scheduled Assessment for Medicare Stay Part A MDS, dated [DATE], indicated Resident 1's cognitive score was nine out of 15 (which means the resident was somewhat functional but confused at times). The MDS indicated the resident required limited assistance when walking in his room and corridor, required extensive assistance during transfers to and from surfaces, and his balance was not steady, but able to stabilize without staff assistance when moving from seated to standing position, walking (with assistive devise if used); turning around and facing the opposite direction while walking, moving on and off the toilet, and surface to surface to surface transfer (transfer between bed and chair or wheelchair. A review of an entry in the licensed personnel progress note, dated 8/30/15 and timed at 2:45 p.m., indicated Resident 1 was found sitting upright on the bathroom floor in his room. The resident told the staff he had attempted to close the bathroom door and lost his balance. The progress notes indicated the resident denied hitting his head and was able to move all extremities freely, but complained of right buttock pain. According to the note, the resident was assisted back to bed and was given pain medication. The facility staff conducted neurology checks for 72 hours. A review of a Fall Risk Assessment, dated 8/30/15, indicated Resident 1's risk for fall was re-assessed and his score was 14, which represented a high risk for falls. A review of the Resident Care Conference (interdisciplinary team (IDT) meeting), dated 9/1/15 (two days after the fall incident), indicated during the meeting, Resident 1 complained he had been having left hip pain and an order for [REDACTED]. The x-ray was positive for a fracture of the left head of the femur (the larger bone in the upper leg). The resident was transferred to the GACH (general acute care hospital) per the physician's orders [REDACTED]. A review of the GACH's records indicated Resident 1's chief complaint was status [REDACTED]. According to the Operative note, dated 9/3/15, the resident underwent [REDACTED]. Resident 1 received intravenous (IV) antibiotics (Ancef), pain management, anticoagulant therapy, and blood transfusions due to the resident's low blood count. Resident 1 required a five day admission to the GACH (9/2-9/7/15) for care and treatment and was transferred back to the SNF on 9/7/15. A review of the clinical record indicated Resident 1 was re-admitted to the facility on [DATE]. A review of the Admission Nursing Assessment, dated 9/7/15, indicated the presence of a deep tissue injury (DTI) ulcer on the sacral area and on the right buttock (DTI is a pressure-related injury to subcutaneous (beneath outer layer of skin) tissues under intact skin that has the appearance of a deep bruise and may be an indicator of subsequent development of a Stage III-IV pressure ulcer. On 9/22/15 at 1:40 p.m., during the initial tour of the facility, Resident 1 was observed lying on a regular bed, and was awake and resting quietly. The bed height appeared to be two and a half to three feet from the mattress surface to the floor. There were no floor mats on either side of the bed. There was an abductor pillow in place (a special pillow used to keep a hip in stable position following surgery and used to pull a body part away from the midline of the body) between the resident's legs. On 9/23/15 at 9:40 a.m., Resident 1 was lying in bed that was in a low position and had an indwelling urinary catheter, (a tube which is inserted into the bladder and left in place in drain urine) in place for wound management. The resident had pulled the bedsheet over his head, but removed the sheet and was disoriented. The resident was able to respond to simple questions. On 9/23/15 at 2:50 p.m., during a concurrent interview with the director of nursing (DON) and the quality assurance (QA) nurse, the DON stated she was unaware Resident 1's bed was not in a low position the day prior (9/22/15), then stated the resident should have been on a low bed. The QA nurse also indicated the resident's bed should be kept in low position, due to the resident was a high risk for falls. The QA nurse stated that prior to the resident's fall incident, the resident required supervision to get up. On 9/23/15 at 4:15 p.m, Resident 1's fall incident was discussed with the administrator. When questioned if the resident was aware that he needed to ask for assistance with getting up, the administrator stated, during an interview, the resident was aware, but the resident wanted to get up by himself. The administrator stated that after Resident 1's fall, there was no observations of redness, swelling, or hip deformities, no complaints of left hip discomfort, and that the resident was still able to ambulate. On 9/23/15 at 3:50 p.m., Resident 1's fall incident was discussed with the certified nursing assistant (CNA 3). During an interview, CNA 3 stated Resident 1 was confused at times but would occasionally walk to the doorway of his room unassisted. On 9/23/15 at 3:55 p.m., Resident 1's fall incident was discussed with CNA 4. During an interview, CNA 4 stated the resident was able to walk around his room by himself, and would put his call light on for assistance when he needed to go to the bathroom. CNA 4 stated the resident initially required more assistance when first admitted , but became stronger and was able to walk around his room without assistance. A review of the clinical record indicated there was no documented evidence a system to supervise the resident was put into place to prevent falls when Resident 1 would get up from the bed unassisted, since the facility staff was aware that Resident 1 would get up unassisted and walk around in his room. On 9/23/15 at 4 p.m., during an interview, a licensed vocational nurse (LVN 4) stated that prior to Resident 1's fall, she observed the resident walking unassisted in his room and in the hallway and to the bathroom by himself, although the resident was assessed to require supervision with walking. When questioned how the resident's balance was at that time, LVN 4 replied, He had a side to side gait- it wasn't perfect. LVN 4 stated she had observed the resident occasionally holding onto the handrail while walking in the hallway and that the staff would remind him to be careful. LVN 4's observation was not consistent with the resident's comprehensive assessment, which indicated the facility staff would provide limited assistance to the resident when the resident was walking. On 9/26/15 at 8:45 a.m., Resident 1 was lying in bed. When asked whether he recalled falling, the resident initially replied, No, then stated, Yes, I remember now. When asked if he was able to recall where he fell , the resident replied, In building, here. When questioned what he was doing at the time of the fall, the resident responded, I don't remember, I fell , that's all I remember. On 9/26/15 at 11:55 a.m., during an interview, CNA 5 stated that after the fall incident, Resident 1 was unable to feed himself and required total care. On 9/26/15 at 2:15 p.m., during an interview and review of the monthly incident logs, the administrator stated that fall concerns were addressed by the safety committee. When questioned whether the facility had conducted a Quality Assurance Performance Improvement (QAPI) project regarding fall prevention, the administrator replied that she had recently mentioned to the DON that they probably needed to do a QAPI on falls. On 9/26/15 at 2:30 p.m., an interview was conducted with the RN supervisor. The supervisor stated he and the DON had recently discussed the resident falls, but they were unable to come to any conclusions. The supervisor then stated, We have had different situations, like assisted falls- it's not always confused, elderly residents, not what you would think. Some of the residents were alert and oriented, but want to be independent and get up by themselves. b. A review of Resident 7's admission face sheet indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/24/15, indicated Resident 7 had no impairment in cognitive skills, made self-understood and understood by others, and required extensive assistance on staff with eating, toileting, dressing, and personal hygiene care. During an observation and interview, on 9/23/15 at 8:25 a.m., Resident 7's bed was raised in mid-position and not in the lowest position that the bed was allowed to go down to. Behind the resident's bed, a picture of a falling star card (to alert staff that the resident was high risk for fall) was posted on the wall. Resident 7 stated his bed was too high, and that it was unsafe and he could fall. On 9/23/15 at 8:35 a.m., during an interview, the licensed vocational nurse (LVN 2) stated Resident 7 was at risk for falls and proceeded to lower the resident's bed into its lowest position. LVN 2 stated the bed should not have been left raised position. During another interview on 9/25/15 at 1:20 p.m., the certified nursing assistant (CNA 2) stated if there was a picture of a falling star posted in the resident's room, it indicated the resident was at risk for falls. CNA 2 stated Resident 7's bed should be in lowest position to prevent falls. A review of Resident 7's, Fall Risk Assessment dated 8/18/15 indicated the resident had a score of 10. The assessment form indicated that a score is 10 or greater would indicate that the resident should be considered as being at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. A review of Resident 7's, Resident Long Term Care Plan for Falls indicated the facility should provide a safe environment with proper arrangement of furniture. c. A review of Resident 21's admission face sheet indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 21's MDS, dated [DATE], indicated the resident did not have any impairment in cognitive skills, was able to make himself understood, and understood others, and required extensive assistance (weight bearing support at all times from staff) with all activities of daily living. During an observation, on 9/26/15 at 8:40 a.m., a picture of a falling star was posted on the wall behind Resident 21's bed. During an interview, on 9/26/15 at 8:50 a.m., Resident 21 stated he could not remember how many falls he has had in the facility. A review of Resident 21's, Fall Risk Assessment, initiated on 7/18/15, indicated the resident had a total score of 10 on 7/18/15, 11 on 8/7/15, 13 on 8/29/15, and 15 on 9/17/15. The assessment form indicated if the total score was 10 or greater, the resident should be considered as being at high risk for potential falls. During an interview and record review, on 9/26/15 at 11:50 a.m., licensed vocational nurse (LVN 3) stated Resident 21 has had three or more falls since 8/7/15. LVN 3 stated after each fall, there should be an IDT (interdisciplinary team) meeting to discuss the resident's fall and update the care plan to prevent any more falls. LVN 3 stated during the review of the resident's care plan for falls, that there were no changes in the nursing interventions. The care plan indicated frequent monitoring without a set timeframe of how often to conduct the monitoring. A review of Resident 21's clinical record, Resident Long Term Care Plan for Falls, dated 7/13/15, did not have updated nursing interventions to prevent subsequent falls. During an interview, on 9/26/15 at 2:55 p.m., the quality assurance nurse (QA) stated that residents with three or more falls were to be placed on hourly rounds and the documentation of the hourly rounds would be posted in the residents' rooms.