Every finding on record at Oak Grove Post Acute

Based on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for two residents (Resident 1 and Resident 2) of 2 sampled residents, when Resident 1's and Resident 2's low-air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) was not correctly calibrated according to their current weights. This deficient practice had the potential to place Resident 1 and Resident 2 at increased risk for developing pressure injuries and/or worsening of their existing skin conditions.Findings: a.During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility with multiple diagnoses including senile degeneration of brain (a medical term when imaging or exams show generalized brain shrinking. A progressive loss of memory, reasoning, and judgement that interferes with daily life), contracture of right and left hand (a permanent tightening and shortening of muscles, skin, or other soft tissues that makes a joint stiff and hard to move), cerebral infarction (it is the death of brain tissue caused by a prolonged lack of blood flow and oxygen), and palliative care (specialized medical care for people living with a serious, chronic, or life-threatening illness). During an observation on 8/21/26, at 9:42 AM, Resident 1 observed lying in bed on a LAL mattress that was set between 120 and 150 pounds (LBS-a unit of measurement), with the pressure adjustment knob positioned approximately midway between the 120 and 150 LBS body weight setting. During a concurrent observation and interview on 8/21/26, at 10:32 AM with the Licensed Nurse (LN) 1, Resident 1 was observed lying in bed on a LAL mattress that was set up between 120 and 150 LBS. LN 1 confirmed the finding and stated that the pressure adjustment knob was positioned approximately midway between the 120 and 150 LBS setting. LN 1 stated that Resident 1 was at risk for developing skin breakdown and pressure injuries and that the purpose of the LAL mattress was to help prevent development of PI. LN 1 stated that nurses were responsible for monitoring the mattress pressure pump and adjusting the pressure according to Resident 1's most current weight every shift. LN 1 further stated that if the air pressure had not been adjusted correctly, either lower or higher than Resident 1's current weight, it could increase the risk of developing PI. During a follow-up interview and record review on 8/21/26, at 10:38 AM, Resident 1's medical record titled Weights & Vitals, dated 8/12/26 was reviewed with LN 1. The review indicated Resident 1's weight was 110.6 LBS on 8/12/26. LN 1 confirmed the finding and stated the air pressure should be adjusted based on Resident 1's current weight to reduce the risk of skin injury and relieve pressure on Resident 1's body. During review of Resident 1's medical record titled Order Summary Report, dated 8/21/26, the review indicated, .May have LAL mattress. every shift for d/t (due to) Hx (history) of PI. with an active date of 6/15/26. During review of Resident 1's medical record titled Braden Scale for Predicting Pressure Ulcer Risk (pressure ulcer, areas of damaged skin typically caused by staying in one position for too long), dated 6/18/26, the scale indicated Resident 1 had a score of 9 (at very high risk, for the development of pressure ulcer). During review of Resident 1's medical record titled Care Plan Report, indicated, .Focus. Risk for IMPAIRED SKIN INTEGRITY due to limited mobility.limited ROM (range on motion) to RUE (right upper extremity), limited ROM to BUE (bilateral [both] upper extremities.contractures.increase risk for skin break down. Interventions.LAL intended to prevent unwanted outcomes before they happen) in place for prophylactic (skin management d/t hx [history] of pressure injury. Monitor function and manufacture's guidelines. the intervention was initiated on 12/15/25. b.During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted to the facility with multiple diagnoses including hidradenitis suppurativa (a long-term inflammatory skin condition that causes painful, boil-like lumps top form deep under the skin), and functional quadriplegia (the complete inability to move the limbs or walk due to severe physical frailty or advanced disease). During a concurrent observation and interview on 8/21/26, at 11:11 AM, Resident 2 was observed lying in bed on a LAL mattress that was set to 540 LBS. Resident 2 stated that she had a long-term skin condition that caused her to develop wounds. Resident 2 explained that the LAL mattress was provided to her to promote comfort and relieve pressure on her skin due to her skin breakdown. Resident 2 stated that she had been using the LAL mattress for more than a year; however, the mattress was uncomfortable to lie on. Resident 2 further expressed concern that the LAL mattress was not functioning properly. During a concurrent observation and interview on 8/21/26, at 11:18 AM with LN 2 in Resident 2's room, LN 2 confirmed that Resident 2 was lying on a LAL mattress which the air pressure was set at 540 LBS body weight. During a follow-up interview and record review on 8/21/26, at 11:23 AM, Resident 2's medical record titled Weights & Vitals, dated 8/3/26 was reviewed with LN 2. The review indicated Resident 2's weight was 194.2 LBS on 8/3/26. LN 2 confirmed the finding and stated the air pressure should be adjusted based on Resident 2's current weight to relieve pressure on Resident 2's body and prevent worsening of skin condition. LN 2 explained that Resident 2 had diagnosis of hidradenitis suppurativa and that there was an increased risk of worsening of the skin condition when LAL mattress air pressure was not adjusted according to Resident 2's current weight. LN 2 further stated that Resident 2's existing skin condition could be worsened, rather than providing the intended pressure relief, comfort, and prevention of additional skin breakdown. During review of Resident 2's medical record titled Order Summary Report, dated 8/21/26, the review indicated active orders included: LAL mattress in place. Monitor function and setting with manufacturer specification. every shift with an active date of 4/23/25, Skin excoriation to R [right] buttock .D/C [discontinue] when resolve. Every shift with an active date of 2/14/25, TX-Left leg hidradenitis. with an active date of 9/30/25, and TX-Right leg hidradenitis. with an active date of 9/30/25. During review of Resident 2's medical record titled Braden Scale for Predicting Pressure Ulcer Risk, dated 1/16/26, the scale indicated Resident 2 had a score of 18 (at risk, for the development of pressure ulcer). During review of Resident 2's medical record titled Care Plan Report, indicated, .Focus. Risk for development and emergence of an unavoidable.skin breakdown and other superficial skin conditions related to the presence of medical conditions. Interventions.Provide pressure reduction/relieving mattress. the intervention initiated on 9/5/24. During an interview on 8/21/26, at 2:25 PM, the Treatment (Tx) Nurse stated that the purpose of LAL mattress was to reduce the risk of pressure injuries to bony prominences by relieving pressure on the skin and promoting wound healing. The Tx Nurse stated that nurses were responsible for monitoring the functionality of the LAL mattress and adjusting the air pressure according to each resident's current weight every shift. The Tx Nurse further stated that when a LAL mattress was not appropriately adjusted according to the resident current weight, the resident could be at increased risk for developing PI and/or worsening of the existing skin conditions. During an interview and record review on 8/21/26, at 3:49 PM with the Director of Nursing (DON), the facility provided undated LAL mattress operator's manual for Resident 1's LAL mattress for [Brand Name], was reviewed with the DON. The review indicated, . INDICATIONS. is indicated for the prevention and treatment of any and all stage pressure ulcers [localized damage to the skin and underlying soft tissue, usually over a bony areas of the body] .PRODUCT FUNCTIONS. Pressure-adjust knob (2) Determine the patient's weight and set the control knob to that weight setting on the control unit. Also, the review of the facility provided LAL mattress user manual for Resident 2's LAL mattress, dated 2014 for [Brand Name], indicated, .INTENDED USE.mattress is designed for bed sore and wound care therapy treatment and prevention.Controls and Feature. COMFORT.To increase or decrease airflow for a softer or firmer setting between 1 to 10 range.HOW TO USE.Position on the Pressure knob 2.Weight 180-270 LBS. The DON stated that the purpose of using the LAL mattresses for Resident 1 and Resident 2 was to relieve pressure on bony prominences, prevent skin injuries, and support wound management. The DON explained that residents with limited mobility were at increased risk for developing PI and that, when the air pressure on the LAL mattresses was not appropriately adjusted according to the residents' current weights, there was an increased likelihood of developing pressure injuries and/or worsening existing wounds. The DON further stated that her expectation was for nursing staff to monitor the functionality of the LAL mattresses and appropriately adjust the air pressure according to each resident's current weight every shift. The DON acknowledged that this expectation had not been met. During a review of the facility provided undated policy statement, the review indicated, .The facility will provide specialized.Support Surfaces (Low Air Loss Mattresses) to residents who meet specific clinical criteria for the prevention of skin breakdown or the treatment of advanced pressure injuries. The equipment will be operated, monitored, and sanitized according to manufacturer guidelines.to ensure resident safety and therapeutic optimization.

Based on observation, interview, and record review, the facility failed to maintain one of three shower stations in good working order for a total of 105 residents when, the North shower station remained nonfunctional despite documented maintenance requests, resulting in residents being transported to other shower areas, waiting for available showers, and having showers delayed or postponed. This failure had the potential to affect residents' dignity and timely access to scheduled showers.Findings:During a concurrent observation and interview on 8/10/26 at 2:46 PM with Certified Nursing Assistant (CNA) 1, the North shower station was observed with no water coming from the shower fixture. CNA 1 stated that the North shower station had been broken for approximately three months. CNA 1 stated that the nonfunctional shower resulted in overlapping shower schedules because residents had to wait until another resident finished using one of the working showers. CNA 1 further stated that some residents changed their minds while waiting and postponed their showers until the following day. CNA 1 stated that the North shower station needed repair.During a review of Work Order #2443 dated 6/19/26 at 4:03 PM, the work order indicated that the north shower room did not have water coming out. The work order also indicated that the work order was completed on 6/20/26 at 10:11 AM.During a review of Work Order #2497 dated 7/2/26 at 7:06 AM, the work order indicated, shower room not working at North station. The work order indicated that it was completed on 7/11/26 at 1:49 PM. The same work order indicated that it was Set to Open on 8/10/26 at 3:47 PM. During a review of plumbing company service QUOTE #27210 dated 8/7/26, the quote indicated, .Estimate to install a new 'Delta' brand single handle shower valves in the shower room on the North side of the facility.this is the middle shower.We will access the plumbing from the shower side of the wall. We will cut out a small portion of the tile.we will install all necessary piping fillings to complete the job. the quote was approved on 8/7/26.During an interview on 8/10/26 at 3:12 PM with Licensed Nurse (LN) 1, LN 1 stated that the North shower station had been broken for a long time. LN 1 stated that residents assigned to the North shower area were transported to the Central or South shower rooms. LN1 stated that residents were transported through the hallway wrapped in a towel and described this as a dignity concern. LN 1 also stated that transporting residents farther from their assigned area represented a safety concern. LN 1 further stated that the nonfunctional North shower caused scheduling conflicts and that residents sometimes did not receive their scheduled showers because CNA's were busy and the available schedules conflicted.During an interview on 8/10/26 at 3:28 PM with the Maintenance Assistant (MAA), the MAA stated that the north shower station had been broken for approximately two (2) months.During an interview on 8/10/26 at 4:30 PM with Resident 1, Resident 1 stated that the North shower was broken and that the resident refused to go across the hallway to use another shower. Resident 1 stated, I think it is degrading to go all the way to the shower with a sheet over you.During an interview on 8/10/26 at 4:45 PM with Resident 2, Resident 2 stated that he was taken to a shower located farther from his area and he had not previously missed a shower. Resident 2 stated that on 8/10/26, he was scheduled to shower after lunch and was still waiting for his shower at the time of interview.During an interview on 8/10/26 at 5:05 PM with CNA 2, CNA 2 stated that the residents were taken to either the South or Central shower station because the North shower station was broken. CNA 2 stated that she sometimes had to wait outside a shower room with a resident while another resident was using the shower. CNA 2 stated that this was inconvenient to residents and that earlier that afternoon, she and a resident waited outside a shower room for approximately 5 minutes or longer. During an interview on 8/10/26 at 5:15PM with the Director of Nursing (DON), the DON stated that residents from the North area were taken to Central shower station because it was the closest available shower.During a concurrent interview and record review on 8/12/26 at 12:04 PM with the DON and the Infection Preventionist/Administrator-in-Training (IP/AIT), the DON stated that the facility did not have a shower policy. The DON stated that having one of the facility's three showers nonfunctional could result in delayed showers and shower-scheduling conflicts.During a review of the facility's policy titled, Maintenance Service, revised on 12/09, indicated, .The Maintenance Department is responsible for maintaining the buildings, ground, and equipment in a safe and operable manner at all times. The policy further indicated that maintenance personnel were responsible for maintaining the building in good repair and maintaining plumbing fixtures in good working order.

Based on observation, interview, and record review, the facility failed to ensure the clinical record was complete and accurately reflected the psychiatric (mental health) care provided for one of five sampled residents (Resident 3), when the clinical record did not contain documentation of a psychiatric consultation referenced as completed in the resident's progress notes, and facility staff could not determine from the clinical record whether a psychiatric consultation had been completed.This failure had the potential to result in incomplete information regarding Resident 3's psychiatric care being available to staff responsible for coordinating and providing his care.Findings:During a review of Resident 3's admission RECORD, the record indicated Resident 3 was admitted to the facility with a diagnosis of major depressive disorder (a mental health condition that causes ongoing feelings of sadness and loss of interest in usual activities), among other diagnoses.During a concurrent observation and interview on 8/13/26 at 9:15 AM with Resident 3, Resident 3 was observed engaged in conversation and interacting pleasantly with staff. Resident 3 stated that he felt more depressed, that his medications did not seem to work, and that he had a psychiatrist. Resident 3 further stated that he last spoke with his psychiatrist approximately two months earlier.During an interview on 8/13/26 at 11:31 AM with the Social Services Assistant (SSA), the SSA stated that Resident 3 had not reported feeling depressed to her and that she was not aware of a psychiatric referral for the resident.During a review of the facility's Progress Notes, dated 2/6/26 at 6:23 PM, the progress note indicated Resident 3 had a diagnosis of depression and was receiving duloxetine (medicine that treats depression) 20 milligrams (mg) daily and trazodone (a medicine for depression that can also help with sleep) 25 mg twice daily. The progress note further indicated that a telephone follow-up with the resident's Licensed Clinical Social Worker (LCSW) was scheduled on 2/25/26 and a psychiatric consultation had been ordered on 2/3/26.During a review of Resident 3's Order Entry, dated 4/1/26, two orders indicated mental health telephone visits with the Licensed Clinical Social Worker (LCSW) were scheduled for 4/12/26 and 4/14/26, both at 7:30 AM.During a review of the facility's Progress Notes, dated 4/27/26 at 1:26 AM, the progress note indicated that a depression screening was completed for Resident 3. The depression screening documented a mood behavior total score of 12, which was identified as mild/moderate depression. Under the assessment and plan, the progress note indicated that .a recent psychiatry consult completed. and that a previously scheduled telephone follow-up with the LCSW had occurred.During a concurrent interview and record review on 8/13/26, at 12:15 PM, Resident 3's clinical record was reviewed with the Infection Preventionist/Administrator-in-Training (IP/AIT) and the Assistant Director of Nursing (ADON). The IP/AIT stated that the psychiatric evaluation/consultation ordered on 2/3/26 was not completed and that the facility did not have documentation of the psychiatric consultation in Resident 3's clinical record. During the continued interview and record review, the IP/AIT identified a Social Services progress note, dated 8/13/26 at 12:36 PM, which documented, .Referral sent for Psych Evaluation. At 2:24 PM, the Assistant Director of Nursing (ADON) joined the interview and stated that she contacted [Hospital Name] Mental Health and was informed that Resident 3 had received a psychiatric consultation by telephone. The ADON stated that the hospital's mental health department would send the consultation documentation to the facility.

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were coordinated and followed up for one of five sampled resident (Resident 3) reviewed for dialysis care when the resident's scheduled arteriovenous (AV) fistula (a surgically created connection between an artery and a vein used for dialysis access) procedure was canceled on 7/9/26, and the facility did not contact the vascular clinic to reschedule the procedure until 8/12/26.This failure had the potential to delay the establishment of a permanent dialysis access and prolong Resident 3's use of an existing chest dialysis access which posses an increased risk for infection. Findings:During a phone interview on 8/12/26 at 11:11 AM with Resident 3, Resident 3 stated his AV fistula surgery had been canceled approximately five weeks earlier because his blood glucose was too high. Resident 3 stated the facility was aware that the surgery had been canceled. Resident 3 stated he had not received a new surgery date.During a concurrent interview and record review on 8/12/26 at 12:04 PM with the Director of Nursing (DON) and the Infection Preventionist/Administrator-in-Training (IP/AIT), the DON and IP/AIT confirmed Resident 3's AV fistula procedure was canceled on 7/9/26. The DON stated the facility should have contacted the surgical clinic or office after the resident returned to the facility to determine the acceptable blood glucose level for anesthesia. The DON stated there was a lack of communication among departments and that the facility needed to advocate for Resident 3 and be a part of his care. The DON further stated Resident 3's dialysis access was located in his chest and was not the preferred method for a permanent dialysis access. During a review of the facility's Progress Notes, dated 2/2/26 through 8/12/26, the progress notes indicated that on 2/6/26 at 6:23 PM, Resident 3 had a right internal jugular tunneled dialysis catheter (TDC, a tube placed into a large vein and used for dialysis) placed on 12/30/25 and he was started on dialysis that day. On 6/9/26 at 9:09 PM, the progress note indicated Resident 3 returned from an appointment related to his dialysis catheter with instructions that (Hospital name) would call regarding surgery to the resident's left arm and to follow up regarding the appointment. On 7/9/26 at 7:53 AM, the progress notes indicated Resident 3 left the facility at 6:30 AM for a scheduled surgical appointment for creation of an AV Fistula. On 7/9/26 at 12:10 PM, the progress notes indicated Resident 3 returned to the facility after the procedure was canceled because his blood glucose and blood pressure were elevated, making anesthesia unsafe to administer. On 7/10/26 at 6:56 PM, the primary care physician (PCP), who was also the facility physician, documented that the AV fistula creation had been canceled and needed to be rescheduled. The next documented follow up in the progress notes regarding rescheduling the AV fistula procedure was on 8/12/26 at 3:02 PM.During a concurrent observation and interview on 8/13/26 at 9:15 AM with Resident 3, Resident 3 was observed to have a catheter located on his right chest. Resident 3 stated that after he returned to the facility following the canceled procedure, he informed the charge nurse. Resident 3 stated the charge nurse told him he needed to speak with his physician. Resident 3 further stated that no one had spoken with him about rescheduling the AV Fistula procedure.During a concurrent interview and record review on 8/13/26 at 12:15 PM with the IP/AIT, the IP/AIT stated there was no copy of the paperwork regarding Resident 3's cancelled AV fistula procedure in the facility's system. The IP/AIT stated there was no comprehensive care plan addressing Resident 3's AV fistula scheduling and follow-up. The IP/AIT stated the vascular clinic had not been contacted to reschedule Resident 3's AV fistula procedure before 8/12/26 and the nephrologist and dialysis center had not been contacted or notified that the AV fistula procedure had been canceled. The IP/AIT stated there was no official tracking system for appointments and referrals until 8/1/26, and that no one followed up with rescheduling the AV fistula procedure until 8/12/26 because of a broken process. The IP/AIT stated the risk associated with Resident 3's continued use of his current dialysis chest access was infection. During a review of the facility's undated policy and procedure titled, Appointments, the policy indicated .Access to Specialty Providers: The facility will help residents contact specialty providers as needed, based on health recommendations.Appointment Assistance: The Facility will assist in scheduling appointments.Communication: Licensed nurse informs the social services department or designee about the appointment order.Appointment Scheduling: The licensed nurse or designee schedules appointments based on medical necessity and other factors.

Based on interview, and record review, the facility failed to provide written notice to the State Agency (SA) at the time of the position change of the Director of Nursing (DON) for a census of 104 residents, when the current DON started the DON position on 6/26/26, and the facility did not report the change of the DON position to the SA as of 7/9/26.This failure delayed the SA from verifying that the DON was qualified to lead clinical services at the skilled nursing facility, which had the potential to compromise resident safety and compliance with federal and state regulation for a census of 104 residents.Findings:During an interview on 7/9/26, at 10:30 AM, with the Administrator (ADM), the ADM stated the facility had a new interim DON. The ADM further stated she had paperwork for the notification of change of the DON, form HS 215A (The form is used to verify compliance with state health and safety regulations during the facility licensing process or when changes in ownership/management occur. Requires owners, operators, and key management of health or community care facilities to disclose their personal details, employment history, criminal records, and affiliations with other licensed care facilities).During an interview, on 7/9/26, at 12:07 PM, with the DON, the DON stated she started working at the facility on 6/26/26 as the interim DON. During a concurrent interview and record review on 7/9/26, at 3:10 PM, with the DON, the DON's HS 215A form was reviewed. The DON confirmed that she signed the form on 7/8/26. The DON stated that she was aware of the state requirement to submit the application.During an interview on 7/9/26, at 3:12 PM, with the ADM, the DON's HS 215A form was reviewed. The ADM confirmed that it had not been submitted to the SA. The ADM stated that the purpose to submit the application form was for license verification along with the applicant's work history and resume. The ADM further stated that it was important to submit this form to the SA to provide notification of change as to who managed the facility. The ADM stated that if the change of leadership notification was not submitted timely, the SA would not be able to determine if proper staff were in place.A review of the SA database did not indicate the DON application was received from the facility.

Based on observation, interview, and record review, the facility failed to ensure a safe environment free of hazards for two of three sampled residents (Resident 1 and Resident 2) who were at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), when: 1. Resident 1 and Resident 2's physician order for checking placement and function of the wander guard device (an alarm that alerts the facility when a wandering resident tries to leave the facility unattended) was not followed; and, 2. Resident 1 and Resident 2's monitoring of their wander guard placement (where the device is located on the body) and function were not consistently documented for the month of April 2026.These failures placed Resident 1 and Resident 2 at risk for elopement and had the potential to result in an injury.Findings:1a. A review of Resident 1's admission RECORD, indicated that Resident 1 was admitted to the facility with diagnoses which included anxiety disorder (excessive, persistent, and uncontrollable fear or worry that interferes with daily life) and multiple sclerosis (long term brain disease that causes weakness, fatigue, numbness/tingling, vision problems, and poor balance).A review of Resident 1's Order Summary Report indicated, Check wander guard for placement every shift .Order Date .4/09/2026 .A review of Resident 1's Care Plan Report initiated on 4/9/26, under the section titled, Focus, indicated, .Risk for Wandering/ Elopement Identified . Further review of the document indicated, .Interventions/ Tasks.Wander Guard to RUE [right upper extremity].During a concurrent observation and interview on 4/22/26, at 8:28 AM, with Licensed Nurse (LN) 1, in Resident 1's room, Resident 1 was observed at bedside without a wander guard. LN 1 confirmed that Resident 1 was not wearing a wander guard device.During a concurrent observation and interview on 4/22/26, at 8:42 AM, with the Assistant Director of Nursing (ADON), Resident 1 was observed without a wander guard. The ADON confirmed that Resident 1 was not wearing a wander guard device. Resident 1 stated she did not know where her wander guard was. The ADON stated a wander guard device was indicated for Resident 1 because she had a behavior of trying to go out and could propel her wheelchair. The ADON further stated that if Resident 1 was not wearing her wander guard device then there was a risk of Resident 1 eloping. The ADON stated Resident 1 was confused and it was not safe for her to be outside unsupervised. The ADON further stated she expected staff to monitor the wander guard device by checking its placement and if it was working. 1b. A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility with diagnoses which included an anxiety disorder.A review of Resident 2's Order Summary, indicated, .Monitor wandergard [sic] for functioning every shift .Monitor wandergaurd [sic] placement daily every shift .Order Date 4/6/2026 .A review of Resident 2's Care Plan Report revised on 8/7/23, under the section titled, Focus, indicated, .risk for Elopement related to WANDERING . Further review of the document indicated, .Interventions.monitor function and placement of wanderguard daily every shift. During a concurrent observation and interview on 4/22/26, at 9:14 AM, with the ADON, Resident 2 was observed without a wander guard. The ADON confirmed Resident was not wearing a wander guard device. The ADON further stated they did not know when Resident 2's wander guard was removed.During an interview 4/22/26, at 9:47 AM, with LN 1, LN 1 stated he did not receive a report from the NOC (night) shift as to why Resident 2's wander guard was removed. LN 1 further stated that he just saw the wander guard on the med cart. LN 1 stated when a wander guard device was noted to be missing or was not functioning, the nurse needed to notify the DON (Director of Nursing) to have the wander guard replaced. LN 1 stated he was not sure if another wander guard was available for Resident 2.2a. During a concurrent interview and record review on 4/22/26, at 8:42 AM, with the ADON, Resident 1's Medication Administration Record (MAR) for the month of April 2026 was reviewed. The ADON confirmed that the NOC shift on had documented that Resident 1's wander guard had been checked for placement and function on 4/21/26. The ADON further confirmed the day shift did not document the placement and function of Resident 1's wander guard on April 11,12, 15, 16, 17 and 18. 2b. During a concurrent interview and record review on 4/22/26, at 9:14 AM, with the ADON, Resident 2's MAR for the month of April was reviewed. The ADON confirmed that NOC shift documented on 4/21 that Resident 2's wander guard was functioning. The ADON further confirmed the day shift did not document if Resident 2's wander guard was functioning on April 11, 12, 15, 16, and 17 and were left blank on the MAR.During a concurrent interview and record review on 4/22/26, at 10:38 AM, with the DON, Resident 1's electronic medical record was reviewed. The DON stated Resident 1 had exit seeking behavior and had tried to leave the facility to go to the store. The DON confirmed Resident 1 had an order for the wander guard and it was also part of Resident 1's care plan. The DON stated the nurses were responsible for checking the placement and function of the wander guard every shift. The DON further stated the risk for a resident to not wear their wander guard could lead the resident to wander outside of the facility. The DON stated she expected the nurses to inform her or a supervisor if a resident's wander guard was missing or not functioning. A review of an undated facility policy and procedure (P&P) titled, Tab Alarms, Bed Alarms, Wanderguard System, indicated, .Wanderguard would be used for residents at risk for elopement.The Wanderguard bracelet will be applied to the resident's wrist or ankle and not removed until replacement is needed.The Wanderguard bracelets are checked daily on the night shifts by the Supervisor and are documented in the treatment book on the units.A review of the facility's P&P titled, Leave of Absence without Notice (LAWN), dated 1/16/26 indicated, .a resident deemed at risk for Leave of Absence without Notice by IDT are to consider the following measures but not limited to: Initiate/Update plan of care Consider application of a wander guard in collaboration with the physician and responsible party In the absence of a wander guard system the IDT to collaborate and identify measures necessary to avoid leaving the facility without notice/authorization.

Based on observation, interview, and record review, the facility failed to ensure a garbage dumpster lid was maintained to properly cover the contents and preventing the harborage and feeding of pests in one of two facility dumpsters.This deficient practice had the potential of disease spreading among residents and visitors by vermin and pest infestation for a census of 109.Findings: During an observation on 4/6/26 at 10:08 AM, two outdoor garbage dumpsters were observed with one bin noted to not be fully closed. During a concurrent observation and interview on 4/8/26, at 4:27 PM, with the Dietary Manager (DM), the outdoor garbage dumpster was observed with an opening in between the lids and was not tightly closed. A two inches gap in-between the lids was also observed. The DM stated that the opening would allow pests to get inside of the garbage dumpster. During a review of the facility's policy and procedure titled, Dispose of Garbage and Refuse, revised 2/25, indicated, .All garbage and refuse will be collected and disposed of in a safe and efficient manner.The Dining Services Director will ensure that:.Appropriate lids are provided for all containers.All trash will be properly disposed of in external receptacles (dumpsters) with lids covered when not in use. Review of the US Food Code 2022, section 501.116 on Cleaning Receptacles, indicated Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. All containers must be maintained in good repair and cleaned as necessary in order to store garbage and refuse under sanitary conditions as well as to prevent the breeding of flies. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. (https://www.fda.gov/food/fda-food-code/food-code-2022)

Based on observation, interview, and record review, the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 102 residents who ate facility prepared meals when:1) Kitchen walls, ceiling vent area, and floor were observed with chips in the paint, drywall, and tiles;2) The can opener, red cutting board, and 2 fry pans were observed worn and damaged;3) Food items (sausage patties and container of rice) were found stored but exposed to air; and4) The resident refrigerator in the center nursing hallway had five days of temperatures logged above the safe food range without intervention, and the north resident refrigerator was observed with ice buildup covering the freezer.These failures had the potential to put residents at risk for foodborne illnesses.Findings: 1. During an observation on 4/6/26, at 8:39 AM, during the initial kitchen tour, the walls in the kitchen were noted to have chipped paint. The floor tiles in the kitchen by the refrigerators were noted to be broken with missing sections. During an interview on 4/6/26, at 9:08 AM, with the Maintenance Director (MD), the MD concurred and stated that the facility had discussed the need for replacing lights, repainting the kitchen, and as well as replacing some tiles. During a concurrent observation and interview on 4/8/26, at 10:33 AM, with the Food Service Director (FSD), two stains surrounding the two ceiling vents over the food preparation area were observed. The ceiling drywall had gouges in it and the paint was noted to be chipped and cracked. The vent at the center of kitchen had a white, approximately 4-inch long item hanging from it. The FSD confirmed the observations and stated the facility had previously had water leaks and that the item hanging may be old caulking. A review of the facility's policy and procedure titled, Maintenance Service, revised 12/09, indicated, .Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards.d. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. A review of the United States (US) FDA (Food and Drug Administration) 2022 Food Code, section 6-501.11 on Repairing, indicated, .physical facilities shall be maintained in good repair . (https://www.fda.gov/food/fda-food-code/food-code-2022) A review of the USFDA 2022 Food Code, section 4-202.16 on Nonfood-Contact Surfaces, indicated, .Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms . (https://www.fda.gov/food/fda-food-code/food-code-2022) A review of the USFDA 2022 Food Code, section 6-201.11 on Floors, Walls, and Ceilings, indicated, . floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable . (https://www.fda.gov/food/fda-food-code/food-code-2022) 2. During a concurrent observation and interview on 4/6/26, at 8:54 AM, with the FSD, a can opener was observed with the blade discolored, and a brownish area along the cutting surface appearing as worn metal. The FSD confirmed the observation and stated that the blade needed to be replaced. A review of the USFDA 2022 Food Code, section 4-501.11 on Good Repair and Proper Adjustment, indicated, .(A) EQUIPMENT shall be maintained in a state of repair and condition . (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. The cutting or piercing parts of can openers may accumulate metal fragments that could lead to food containing foreign objects and, possibly, result in consumer injury . (https://www.fda.gov/food/fda-food-code/food-code-2022) During a concurrent observation and interview on 4/6/26, at 9:55 AM, with the FSD, a red cutting board (used for preparing beef) was observed in the kitchen food preparation area with deep gouges. The FSD concurred that the cutting board was worn and should have been replaced. A review of the USFDA 2022 Food Code, section 4-501.12 on Cutting Surface, indicated, .Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces . During an observation and interview on 4/6/26, at 10:04 AM, with the FSD, two fry pans were observed with dark buildup and discoloration of up to three inches covering the sides of the pans. A saucepan was also observed stored in this cook's preparation area, that was worn and had deep pitting in the metal. The FSD confirmed the observations and stated they should not be used as it was not good for the health of the residents as the scratches could contain bacteria. A review of the USFDA 2022 Food Code, section 4-202.11 on Food-Contact Surfaces, indicated, .(A) Multiuse food-contact surfaces shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints; . Food contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts . (https://www.fda.gov/food/fda-food-code/food-code-2022) A review of the facility's policy and procedure titled, Equipment, revised 9/17, indicated, .All food service equipment will be clean, sanitary, and in proper working order.All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 3. During a concurrent observation and interview on 4/6/26, at 9:47 AM, with the FSD, during the initial kitchen tour, a box of sausages was observed in the freezer with the plastic covering left open and the contents exposed to the air. During a subsequent interview with the FSD on 4/6/26/ at 9:55 AM, the FSD confirmed that the plastic bag had been left open and stated it should have been tightly closed before the sausage was returned to the box. During a concurrent observation and interview on 4/6/26, at 10:17 AM, a small steam table pan of rice covered with foil was observed in the reach in refrigerator with a punctured hole on the foil, exposing the rice to the air. The FSD confirmed the observation. The FSD stated the rice should have been discarded. A review of the facility's policy and procedure titled, Food Storage: Cold Foods, revised 2/23, indicated, .All Time/Temperature Control for Safety (TCS) foods, frozen, and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A review of the USFDA 2022 Food Code, section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation, 1/18/23 version, indicated, . Food shall be protected from cross contamination by .storing the food in packages, covered containers, or wrappings . (https://www.fda.gov/food/fda-food-code/food-code-2022) 4. During a concurrent interview and record review on 4/7/26, at 2:48 PM, at the Center Nurse's station, with Licensed Nurse (LN) 1, LN 1 confirmed that the temperature log showed a temperature ranging from 38 degrees F (degrees Fahrenheit, a unit of measurement) to 48 degrees F for the Resident refrigerator in the center hall nurse's station. A temperature of 48 degrees F was entered on the morning shift log for the dates of April 1, 2, and 3 of 2026 and a temperature of 42 degrees F on the morning shifts for both April 6 and 7 of 2026. The temperature log document indicated that the expected temperature should be below 40 degrees F for the refrigerator and below 0 degrees F for the freezer. The log did not indicate any actions were taken due to the high temperature of the refrigerator on those dates. During an interview on 4/7/26, at 2:37 PM, with LN 2, LN 2 stated that the nurse on duty each shift is responsible for logging the temperature of the refrigerator, and if there was an issue with the refrigerator, the nurse would create a work order in the computer to notify the maintenance staff. During a concurrent observation and interview on 4/7/26, at 2:46 PM, with the Maintenance Director (MD) at the Center nurse's station, the MD stated he had not been informed that the refrigerator was not at the correct temperature range. During a concurrent observation and interview on 4/7/26, at 2:56 PM, with the MD at the north nurse's station refrigerator, ice buildup was observed on the freezer compartment. The MD stated he had not been informed about it. The MD stated that the issue should have been reported in their computer system to create a work order. During an interview on 4/8/26, at 4:12 PM, with the FSD, the FSD stated the resident refrigerator should be below 40 degrees F, as being over that temperature would be a food safety issue. During an interview on 4/9/26, at 9:19 AM, with the Assistant Director of Nursing (ADON), the ADON stated that she expected the nurses to report if the refrigerator was not properly working to the maintenance. The ADON stated that the nurses must notify maintenance if the temperature of the refrigerator was high or incorrect. The ADON stated that if the temperature was not within the acceptable range which is below 40 degrees F, the food could spoil and cause the residents to have stomach issues. A review of the facility's policy and procedure titled, Food Brought by Family/Visitors, revised 3/8/24, indicated, .Refrigerator/freezer for storage of foods brought in by visitors will be properly maintained and.Have temperature monitored daily for refrigeration <41 [less than forty one] deg F [degrees Fahrenheit] and freezer ≤ 0 [less than or equal to zero] degrees F. A review of the USFDA 2022 Food Code, section 3-501.16 on Time/Temperature Control for Safety Food, Hot and Cold Holding, indicated, .Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of . (41 degrees F to 135 degrees F) too long .

Based on observation, interview, and record review, the facility failed to ensure two out of 32 sampled residents (Resident 49 and Resident 85) were assisted with nail care as part of the Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 49 and Resident 85 had long fingernails. This failure had the potential for Resident 49 and Resident 85 to sustain skin injury and/or to acquire an infection, and not achieve the highest practicable well-being.Findings:During a concurrent observation and interview on 4/7/26 at 8:52 a.m. with CNA 4, in Resident 49's room, CNA 4 confirmed that Resident 49 had long fingernails with green substance underneath the fingernails. CNA 4 stated Resident 49's fingernails should have been trimmed short. CNA 4 stated she had trimmed Resident 49's fingernails in the past. CNA 4 further stated Resident 49 could hurt herself by scratching herself with long fingernails.During a review of Resident 49's admission Record, the record indicated Resident 49 was admitted to the facility with diagnoses that included senile degeneration of brain (a progressive, age-related neurological decline), vascular dementia (a progressive decline in thinking, memory, and behavior caused by impaired blood flow to the brain, often following strokes or chronic vascular damage), age-related nuclear cataract (a common, slow-progressing clouding of the eye's central lens (nucleus) caused by protein hardening), contracture (the permanent, painful tightening of muscles, tendons, skin, or tissues, causing rigid joint deformities and reduced motion) of right hand and contracture of left hand.Review of Resident 49's Care Plan, initiated on 3/10/20, indicated, Focus.Resident has PHYSICAL FUNCTIONING DEFICIT related to [history] of cerebral infarction.limited mobility.requires physical staff assistance in ADLs.Goal .Physical functioning comfort will be maintained .Interventions.Inspect skin with care .Provide assistance in ADL.Review of Resident 49's Care Plan, initiated on 7/8/22, indicated, Focus.risk for DECLINE IN ADL FUNCTION/SELF CARE DEFICIT .Goal .Overall comfort in ADL activities/functional abilities will be maintained .Interventions.Use consistent routines and allow adequate time for [resident] to complete tasks.A review of Resident 49's Minimum Data Set (MDS- a federally mandated resident assessment tool) Functional Abilities, dated 3/18/26, indicated Resident 49 dependent with toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene.Review of Resident 49's Physician Order dated 6/26/25, indicated, Podiatry, Dental and Ophthalmology Consult and treatment as needed for [resident] health and comfort. During an observation and interview on 4/6/26 at 12:23 a.m. with Resident 85, in Resident 85's room, Resident 85 had long fingernails. Resident 85 stated he would like to have short fingernails.During a concurrent observation and interview on 4/6/26 at 12:26 a.m. with Certified Nurse Assistant (CNA) 3, in Resident 85's room, CNA 3 confirmed that Resident 85 had long fingernails. CNA 3 stated she did not know when the last time was Resident 85 had his nails trimmed short. CNA 3 stated Resident 85 should have had his fingernails trimmed. CNA 3 stated Resident 85 could get skin tears by scratching himself with long fingernails. CNA 3 stated after she trimmed a resident's nails short, she would notify a Licensed Nurse (LN).During a review of Resident 85's admission Record, the record indicated Resident 85 was admitted to the facility with diagnoses that included disorder of urea cycle metabolism (a group of rare disorders where the body cannot break down ammonia, causing a toxic buildup that can affect brain and liver), Todd's paralysis (temporary weakness or paralysis of one side of the body or a specific limb, lasting from 30 minutes to 36 hours average 15 hours following a seizure), type 2 diabetes mellitus (a chronic metabolic condition where the body resists insulin or fails to produce enough, causing high blood sugar. It is characterized by symptoms like increased thirst, frequent urination, fatigue, and blurred vision), hepatic failure (a critical condition where the liver loses function rapidly [acute] or progressively [chronic], causing toxins to build up, impaired clotting, and potential multi-organ failure), primary osteoarthritis (a chronic, non-inflammatory joint disease caused by the breakdown of cartilage due to age and mechanical stress, rather than injury. It typically causes pain, stiffness, and reduced mobility in the hands) right hand and primary osteoarthritis left hand.Review of Resident 85's Care Plan, initiated on 9/29/22, indicated, Focus.risk for DECLINE IN ADLS/SELF CARE DEFICIT .Goal .Resident will participate as able in ADL's and have all basic self care needs met at all times .Interventions.Assist resident with activities he is unable to perform independently.Assure that all tasks are done up to facility standards.Encourage resident to do as much self care as possible .A review of Resident 85's MDS Functional Abilities and Goals, dated 3/13/26, indicated Resident 85 required substantial/maximal assistance with upper and lower body dressing, and personal hygiene.Review of Resident 85's Physician Order dated 6/28/24, indicated, May Cut Nail one time a day every 4 weeks on [Sunday] .Review of Resident 85's Physician Order dated 6/28/24, indicated, May see podiatrist with follow-up treatment as indicated.During an interview on 4/7/26 at 4:14 p.m. CNA 5 stated she made sure residents had short and clean nails during ADL care. CNA 5 stated in the past she had clipped residents' nails with the approval of a LN. CNA 5 further stated residents who had diabetes had their nails cut by the podiatrist (is a medical specialist focused on diagnosing, treating, and preventing conditions affecting the foot, ankle, and lower leg). During a concurrent interview and record review on 4/8/26 at 9:56 a.m. LN 2 stated CNA and LN were both responsible for trimming residents' fingernails. LN 2 stated the CNA would notify the LN after completing nailcare on a resident. LN 2 stated nailcare that was done by CNA was documented in a resident's medical records in the progress note section. LN 2 stated there was no documentation indicating Resident 49 and Resident 85's nails were clipped short. LN 2 stated resident with long fingernails could scratch themselves and get a skin tear which could lead to an infection.During a concurrent interview and record review on 4/8/26 at 11:13 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the expectation was to have residents have their nails short and clean. The ADON stated residents with long fingernails could have pain and get an infection by scratching themselves.During a concurrent interview and record review on 4/8/26 at 3:45 p.m., LN 8 stated both CNA and LN are responsible to keep residents' fingernails trimmed short and clean. LN 8 stated a podiatrist visited the facility every three months and trimmed nails for residents who had diabetes. LN 8 stated there was no documentation that nail care was provided for Resident 49 and Resident 85 in the last 30 days. LN 8 further stated there was no documentation for a podiatry visit for Resident 49 and Resident 85 from 1/26 to 3/26.During an interview on 4/9/26 at 9:29 a.m., LN 5 stated Resident 49 was not diabetic, and a CNA or LN should have clipped Resident 49's fingernails. LN 5 stated Resident 85 had an order to be seen by a podiatrist. LN 5 stated she had not seen a podiatrist do nail care to Resident 85 in a long time. LN 5 stated Residents could get bacteria under their long fingernails, get an infection or residents could scratch themselves and create an open wound.During an interview on 4/9/26 at 11:51 a.m. with the Administrator (ADM), the ADM stated the facility should have called a podiatrist for nail care for a resident who is diabetic and has thick nails. The ADM stated the LN could have also trimmed residents' nails short. The ADM further stated long finger nails have a risk of an infection and residents' fingernails should have been trimmed on a routine.A review of the facility's policy and procedures (P&P) titled, Fingernails/Toenails, Care of, revised 2/2018, the P&P indicated, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.Nail care includes daily cleaning and regular trimming.Proper nail care can aid in the prevention of skin problems around the nail bed.Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin.Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.The following information should be recorded in the resident's medical record: 1.The date and time that nail care was given.2.The name and title of the individual(s) who administered the nail care.A review of the facility's policy and procedures (P&P) titled, Activities of Daily Living (ADLs), Supporting, revised 3/2018, the P&P indicated, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .

Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication rooms and medication refrigerators for a resident census of 109, when:1. North station medication room stored four (4) outdated intravenous (IV) fluid bags of antibiotics (medications used to treat infections) in the medication refrigerator together with other active medications;2. An unauthorized facility staff was in the North station medication room unaccompanied by a licensed nurse;3. South station medication room [ROOM NUMBER] stored multiple enteral feedings in bottles and cartoons and five (5) emergency medication kits (e-kits, portable collection of essential prescription medicines designed to provide immediate care during crisis) with no daily log to document and monitor the temperature of the medication room;4. An e-kit stored in South station medication room [ROOM NUMBER] containing mostly antibiotic oral medications (to treat infections) sealed with a yellow tag (indicates the e-kit was opened and a medication was pulled out for emergency use) was not replaced in a timely manner;5. South station medication room [ROOM NUMBER] stored active medications in the medication refrigerator with extensive frost built up and had days where the temperature was out of range per facility guidelines;6. The medication refrigerator in South station medication room [ROOM NUMBER] stored two (2) bottles of medications without a readable label and one of the medication bottles had a handwritten label; and,7. South station medication room [ROOM NUMBER] stored a pharmaceutical waste container without a seal and had disposed/discarded medications that were recognizable and retrievable by hand.These failures could contribute to unsafe medication use, medication error, risk of residents receiving medications that were contaminated, spoiled, expired or reduced potency, and the potential for medication misuse and/or drug diversion (when individuals steal controlled substances-highly regulated medications-for recreational use).Findings: 1. During a concurrent medication storage observation and interview on 4/6/26, at 8:40 a.m. with License Nurse (LN) 9 in the North station medication room, there were four expired IV antibiotic bags stored in the medication refrigerator with other active medications. Two of the IV fluid antibiotic bags had an expiration date of 3/23/26 and the other two IV fluid antibiotic bags had an expiration date of 3/29/26. LN 9 confirmed that the individual whom the IV antibiotics were prescribed for was still a current resident in the facility. LN 9 stated that the expired IV antibiotics should not be used and should have been taken away from the active medications and should have been discarded. LN 9 also stated there could be a potential risk for accidental use of expired IV antibiotics that may not have been good to use or may not have been effective and would not treat the infection and could have resulted in harm to the resident. During an interview on 4/6/26, at 11:10 a.m. with the Director of Nursing (DON), the DON stated that expired medications still stored with the active medications had the potential for being administered to the residents. During a phone interview on 4/9/26, at 9:49 a.m. with the Pharmacy consultant (PC), the PC stated that expired medications still stored with the active medications had an increased risk for staff grabbing it and could potentially be used and may have caused harm to the residents. During a review of the facility's Policy and Procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY, revised 1/25, the P&P indicated, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 2. During a concurrent medication storage observation and interview on 4/6/26, at 8:40 a.m. with LN 9 and the Central Supply (CS) staff in the North station medication room LN 9 knocked on the door and the CS staff opened the medication room. Upon entering the medication room, the CS staff was found to be alone and there was no licensed nurse with him. The medication room stored multiple active overflow medications on open shelves that were prescribed for the residents in the North Unit and for the residents in the Center Unit. The CS staff explained that the licensed nurse usually gave the key to him so he could replenish supplies and over-the-counter medications. The CS staff stated he usually was in the medication room by himself and unaccompanied by a licensed nurse. The CS staff also stated that he replenished all supplies and over-the-counter medications in every medication room with no licensed nurse with him. LN 9 confirmed the CS staff was in the medication room by himself. LN 9 stated that the CS staff should not be by himself and should have been accompanied by a licensed nurse. LN 9 further stated that only licensed nurses were allowed in the medication room and other personnel such as the CS staff should be accompanied. During an interview on 4/6/26, at 9:02 a.m. with the CS staff, the CS staff explained that he asked for the keys to the medication rooms from the licensed nurse on duty to refill over-the-counter medications and other supplies. The CS staff stated that he had always refilled the medication rooms this way and he also stated that he checked medication rooms twice a week. During an interview on 4/6/26, at 9:20 a.m. with the Assistant Director of Nursing (ADON), the ADON stated only authorized licensed nurses such as the LNs, DON, ADON, and treatment licensed nurses have access to all the medication rooms and all other unauthorized personnel such as the housekeepers including the central supply staff members should be accompanied by licensed staff when entering the medication room. During an interview on 4/6/26, at 11:10 a.m. with the DON, the DON stated non-nursing personnel other than the licensed staff should be accompanied by an authorized licensed nurse when entering the medication room. The DON stated unauthorized personnel should not be in the medication room without a licensed nurse to prevent the risk for misuse and/or drug diversion of prescribed medications and/or over-the-counter medications. During a phone interview on 4/9/26, at 9:49 a.m. with the PC, the PC stated she would have expected the licensed nurses to stay with the non-nursing staff going into the medication rooms. The PC also stated there would be an increased risk for non-authorized personnel to take something from the medication room when the licensed nurse is not present. The risk for misuse and/or drug diversion could potentially happen. During a review of the facility's Policy & Procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY, revised 1/25, the P&P indicated, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized.Only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications, Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 3. During a concurrent medication storage observation and interview on 4/6/26, at 9:20 a.m. with the ADON in the South station medication room [ROOM NUMBER], multiple enteral feeding nutrition (nutrition administered directly into the stomach through a tube) in bottles and in cartoons together with active overflow medications prescribed for residents in the South Unit were stored. There were also five e-kits sealed with red tags and one e-kit sealed with yellow tag stored in this medication room. The ADON confirmed the thermometer in the medication room registered a temperature of 72 (degrees Fahrenheit-unit of measurement). The ADON also confirmed that there was no temperature log to monitor and document the registered temperatures in the medication room on a daily basis. The ADON also confirmed the medication room stored multiple enteral nutrition, overflow medications, and e-kits. The ADON stated unregulated temperatures in the medication room had the potential to spoil the enteral nutrition and may potentially affect the potency of the overflow medications and the medications or supplies stored in the e-kits. During an interview on 4/6/26, at 11:10 a.m. with the DON, the DON stated that temperatures in all medication rooms should be monitored and logged on a daily basis and should be maintained in the correct temperature range as indicated on the log guidelines to prevent the spoilage of the enteral nutrition by heat. The DON also stated that the enteral nutrition should be stored at room temperature. The DON further stated that the medications along with the medications in the e-kit should be stored in the same way. During a phone interview on 4/9/26, at 9:49 a.m. with the PC, the PC stated that medications stored in a medication room with unregulated temperature with no method of monitoring could potentially affect the stability of the medication if temperatures were not in the proper range. During a review of the facility's Policy & Procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY, revised 1/25, the P&P indicated, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.Medications requiring storage at room temperature are kept at temperatures ranging from 15 [degrees centigrade-unit of measurement] (59 ) to 30 (86 ). 4. During a concurrent medication storage observation and interview on 4/6/26, at 9:20 a.m. with the ADON in the South station medication room [ROOM NUMBER], an e-kit sealed with a yellow tag was stored in the medication room. The ADON explained an e-kit sealed with a yellow tag would indicate that the e-kit was opened and a medication was taken out and administered to a resident who was in immediate need, such as an antibiotic. The ADON also explained that any medication taken out from the e-kit should be logged out and documented on the form provided and kept inside the e-kit for the pharmacist to know which medication was taken out for replacement. The ADON confirmed the antibiotic was removed from the e-kit on 3/28/26. The ADON stated the e-kit should have been replaced immediately within 72 hours. The ADON confirmed the e-kit was not replaced within 72 hours. During an interview on 4/6/26, at 11:10 a.m. with the DON, the DON stated open e-kits should be replaced within 24 hours, a day or two days. The DON also stated the pharmacy should have been called to let them know an e-kit was opened and needed to be replaced. During a phone interview on 4/9/26, at 9:49 a.m. with the PC, the PC stated e-kits with yellow tags should be replaced within 72 hours of opening. During a review of the facility's Policy & Procedures (P&P) titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, revised 1/25, the P&P indicated, .An emergency supply of medications including emergency drugs, antibiotics, controlled substances.is supplied by the provider pharmacy in limited quantities in portable, sealed containers that are in compliance with applicable state regulations.After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply.As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the emergency drug supply.If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening. 5. During a concurrent observation and interview on 4/6/26, at 9:30 a.m., with the Assistant Director of Nursing (ADON), the ADON verified the South medication room [ROOM NUMBER]'s medication refrigerator was noted with extensive frost built up and the temperature's recorded were out of range per facility guidelines on 4/1/26, 4/2/26, 4/3/26, and 4/6/26 during the AM shift. The ADON stated maintenance should have been made aware of the refrigerator temperatures being out of range and the ice build up. The ADON further stated the refrigerator temperature out of range may cause the medication stored to lose effectiveness. During an interview on 4/6/26, at 11:55 a.m., with the Director of Nursing (DON), the DON stated it was her expectation for licensed nursing staff to notify maintenance regarding ice build up in the medication refrigerators, and that ice build up will affect the temperature in the medication refrigerator. During an interview on 4/9/26, at 9:49 a.m., with the Pharmacist Consultant (PC) the PC stated there should have not been ice buildup in the medication refrigerator and if the medication refrigerator was not within range per guidelines the stability of the medication could potentially be affected. A review of the facility's policy and procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY revision date 1/25, the P&P Indicated, .Medications and biologicals are stored safely, securely, and properly.Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified . 6. During a concurrent observation and interview on 4/6/26, at 9:30 a.m., with the Assistant Director of Nursing (ADON), the ADON verified South medication room [ROOM NUMBER]'s medication refrigerator stored 2 bottles of medications without a readable label and one of the medication bottles had a handwritten label. During an interview on 4/6/26, at 11:55 a.m., with the Director of Nursing (DON), the DON stated it was her expectation for licensed nursing staff to notify the pharmacy if a medication label was not readable and not to hand write on the medication labels. The [NAME] further stated that stored medication without a readable label placed residents at risk of a medication error. During an interview on 4/9/26, at 9:49 a.m., with the PC, the PC stated if a medication label was not readable medication should have been removed and pharmacy notified to replace the medication. The PC further stated staff should not be hand writing on the medication labels. A review of the facility's policy and procedure (P&P) titled, MEDICATION STORAGE IN THE FACILITY revision date 1/25, the P&P Indicated, .Refrigerated medications are kept in closed and labeled containers.Outdated, contaminated, or deteriorated medications and those in containers cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from pharmacy if a current order exists. 7. During a concurrent observation and interview on 4/6/26, at 9:30 a.m., with the Assistant Director of Nursing (ADON), the ADON verified the South medication room [ROOM NUMBER] stored a pharmaceutical waste container without a seal and had disposed/discarded medications that were recognizable and retrievable by hand. During an interview on 4/6/26, at 11:55 a.m., with the Director of Nursing (DON), the DON stated it was her expectation for the pharmaceutical waste container to use drug buster (a specialized disposal system designed to securely and safely get rid of unwanted or expired medication, preventing them from being misused or harming the environment) and that medications were at risk of being taken out and used from the pharmaceutical waste container. During an interview on 4/9/26, at 9:49 a.m., with the PC, the PC stated a pharmaceutical waste container should be used with a drug destroyer so that medications cannot be recognizable and there was risk of medications being taken from the pharmaceutical waste container.

Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control measures for a census of 109, when:1. Resident 50's oxygen tube (a flexible, lightweight, and typically transparent tube used to deliver supplemental oxygen from a source-like a concentrator-directly to a patient's nostrils or mask) was found on the floor without a date and it was not connected to the oxygen concentrator (a medical device that provides purified oxygen to people with breathing disorders by filtering, compressing, and concentrating ambient air into 90%-95% pure oxygen);2. The Glucometer (a small, portable, battery-powered device used to measure the concentration of sugar (glucose) in a small sample of blood) was not cleaned properly and adequately in between Resident 92, Resident 107, and Resident 63 use; and,3. Personal Protective Equipment (PPE, specialized clothing and gear-such as masks, gloves, gowns, and face shields-designed to create a barrier against infectious materials, blood, and body fluids essential for infection control minimizing the spread of germs) was not utilized for Resident 11 and Resident 123, who were on Enhanced Barrier Precautions (an infection control intervention involving the use of a gown and gloves for high-contact resident care activities to help stop or reduce the spread of germs). These failures in infection prevention and control practices had the potential to contribute to the spread of infection among residents and staff within the facility.Findings: 1. During a review of Resident 50's admission RECORD, the record indicated Resident 50 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a progressive, long-term lung disease that makes breathing difficult by damaging lung tissue and narrowing airways) and malignant neoplasm of other parts of the uterus (cancerous tumor of the uterus that can grow uncontrolled and spread to other parts of the body). During a review of Resident 50's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/26, the MDS revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating Resident 50 had moderate problems with thinking and memory. During a review of Resident 50's Order Summary Report, active physician's orders as of 4/9/26, the order indicated, .OXYGEN: O2 [oxygen] 2LPM [liters per minute-unit of measurement] via NC [nasal cannula-a transparent tube with two prongs that rest on the nostrils to deliver oxygen] as needed for SOB [shortness of breath]. During a review of Resident 50's Care Plan Report (a form where you can summarize a person's health conditions, specific care needs, and current treatments), dated 5/2/23, the care plan indicated, .Potential for impaired gas exchange [a disruption of the oxygen and carbon dioxide exchange in the lung tissues] r/t [related to] CHRONIC OBSTRUCTIVE PULMONARY DISEASE.Implement measures to improve respiratory status.O2 per order. During a concurrent observation and interview on 4/6/26, at 12:42 p.m. with Resident 50 in her room and Certified Nursing Assistant (CNA) 2, Resident 50 was in bed and her oxygen tube was on the floor disconnected from the oxygen concentrator that was placed on her right side next to the bed with the power on. The oxygen tube also did not have a date when the tube was replaced or changed. Resident 50 stated she did not have her NC because she did not need oxygen at that time but went on to say that she needed oxygen most of the time because she had shortness of breath at times. CNA 2 entered Resident 50's room to deliver her lunch tray and CNA 2 confirmed Resident 50's oxygen tubing was on the floor disconnected from the concentrator and without a date. CNA 2 also confirmed the oxygen concentrator belonged to Resident 50. CNA 2 stated the oxygen tubing should not be on the floor and should be connected to the concentrator. CNA 2 stated this practice increased the risk of infection because the tube was contaminated. CNA 2 stated she would get a new oxygen tube. During an interview on 4/8/26, at 10:21 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the oxygen tube should not be on the floor and should have been connected to the oxygen concentrator. The ADON explained the tube should have been in a plastic bag when not in use to prevent the risk of contamination and that could cause possible infection. The ADON also explained the oxygen tube and all other tubes should be changed per facility policy and should be dated when it was changed to know when the tubes would be replaced. During an interview on 4/9/26, at 12:23 p.m. with the Infection Preventionist (IP), the IP stated oxygen tubes should not be on the floor to prevent the risk of contamination that could lead to the spread of infection among the residents and staff. The IP also stated oxygen tubes should be dated to make sure the tubes were changed properly and at the correct time. During a review of the facility's Procedure titled, Departmental (Respiratory Therapy) – Prevention of Infection, revised 11/11, the procedure indicated, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment.among residents and staff.Infection Control Considerations Related to Oxygen Administration.Change the oxygen cannula and tubing every seven (7) days or as needed.Keep the oxygen cannula and tubing used PRN [as needed] in a plastic bag when not in use. 2a. During a review of Resident 92's admission RECORD, the record indicated, Resident 92 was admitted to the facility with diagnoses including type 2 diabetes mellitus (this happens when the body cannot use insulin correctly and sugar builds up in the blood. Insulin is a hormone produced by the pancreas that regulates blood sugar (glucose) levels by allowing cells to absorb glucose for energy). During a review of Resident 92's Order Summary Report, active physician's orders as of 4/9/26, the order indicated, .Check finger stick blood sugar before meals and at bedtime before administering insulin. During a review of Resident 92's Care Plan Report, dated 6/3/24, the report indicated, .risk for s/s [signs & symptoms] of hypoglycemia [low blood sugar/glucose] / hyperglycemia [high blood sugar/glucose] due to TYPE 2 DIABETES MELLITUS.Check FSBS [finger stick blood sugar]. During a medication observation on 4/8/26, at 7:22 a.m. at the South Unit outside Resident 92's room, Licensed Nurse (LN) 4 took out the glucometer from the medication cart and placed it on a tray. LN 4 then took the glucometer and other necessary supplies to Resident 92's room to check her blood sugar. Resident 92's blood sugar reading was 197 and LN 4 indicated Resident 92 needed insulin (medication used to lower the blood sugar level) as per physician's order. LN 4 returned to his medication cart with the used glucometer and other supplies. LN 4 took one wipe of micro-kill one Germicidal Alcohol Wipes and cleaned all surfaces of the glucometer. LN 4 then took another wipe and laid the glucometer on top the wipe until the next use. 2b. During a review of Resident 107's admission RECORD, the record indicated Resident 107 was admitted to the facility with diagnoses including type 2 diabetes mellitus. During a review of Resident 107's Order Summary Report, active physician's orders as of 4/9/26, the order indicated, .Notify MD [Doctor of Medicine] if FSBS <60 or >400 [< less than or > greater than]. During a review of Resident 107's Care Plan Report, dated 2/24/26, the care plan indicated, .The resident is at risk for s/s of hyperglycemia/hypoglycemia r/t DAIBETES MELLITUS TYPE 2 and insulin dependent. During a medication administration on 4/8/26, at 7:32 a.m. at the South Unit outside Resident 107's room, LN 4 took the same glucometer that he used previously with Resident 92 and placed it on the tray with the other supplies that would be needed to take Resident 107's blood sugar levels. Resident 107's blood sugar reading was 175. LN 4 returned to his medication cart with the used glucometer and other supplies. LN 4 took one wipe of micro-kill one Germicidal Alcohol Wipes and cleaned all surfaces of the glucometer. LN 4 then took another wipe and laid the glucometer on top the wipe until the next use. 2c. During a review of Resident 63's admission RECORD, the record indicated, Resident 63 was admitted to the facility with diagnoses including type 2 diabetes mellitus. During a review or Resident 63's Order Summary Report, active physician's orders as of 4/9/26, the order indicated, .Blood sugar checks before meals and at bedtime. During a review of Resident 63's Care Plan Report, dated 5/27/25, the care plan indicated, .Monitor FSBS [fasting blood sugar] QID [four times a day] before meals and at bedtime. During a medication administration on 4/8/26, at 7:48 a.m. at the South Unit outside Resident 63's room, LN 4 took the same glucometer that he used previously with Resident 107 and placed it on the tray with the other supplies that would be needed to take Resident 63's blood sugar levels. Resident 63's blood sugar reading was 144. LN 4 returned to his medication cart with the used glucometer and other supplies. LN 4 took one wipe of micro-kill one Germicidal Alcohol Wipes and cleaned all surfaces of the glucometer. LN 4 then took another wipe and laid the glucometer on top the wipe until the next use. During a subsequent interview on 4/8/26, at 7:48 a.m. with LN 4, LN 4 stated when cleaning a used glucometer that he would clean first using the germicidal alcohol wipes the facility provided and then take a second wipe to wrap around the glucometer for about 1 minute after each use for Resident 92, Resident 107, and Resident 63. LN 4 stated he did not wrap the glucometer with the wipe but laid it on the wipe. LN 4 explained that the glucometer was not cleaned properly and there could be a possibility that the glucometer was still contaminated and could cause infections between residents. During an interview on 4/9/26, at 12:23 p.m. with the IP, the IP stated the process of cleaning a multi-use glucometer was to clean all surfaces first for 30 seconds with the germicidal alcohol wipes then get a second wipe and wrap that wipe around the glucometer for another 30 seconds to ensure the glucometer was cleaned properly and adequately in between use. During a review of the undated Germicidal Alcohol Wipes cleaning and disinfecting guidelines printed on the container, the cleaning guidelines indicated, .use one or more wipes, as necessary, to wet surface sufficiently and to thoroughly clean the surface. and the disinfecting guidelines indicated, .use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens listed on the label.Allow surfaces to air dry. During a review of the undated facility's Administrative Policies titled, Glucometer Cleaning, the policy indicated, .All glucometers will be cleaned and disinfected using [brand] Germicidal wipe, EPA regulated [Environmental Protection Agency; the EPA verifies disinfectants work according to their label directions].All glucometers that will be shared by multiple patients will be thoroughly wiped with disinfectant and allowed to air dry after every use and between every patient.All to air dry before using on next patient.Ensure the meter stays wet for 1 minute and is allowed to dry an additional. 3a. During a review of Resident 11's admission RECORD the record indicated Resident 11 was admitted to the facility with diagnoses including but not limited to Unspecified contact dermatitis (a skin rash caused by an unidentified irritant or allergen. It presents as itching, redness, swelling, or blisters when the skin reacts to an unknown substance), allergic rhinitis (an immune system response to allergens like pollen, dust mites, or pet dander, causing nasal inflammation) and Pressure Ulcer of Sacral Region (back and buttocks area), Stage 3 (a full-thickness tissue loss injury, presenting as a deep crater where subcutaneous fat may be visible, but muscle, tendon, or bone are not exposed). During a review of Resident 11's record titled Order Details, active physician's orders as of 10/10/25, the order indicated, .Enhanced Barrier Precaution [EBP; an infection control intervention designed to reduce the spread of multidrug-resistant organisms]: Stage 3, pressure ulcer to coccyx [the last bone at the bottom (base) of your spine]. During a review of Resident 11's record titled Care Plan Report, dated 9/22/25, the care plan indicated, .Resident requires Enhanced Standard Precautions for High Risk for Infection or Transmission R/T [related to] Stage 3 pressure ulcer to coccyx. During an interview with CNA 6 (Certified Nursing Assistant 6) on 4/8/26, at 9:25 a.m., CNA 6 stated they were not using EBP for Resident 11 as there was no yellow dot by Resident 11's name outside her room. CNA 6 said a yellow dot by the name meant that resident was on EBP. CNA 6 further stated he did not think Resident 11 was on EBP. During a concurrent interview and record review with LN 7 (Licensed Nurse 7) on 4/8/26, at 9:28 a.m., LN 7 confirmed a yellow dot by a resident's name indicated that resident was on precautions. LN 7 confirmed there was no yellow dot by Resident 11's name located outside of Resident 11's room. LN 7 checked Resident 11's medical record and confirmed that Resident 11 required EBP. LN 7 stated not having a yellow dot by the name could lead to staff confusion, and that could be why some of the staff might not be using EBP when caring for Resident 11. During an interview with the IP (Infection Preventionist) on 4/8/26 at 10:07 a.m., the IP confirmed that they use yellow dots by resident's names outside the room when a resident was on EBP. The IP stated if there was not a yellow dot by the residents name, the staff might not use the EBP PPE which would lead to a risk of spreading the infection. The IP stated EBP was very important for protection of residents and staff against infections. 3b. A review of Resident 123's admission RECORD, the record indicated Resident 123 was admitted to the facility with diagnoses that included but not limited to Sepsis (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to tissue damage and organ failure), bacteremia (the presence of bacteria in the bloodstream), and bell's palsy (a sudden, temporary weakness or paralysis of facial muscles caused by inflammation of the 7th cranial nerve, typically affecting one side of the face). A review of Resident 123's record titled Order Listing Report, with a revision date of 3/27/26, indicated an order of Enhanced Barrier Precautions related to IV-PICC (Peripherally Inserted Central Catheter is a thin, flexible tube inserted into an upper arm vein and guided to a large vein near the heart. It provides long-term IV access (weeks to months) for medications, fluids, nutrition, or blood sampling, avoiding repeated needle sticks). During an interview on 4/6/26 at 10:20 a.m., Resident 123 stated the staff were not using EBP PPE when caring for her. During an interview on 4/6/26, at 10:24 a.m. with LN1 (Licensed Nurse 1), LN 1 stated Resident 123 should be on EBP as she had a PICC line. LN1 confirmed that there was no EBP sign on the door and no EBP PPE supplies outside of Resident 123's room. LN1 explained that this situation increased Resident 123's risk of acquiring additional infections from staff and other residents. During an interview on 4/8/26, at 10:11 a.m. with the IP, the IP confirmed Resident 123 should have had EBP, an EBP sign on the door, a cubby on the door with PPE, and a yellow dot by her name. The IP stated that not having EBP in place put Resident 123 at increased risk of spreading infection and getting infected more. The IP further stated that she expected the use of EBP as it was very important in protection against infections. During an interview on 4/9/26, at 10:41 a.m., with the DON (Director of Nursing), the DON confirmed that a resident with a PICC line should have been on EBP. The DON stated that residents were at risk of acquiring infections from staff, visitors, and other residents when EBP were not implemented. The DON further emphasized the importance of EBP by saying that EBP prevented the transmission of infections. A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, revised 12/24, the policy indicated, .Enhanced barrier precautions apply when. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices.Indwelling medical devices include central lines, urinary catheters, feeding tubes.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.Enhanced barrier precautions are in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that place that at higher risk.Staff are trained prior to caring for residents on EBPs.Signs are posted on the door or wall outside resident's rooms which communicate the type of precautions and PPE required.

Based on observation, interview, and record review the facility failed to implement a comprehensive care plan (a list of resident specific problems, goals, and interventions) for five of 32 sampled residents (Resident 1, Resident 15, Resident 54, and Resident 123), when:1. Resident 1's Physician was not notified when Resident 1's arteriovenous (AV) fistula (a surgically created connection of an artery directly to a vein allowing high blood flow during hemodialysis (HD), a life-saving treatment that acts as an artificial kidney that removes waste and extra fluid from the blood and regulates blood pressure) was negative for thrill (vibration) and bruit (buzzing or swoosh sound) indicating a blockage or failure.2. Resident 15 was receiving oxygen without a physician's order.3. Resident 15 and Resident 54 did not receive one to one activities at least once a week.4. An Enhanced Barrier Precautions care plan was not developed for Resident 123. These failures had the potential to negatively affect the health and well being of Resident 1, Resident 15, Resident 54, and Resident 123.Findngs: 1. A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility with diagnoses that included but not limited to hypertension (a chronic condition where the force of blood pushing against artery walls is consistently too high, forcing the heart to work harder), chronic kidney disease (a long term, irreversible loss of kidney function where the kidney cannot effectively filter waste and excess water from the blood), and dependance on renal (kidney) dialysis. A review of Resident 1's AV fistula for dialysis care plan dated 1/13/26, the care plan indicated, .Monitor skin condition around catheter insertion site and report to physician as indicated. During a concurrent interview and record review on 4/9/26, at 9:40 a.m., with the Director of Nursing (DON), Resident 1's MEDICATION ADMINISTRATION RECORD dated March 2026 was reviewed. The DON verified on dates 3/14, 3/24, 3/25, 3/26, 3/27, 3/28, and 3/31 licensed nursing staff documented negative for thrill and bruit (the nurse performed a physical exam and did not feel a thrill (vibration) or bruit (buzzing or swishing sound) over a blood vessel indicating a blockage or failure). The DON also verified that a change of condition assessment or informing the physician was not done. The DON stated it was her expectation of licensed nursing staff to notify the MD of the change in condition. The DON further stated this placed Resident 1 at risk of missing hemodialysis. 2.A review of Resident 15's, admission Record indicated Resident 15 was admitted to the facility with diagnoses that included but not limited to traumatic brain injury, schizophrenia (chronic brain disorder that causes people to lose touch with reality, making it difficult to distinguish what is real from what is not), and insomnia (chronic inability to get enough sleep). During an observation on 4/7/26, at 12:30 p.m., Resident 15 was observed laying in bed with oxygen running through a nasal cannula (a lightweight, flexible plastic tube with two small prongs that sit just inside the nostrils to deliver extra oxygen). During a concurrent interview and record review on 4/7/26, at 12:35 p.m., with the Assistant Director of Nursing (ADON), Resident 15's at risk for myocardial infarction (when blood flow, carrying essential oxygen, is suddenly blocked from reaching a part of the heart muscle) care plan dated 12/22/25, and Resident 15's Order Summary Report dated 4/7/26, was reviewed. The ADON verified Resident 15's care plan indicated to apply oxygen as ordered and the ADON also verified Resident 15's order summary did not have an order for oxygen. During a concurrent observation and interview on 4/7/26, at 12:40 p.m., with the ADON, Resident 15 was observed receiving oxygen via nasal cannula and the ADON verified the care plan was not followed. The ADON stated the care plan was not followed, and the order should have been in place so the use of oxygen can be monitored by nursing staff. The ADON further stated Resident 15 was at risk for unnecessary side effects of supplemental oxygen use if the supplemental oxygen was not indicated such as tachycardia (abnormally fast heartbeat) and headache. 3. A review of Resident 15's activity care plan dated 5/5/25, indicated, .the resident needs 1 to 1 bedside/in-room visits and activities if unable to attend out of room events. A review of Resident 15's, Participation Record dated March 2026, indicated Resident 15 did not participate in group activity and between 3/11/26 to 3/17/26, Resident 15 did not receive one to one activities. A review of Resident 54's admission Record, indicated Resident 54 was admitted to the facility with diagnoses that included but not limited to adult failure to thrive (rapid or gradual decline in an older person's physical, mental, or social functioning, often characterized by unexplained weight loss, poor appetite, exhaustion, and loss of independence), delusional disorders (mental health condition where a person holds a firm, unshakable belief in something that is untrue, despite clear evidence to the contrary), and insomnia. During an interview on 4/7/26, at 8:25 a.m., with Resident 54, Resident 54 stated she used to get one to one visits from activities once or twice a week, but last couple of weeks the one to one visits have stopped and she no longer gets visited. Resident 54 further stated she was a little sad about it and she used to look forward to one to one activity visits since she was bedbound. A review of Resident 54's activity care plan dated 1/4/26, indicated, .one to one room visits 1-3x per week.the residents preferred activities are writing, conversing. During a concurrent interview and review with the assistant director of activities (ADA) Resident 54's, Participation Record dated March 2026, was reviewed the ADA verified the record indicated between 3/19/26, to 3/29/26, Resident 54 did not receive a one to one visit or activity. The ADA stated Resident 54 only participates in one to one activities. The ADA further stated if residents did not receive one to one activities when unable to attend group activity, it can negatively impact resident's mood and potentially experience loneliness. A review of the facility's policy and procedure (P&P) titled, Individual Activities and Room Visit Program dated 6/2018, indicated, .Individual activities will be provided for those residents whose situations or conditions prevent participation in other types of activities , and for those residents who do not wish to attend group activities.individualized activities offered are reflective of the resident's activity interests, as identified in the Activity Assessment, progress notes, and the resident's Comprehensive Care Plan.It is recommended that residents with in-room activity programs receive, at a minimum, three in-room visits per week. 4. During a review of Resident 123's admission RECORD dated 4/7/26, the record indicated, Resident 123 was admitted to the facility with diagnoses that included but not limited to Sepsis (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, leading to tissue damage and organ failure), bacteremia (the presence of bacteria in the bloodstream) and bell's palsy (a sudden, temporary weakness or paralysis of facial muscles caused by inflammation of the 7th cranial nerve, typically affecting one side of the face). A review of Resident 123's record titled Order Listing Report with a revision date of 3/27/2026, indicated an order of Enhanced Barrier Precautions (EBP) [an infection control intervention designed to reduce the spread of multidrug-resistant organisms (MDROs)] r/t IV-PICC (Peripherally Inserted Central Catheter is a thin, flexible tube inserted into an upper arm vein and guided to a large vein near the heart. It provides long-term IV access (weeks to months) for medications, fluids, nutrition, or blood sampling, avoiding repeated needle sticks). During a concurrent interview and record review with the IP (Infection Preventionist) on 4/8/26 at 2:48 p.m., the IP confirmed there was no care plan for Enhanced Barrier Precautions for Resident 123. The IP stated Resident 123 is on EBP for PICC line. The IP further stated there should have been a care plan for EBP. The IP stated there was a risk for delay in care and delay in precautions due to not having a care plan. The IP stated it was very important to have a care plan to properly care for the resident. During an interview with the DON (Director of Nursing) on 4/9/26 at 10:41 a.m., the DON stated there should be a care plan for a resident on EBP. The DON confirmed there was a risk of infection spreading to other staff, visitors and other residents. The DON stated it was important to make care plan to prevent the spread of infection. A review of the facility policy and procedure (P&P) titled CARE PLAN COMPREHENSIVE, dated 8/25/2021, indicated, .Incorporate identified problem area, b. Incorporate risk and contributing factors associated with identified problems.Identify professional services that are responsible for each element of care.Reflect currently recognized professional standards of practice for problem areas and conditions.The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.The resident's goals for admission and desired outcomes.the reductions of factors leading to preventable readmissions.Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition change.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services to four of eight sampled residents (Resident 92, Resident 107, Resident 63, and Resident 95) during medication administration when:1. The first drop of blood sample for glucose level reading for Resident 92, Resident 107, and Resident 63 was not discarded before a sample was obtained on 4/6/26;2. Several crushed and liquid medications in plastic medication cups for gastrostomy tube (GT-also referred to as enteral feeding/tube feeding-a tube inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications when swallowing is not possible or safe) medication administration for Resident 95 were left at the bedside table unattended and unsupervised on 4/9/26; and,3. Resident 95's GT placement (the placement of a feeding tube directly into the stomach) and residual (the amount of fluid/contents that are in the stomach) were not checked before medication administration per physician's order on 4/9/26. These failures had the potential for inaccurate glucose level readings that could affect the dosage of insulin administered for Resident 92, Resident 107, and Resident 63 leading to possible adverse (undesirable or harmful) outcome, potential for drug misuse and/or drug diversion, and potential for Resident 95 aspirating (when food or fluid enters the airway of lungs by accident) which could lead to lung problems such as pneumonia (a lung infection) and possibly result in death.Findings:1a. During a review of Resident 92's admission RECORD, dated 4/9/26, the record indicated, Resident 92 was admitted to the facility with diagnoses including type 2 diabetes mellitus (this happens when the body cannot use insulin correctly and sugar builds up in the blood. Insulin is a hormone produced by the pancreas that regulates blood sugar (glucose) levels by allowing cells to absorb glucose for energy).During a review of Resident 92's Order Summary Report, active physician's orders as of 4/9/26, the order indicated, .Check finger stick blood sugar before meals and at bedtime before administering insulin.During a medication administration observation on 4/8/26, at 7:22 a.m. at the South Unit outside Resident 92's room, Licensed Nurse (LN) 4 prepared supplies to obtain Resident 92's fingerstick blood sugar (FSBS) level reading. The supplies including glucometer (a small, portable, battery-powered device used to measure the concentration of sugar (glucose) in a small sample of blood), lancet (used to make punctures, such as fingerstick, to obtain small blood specimens), test-strip (a band/piece/strip of paper or other material used for biological testing such as blood sugar), and an alcohol pad (a fast-acting antiseptic to sterilize skin before injections, blood draws, or glucose monitoring) were on a tray and LN 4 brought the tray into Resident 92's room to obtain a blood sample. LN 4 took the alcohol pad and cleaned Resident 92's fingertip, took the lancet and pricked her sanitized fingertip, a drop of blood sample appeared, placed the test-strip into the glucometer and with the test-strip, LN 4 collected the sample. LN 4 did not wipe off the first drop of blood before collecting a sample.1b. During a review of Resident 107's admission RECORD, dated 4/9/26, the record indicated, Resident 107 was admitted to the facility with diagnoses including type 2 diabetes mellitus.During a review of Resident 107's Order Summary Report, active physician's orders as of 4/9/26, the order indicated, .Notify MD [Doctor of Medicine] if FSBS <60 or >400 [< less than or > greater than].During a medication administration on 4/8/26, at 7:32 a.m. at the South Unit outside Resident 107's room, LN 4 prepared supplies to obtain Resident 107's FSBS level reading. The supplies including glucometer, lancet, test-strip, and an alcohol pad were on a tray and LN 4 brought the tray into Resident 107's room to obtain a blood sample. LN 4 took the alcohol pad and cleaned Resident 107's fingertip, took the lancet and pricked her sanitized fingertip, a drop of blood sample appeared, placed the test-strip into the glucometer and with the test-strip, LN 4 collected the sample. LN 4 did not wipe off the first drop of blood before collecting a sample.1c. During a review of Resident 63's admission RECORD, dated 4/9/26, the record indicated, Resident 63 was admitted to the facility with diagnoses including type 2 diabetes mellitus.During a review or Resident 63's Order Summary Report, active physician's orders as of 4/9/26, the order indicated, .Blood sugar checks before meals and at bedtime.During a medication administration on 4/8/26, at 7:48 a.m. at the South Unit outside Resident 63's room, LN 4 prepared supplies to obtain Resident 63's FSBS level reading. The supplies including glucometer, lancet, test-strip, and an alcohol pad were on a tray and LN 4 brought the tray into Resident 63's room to obtain a blood sample. LN 4 took the alcohol pad and cleaned Resident 63's fingertip, took the lancet and pricked her sanitized fingertip, a drop of blood sample appeared, placed the test-strip into the glucometer and with the test-strip, LN 4 collected the sample. LN 4 did not wipe off the first drop of blood before collecting a sample.During a subsequent interview on 4/8/26, at 7:48 a.m. with LN 4, LN 4 stated that when collecting blood sample for glucose level reading was to wipe off the first blood sample then collect the next drop of blood. LN 4 stated he did not wipe off the initial drop of blood when obtaining the FSBS for Resident 92, Resident 107, and Resident 63. LN 4 stated he should have wiped off the first drop of blood because it may have registered an inaccurate reading.During an interview on 4/9/26, at 12:23 p.m. with the Infection Preventionist (IP), the IP stated when taking blood sample for FSBS, the LN was to wipe off the initial sample then collect the second drop of blood. The IP stated this practice would ensure to collect uncontaminated blood samples with whatever contaminants were present on the surface of the skin. The IP stated this method would have more accurate blood glucose readings.During a review of the facility's Procedure titled, Obtaining a Fingerstick Glucose Level, revised October 2011, the procedure indicated, .The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level.Obtain a blood sample by using a sterile lancet.Discard the first drop of blood if alcohol is used to clean the fingertip because alcohol may alter the results.2. During a review of Resident 95's admission RECORD, dated 4/9/26, the record indicated, Resident 95 was admitted to the facility with diagnoses including dysphagia (difficulty swallowing), cerebral infarction (also known as stroke-occurs when blood flow to the brain is blocked), and encounter for attention to gastrostomy.During a review of Resident 95'a Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 1/2/26, the MDS revealed Resident 95's Brief Interview for Mental Status (BIMS-a tool to assess mental functioning) score was entered 3 indicating severe problems with thinking and memory. The MDS also revealed that Resident 95 had a feeding tube while as a resident in the facility.During a review of Resident 95's Order Summary Report, active physician's orders as of 4/9/26, the order indicated the medications as followed, .Prostat [a dietary supplement] one time a day.BusPIRone HCL [treats anxiety disorders] Tablet 5 MG [milligram, unit of measurement] Give 1 tablet.Carvedilol [treats high blood pressure] Tablet 6.25 MG Give 1 tablet.Cholecalciferol [dietary supplement to treat vitamin D deficiency] Tablet 1000 UNIT [amount of drug in a single dose] Give 1 tablet.Docusate Sodium [treats constipation] Tablet 100 MG Give 1 tablet.levETIRAcetam [use to help control certain types of seizures] Solution 500 MG/5ML [milliliter, unit of measurement] Give 10 ml.Lisinopril [treats high blood pressure] Tablet 10 MG Give 1 tablet.Omeprazole [treats acid reflux] Oral Capsule 20 MG Give 1 capsule.Phenytoin [treats and prevents seizures] Oral Suspension 100 MG/4ML Give 4 ml.Valproic Acid Solution 250 MG/5ML give 5 ml [treats and prevents seizures].During a medication administration observation on 4/9/26, at 7:50 a.m. in the North Unit outside Resident 95's room, LN 5 prepared each medication, crushed each tablet and placed it in separate plastic medicine cup, poured each solution (liquid medications) into different medicine cup, and opened the capsule and poured the contents into the medicine cup. LN 5 then added 5 ml of water into each solid medication to dilute it. LN 5 brought all the medicine cups into Resident 95's room and placed them on the bedside table. LN 5 had indicated that she forgot a towel to use during administering the medications through the GT. LN 5 left Resident 95's room and the medications on the bedside table were unattended and unsupervised. There were no other licensed nurses when LN 5 left the room.During a subsequent interview on 4/9/26, at 7:50 a.m. with LN 5, LN 5 confirmed she left the room to get a towel and left the medications at the bedside table. LN 5 stated she should not have left the room and the medications at the bedside table and should have gathered all her supplies prior to preparing her medications. LN 5 also stated that leaving medications unattended and unsupervised would increase the risk for someone taking the medications and/or potential for medication misuse.During an interview on 4/9/26, at 10 a.m. with the Pharmacy Consultant (PC), the PC stated that medications should not have been left at the bedside unattended. The PC also stated the risk for medications at the bedside and unsupervised had the potential to be taken, hidden, thrown away, or taken by another resident or staff member.During an interview on 4/9/26, at 12:29 p.m. with the Director of Nursing (DON), the DON stated medications should never be left unattended to ensure the intended resident should be the one receiving the medications and no one else.During a review of the facility's Policy titled, Administering Medications, revised April 2019, the policy indicated, .Medications are administered in a safe and timely manner, and as prescribed.Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.3. During a review of Resident 95's Order Summary Report, active physician's orders as of 4/9/26, the order indicated, .Enteral Feed Order every shift Check GT for proper placement before giving medications, feedings and/or flushes [introducing with water through the tube after each feeding and before and after giving medicines]. The report also indicated, .Enteral Feed Order every shift Check residual before feeding.During a review of Resident 95's Care Plan Report (a form where you can summarize a person's health conditions, specific care needs, and current treatments), dated 3/19/26, the report indicated, .Resident has an enteral feeding tube.check patency, placement of tube and gastric contents/residual volume, as ordered.During a medication administration observation on 4/9/26, at 7:50 a.m. in the North Unit outside Resident 95's room, LN 5 prepared ten medications and placed each medicine in separate plastic medicine cups. LN 5 diluted the crushed medicines with 5 ml water and took all the medications in Resident 95's room and placed them on the bedside table. When LN 5 came back to the room, she started administering the medications after flushing the GT with water, took one medicine cup and poured it into the syringe, took plunger of the syringe and pushed the medicine into the GT while Resident 95 was trying to spit at LN 5 and the Certified Nurse Assistant. LN 5 indicated Resident 95 was not cooperating with medication administration during that time.During a subsequent interview on 4/9/26, at 7:50 a.m. with LN 5, LN 5 confirmed she did not check the GT for placement before medication administration by auscultation (listening to a sound in the stomach when air is introduced through a syringe) or by checking the residual. LN 5 stated she should have checked for placement first to make sure the GT was in the correct place and it was not dislodged. LN 5 further stated Resident 95 was at risk for medications going to the wrong place and at risk for aspiration. LN 5 also stated she did not check the residual prior to flushing and medication administration. LN 5 further stated Resident 95 could potentially be at risk for fluid overload.During an interview on 4/9/26, at 12:55 p.m. with the DON, the DON stated Nurses needed to check for GT placement by listening with stethoscope (a tool to listen to body sounds such as the stomach) or checking residual because it was important for the medications to be going in the right place.During a review of the facility's Policy & Procedure (P&P) titled, ENTERAL TUBE MEDICATION ADMINISTRATION, effective date August 2014, the P&P indicated, .The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes.

Based on observation, interview, and record review, the facility failed to accommodate the needs of 2 of 32 sampled residents (Resident 85 and Resident 96) when, Resident 85 and Resident 96 had a call light (device used to contact staff for assistance) that was not within Resident 85 and Resident 96's reach.This deficient practice placed Resident 85 and Resident 96 at increased risk for unmet care needs, delayed staff response, falls, and potential injury.Findings:During a review of Resident 85's admission Record, the record indicated Resident 85 was admitted to the facility with diagnoses that included disorder of urea cycle metabolism (a group of rare disorders where the body cannot break down ammonia, causing a toxic buildup that can affect brain and liver), Todd's paralysis (temporary weakness or paralysis of one side of the body or a specific limb, lasting from 30 minutes to 36 hours average 15 hours following a seizure), type 2 diabetes mellitus (a chronic metabolic condition where the body resists insulin or fails to produce enough, causing high blood sugar. It is characterized by symptoms like increased thirst, frequent urination, fatigue, and blurred vision), hepatic failure (a critical condition where the liver loses function rapidly [acute] or progressively [chronic], causing toxins to build up, impaired clotting, and potential multi-organ failure), primary osteoarthritis (a chronic, non-inflammatory joint disease caused by the breakdown of cartilage due to age and mechanical stress, rather than injury. It typically causes pain, stiffness, and reduced mobility in the hands) right hand and primary osteoarthritis left hand. During a concurrent observation and interview on 4/6/26 at 12:23 p.m., with Resident 85 in Resident 85's room, Resident 85 was lying in his bed. Resident 85's call light was on the floor next to Resident 85's bed. Resident 85 stated he was thirsty.During a concurrent observation and interview on 4/6/26 at 12:26 p.m., with Certified Nursing Assistant (CNA) 3 in Resident 85's room, CNA 3 confirmed Resident 85's call light was not within reach of Resident 85. CNA 3 stated Resident 85's call light was on the floor in Residents 85's room. CNA 3 stated Resident 85 should have his call light within reach. CNA 3 stated Resident 85 could have fallen from his bed when trying to reach for his call light.Review of Resident 85's Care Plan, initiated on 9/29/22, indicated, Focus.risk for DECLINE IN ADLS/SELF CARE DEFICIT .Goal .Resident will participate as able in ADL's and have all basic self care needs met at all times .Interventions.Assist resident with activities he is unable to perform independently.Keep call light within reach and provide verbal reminders to use call light for staff assistance .During a review of Resident 96's admission Record, the record indicated Resident 96 was admitted to the facility with diagnoses that included hypertensive heart disease with heart failure (occurs when chronic high blood pressure forces the heart to work harder, leading to thickened heart muscles [left ventricular hypertrophy] and weakened function. This often results in fluid buildup [shortness of breath, swelling] and reduced heart efficiency), muscle weakness and hemiplegia and hemiparesis (one-sided body weaknesses caused by brain damage).During a concurrent observation and interview on 4/6/26 at 1:48 p.m., with Resident 96 in Resident 96's room, Resident 96 was lying in her bed. Resident 96's call light was on the floor under Resident 96's bed. Resident 96 stated she could not find her call light.During a concurrent observation and interview on 4/6/26 at 1:50 p.m., with Licensed Nurse (LN) 9 in Resident 96's room, LN 9 confirmed Resident 96's call light was on the floor. LN 9 stated Resident 96 could fall out of her bed when trying to reach for her call light. LN 9 picked the call light from Residents 96's bedroom floor and placed the call light next to Resident 96.Review of Resident 96's Care Plan, initiated on 11/14/23, indicated, Focus.risk for and actual FALLS/INJURY.Goal .Safety measures/new fall interventions will be maintained to prevent or lessen any injury from fall.Interventions.Keep frequently used items within easy reach.Review of Resident 96's Care Plan, initiated on 11/14/23, indicated, Focus.risk for and actual SELF-CARE DEFICIT/DECLINE in ADLS. Goal .Resident will participate as able in ADL's and have all basic self care needs met at all times.Interventions.Keep call light within reach and provide verbal reminder for resident to use call light. During an interview on 4/8/26 at 11:13 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Residents should have their call light within reach. The ADON stated call light is a source of communication between the residents and staff. The ADON stated Residents could fall when trying to reach for their call light. During an interview on 4/9/26 at 11:51 a.m., with the Administrator (ADM), the ADM stated residents should have their call light within reach in case residents need immediate assistance which could be when residents are soiled or when residents are choking.Review of facility's policy and procedure (P&P), titled Answering the Call Light, revised 10/24, the P&P indicated .Ensure that the call light is accessible to the resident when in bed.Review of facility's policy and procedure (P&P), titled Activities of Daily Living (ADLs), Supporting, revised 3/18, the P&P indicated Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.Communication (speech, language, and any functional communication systems) .

Based on interview and record review the facility failed to honor the resident's right to choose for 1 of 32 residents (Resident 27), when the facility failed to honor Resident 27's request for a schedule concerning when their room would be deep cleaned (an intensive, systematic disinfection process-often called terminal cleaning-that goes beyond daily cleaning to eliminate pathogens and prevent Healthcare Associated Infections) and by which housekeeping team member. This failure caused Resident 27 to experience psychosocial distress that included feeling harassed by housekeeping staff.Findings:On 3/30/26 at 3:15 PM the Department received a complaint from Resident 27 regarding concerns over a housekeeping (HSK) employee's continued attempts to enter Resident 27's room and talk about deep cleaning Resident 27's room even though the HSK had been told to not have any direct contact with Resident 27. Resident 27 stated in her complaint that the HSK had confronted her and made her feel uncomfortable and felt the facility was not looking out for her best interested. This reported incident was investigated during the facility's annual recertification with a start date on 4/6/26.A review of Resident 27's admission RECORD, indicated Resident 27 admitted to the facility with diagnosis that included functional quadriplegia (a state of complete immobility, where a patient is unable to move due to extreme frailty or severe disability rather than a direct brain or spinal cord injury).A review of Resident 27's clinical record titled 'Minimum Data Set, (MDS- a standardized, federally mandated assessment tool used to evaluate a resident's functional, medical, psychosocial, and cognitive status) dated 1/16/26 indicated a Brief Interview for Mental Status (BIMS - a standardized assessment tool used to measure a person's cognitive function. A higher score indicates better function. It tests orientation, short-term memory, and attention, with scores of 13-15 indicating intact cognition, 8-12 moderate impairment, and 0-7 severe impairment) score of 15.During an onsite visit from 4/6/26 through 4/9/26, attempts to interview Resident 27 were made on 4/7/26 and 4/8/26. Resident 27 declined both times to be interviewed about the situation stating that the complaints already been discussed.During an interview on 4/7/26 at 4:11 PM with the Social Services Director (SSD), the SSD stated that Resident 27 would only allow certain housekeeping staff members to clean Resident 27's room and that Resident 27 had requested a schedule for when the deep cleaning of the room would occur.During an interview on 4/7/26 at 4:24 PM with the Administrator (ADM), the ADM stated one of the housekeeping team members had been directed to have no direct contact with and to stay out of Resident 27's room at Resident 27's request. The ADM stated that the housekeeping team member ignored that directive and went into Resident 27's room to discuss the request for deep cleaning schedule. During an interview on 4/8/26 at 11:52 AM with the HSK, the HSK stated that she had been notified on 3/16/26 that Resident 27 did not want her to come into her room again and that only two specific housekeepers were allowed to clean Resident 27's area of the room. The HSK stated that after 3/16/27 she did go into Resident 27's room to discuss changing the date of the schedule deep cleaning of the room and when she entered the room, Resident 27 started yelling and screaming at her, even after the HSK attempted to explain why she had come back into the room. The HSK stated that Resident 27 was definitely upset by her presence in the room and that she should have listened when she was told not to go in Resident 27's room again and to send someone else in.During a review of the facility's policy and procedure titled, Resident Rights, dated 12/2021, indicated .Federal and state laws guarantee certain basic rights to all residents of this facility. these rights include the resident's right to.be treated with respect, kindness, and dignity.self-determination.communication with and access to people and services, both inside and outside the facility.be supported by the facility in exercising his or her rights.

Based on observation, interview, and record review, the facility failed to provide a safe and comfortable homelike environment to 4 of 32 sampled residents (Resident 24, Resident 51, Resident 57, and Resident 98) when: 1.Comfortable sounds were not maintained for Resident 24, Resident 57, and Resident 98 when Resident 55 yelled loud; and,2. Resident 24, Resident 51, and Resident 98's drawers were broken.These failures removed Resident 24, Resident 51, Resident 57, and Resident 98's right to a dignified homelike environment, with the potential to result in psychosocial harm.Findings:1.A review of Resident 24's admission RECORD indicated, Resident 24 was admitted to the facility with diagnoses which included anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life, affecting job performance, schoolwork, and relationships. Symptoms include restlessness, rapid heart rate, fatigue, and muscle tension), and muscle weakness.During a review of Resident 24's Care Plan, initiated on 8/3/24, the record indicated, .Goal: Will verbalize feeling well rested.Interventions. Identify factors that affect sleep.During an interview on 4/7/26, at 8:05 a.m., with Resident 24 in her room, Resident 24 stated Resident 55 yelled loud all the time. Resident 24 stated she could not sleep when Resident 55 yelled. Resident 24 stated staff knew that Resident 55 had been yelling loud for a long time. Resident 24 stated staff closed Resident 24's room door when Resident 24 told staff in the past that Resident 24 couldn't sleep because of the noise made by Resident 55. Resident 24 stated she felt bad for Resident 55's room mates because Resident 55 yelled and threw things on the floor in the past. Resident 24 stated she did not like it when Resident 55 yelled loudly. Resident 24 stated staff had tried to take Resident 55 to his room when Resident 55 yelled loudly and threw things.A review of Resident 57's admission RECORD indicated, Resident 57 was admitted to the facility with diagnoses which included hypertensive heart disease with heart failure (a critical condition where long-term high blood pressure [hypertension] causes the heart muscle to thicken, stiffen, or weaken, resulting in the heart's inability to pump blood efficiently), essential (primary) hypertension, and low back pain.During an interview on 4/7/26, at 8:39 a.m., with Resident 57 in her room, Resident 57 stated she had to wear headphones to cancel noise. Resident 57 stated she was bothered by Resident 55 yelling all the time. Resident 57 stated her sleep got interrupted when Resident 55 yelled. Resident 57 stated the sound from Resident 55 yelling got to her ears and she felt there was no stop to the loud noise. Resident 57 further stated she would feel better if Resident 55 did not yell all the time and her sleep did not get interrupted. Resident 57 stated she did not feel Resident 55 was placed with the correct group of residents because of Resident 55's yelling.A review of Resident 51's admission RECORD indicated, Resident 51 was admitted to the facility with diagnoses which included major depressive disorder (a serious, common mood disorder characterized by at least two weeks of persistent, severe low mood or loss of interest/pleasure in daily activities), venous insufficiency (occurs when leg vein valves become weak or damaged, failing to effectively return blood to the heart, causing blood to pool in the lower legs), and bilateral primary osteoarthritis (a chronic, degenerative joint disease where cartilage breaks down, causing pain, stiffness, and reduced mobility) of hip.During a review of Resident 51's Care Plan, initiated on 12/10/24, the record indicated, .Interventions.Respect preference and explain risk of scattered belongings.During a review of Resident 51's Care Plan, initiated on 9/2/25, the record indicated, .Interventions.Provide a pleasant and quiet environment.A review of Resident 55's admission RECORD indicated, Resident 55 was admitted to the facility with diagnoses which included essential (primary) hypertension, and schizophrenia (a severe, chronic mental disorder characterized by disruptions in thought, perception, and emotion, causing individuals to lose touch with reality).During a review of Resident 55's Care Plan, initiated on 4/6/26, the record indicated, Focus: Resident/Patient exhibits symptoms of psychosis related to .continuous laughter and yelling.Goal.Resident/Patient will demonstrate increased involvement/improved relationships with other residents.Interventions.Create a calm, soothing environment.During a review of Resident 55's Progress Note, dated 4/6/26, the record indicated, .IDT [Interdisciplinary Team: a coordinated group of professionals from various disciplines -medicine, nursing, social work, therapy, who collaborate to create, implement, and evaluate comprehensive care plans. They work together to address a patient's complex physical, functional, and psychosocial needs] met on 4/6/26 to discuss [Resident 55] capacity and active behaviors affecting self and others. MD [Medical Doctor] was in the facility and saw [Resident 55] during rounds. [Resident 55] has a [diagnosis] of schizophrenia and has been laughing out loud, yelling at staff.The physician has assessed the resident's condition and has proposed medical intervention by having him sent to the acute to be seen further by psych.A review of Resident 98's admission RECORD indicated, Resident 98 was admitted to the facility with diagnoses which included major depressive disorder and mild neurocognitive disorder (a stage between normal aging and dementia, involving a noticeable decline in cognitive abilities -memory, language, or thinking) due to known physiological condition without behavioral disturbance.During a review of Resident 98's Care Plan, initiated on 6/13/25, the record indicated, Focus: Resident is at risk for complications related to the use of psychotropic drug.Goal.Resident will have no episodes of verbalizations of sadness.Intervention.Monitor for episodes of verbalizations of sadness.During a review of Resident 98's Care Plan, initiated on 6/17/25, the record indicated, .Interventions.Assess/reassess for triggers if change in mood.Allow time for feelings; provide empathy, encouragement, and reassurance.During an observation on 4/6/26, at 9:53 a.m., observed Resident 55 sitting in his room in his wheelchair and yelling at staff when staff tried to talk to Resident 55. During an observation on 4/6/26, at 9:56 a.m., observed Resident 55 yelled at staff and shut his room door loud.During an interview on 4/6/26, at 9:58 a.m., with Licensed Nurse (LN) 6, LN 6 stated Resident 55 had behavior issues where Resident 55 yelled at staff and threw things on the floor. LN 6 stated it would have been nice if Resident 55 had been moved to another room. LN 6 stated due to Resident 55 yelling loud, Resident 98 was moved to the activity room. LN 6 stated Resident 98 should have been able to stay in his room and not taken to activity room due to Resident 55 yelling. LN 6 stated staff had reminded Resident 55 not to close his room door. LN 6 further stated she felt bad for Resident 98 for being moved to the activities room due to Resident 55 yelling loud.During an interview on 4/6/26, at 10:05 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated she had moved Resident 98 to the activity room after Resident 55 yelled and cussed at Resident 98. CNA 3 stated Resident 55 should have been moved to a separate room. CNA 3 stated she felt other residents did not feel safe when Resident 55 yelled and threw things. CNA 3 further stated it would have been better for Resident 98 to be able to stay in his room. CNA 3 stated Resident 55 had been having behavior issues where Resident 55 had been yelling loud and disturbing rest of the residents almost every day for the last few months. CNA 3 stated when Resident 55 got loud staff reoriented Resident 55 and shut Resident 55's room door with Resident 55 inside his room.During an interview on 4/6/26, at 10:33 a.m., with Resident 98 in the dining room, Resident 98 stated he wanted Resident 55 to stop yelling.During an interview on 4/6/26, at 12:13 p.m., with LN 7, LN 7 stated Resident 55 yelled at other residents most of the time. LN 7 stated sometimes Resident 55 got aggressive with the staff and slammed his room door. LN 7 stated staff took Resident 98 from his room to the activity room when Resident 55 got loud. LN 7 stated Resident 24 had asked LN 7 to close Resident 24's room door in the past when Resident 55 was loud. LN 7 stated she felt bad for Resident 98 due to having Resident 55 as a roommate who yelled, talked loudly and slammed the room door. During a concurrent observation and interview on 4/7/26, at 7:39 a.m., with Housekeeper (HK) 2, the HK 2 confirmed Resident 55 sat in his room in his wheelchair laughed loudly and yelled at staff. HK 2 stated Resident 55 yelled all the time and she felt bad for other residents. HK 2 stated Resident 98 might feel uncomfortable when Resident 55 yelled all the time.During an observation on 4/7/26, at 7:47 a.m., Resident 55 sat outside his room in his wheelchair and laughed loudly.During an interview on 4/7/26, at 8:08 a.m., with LN 2, LN 2 stated when Resident 55 did not like someone Resident 55 yelled and threw things on the floor. LN 2 stated he felt the other residents might feel bad because Resident 55 was yelling loud. During an observation on 4/7/26, at 3:40 p.m., Resident 55 was in his room with his room door closed.During an interview on 4/7/26, at 4:14 p.m., with CNA 5, CNA 5 stated Resident 24 had told CNA 3 many times in the past that Resident 24 could not sleep because Resident 55 was loud. CNA 3 stated she had closed Resident 24's room door to minimize the loud noise made by Resident 55. CNA 3 stated Resident 57 had also told CNA 3 in the past Resident 57 could not sleep because Resident 55 was yelling in the hallways outside Resident 57's room. CNA 3 stated when Resident 55 yelled CNA 3 tried to offer Resident 55 snacks and reorient Resident 55. CNA 3 stated Resident 55 had been yelling and having behavior issues for the last few months. CNA 3 stated when Resident 55 did not get what he wanted then Resident 55 would yell and throw things. CNA 3 stated Resident 98 was taken outside his room when his roommate Resident 55 was being loud. CNA 3 stated she felt bad for Resident 98 as Resident 98 shared room with Resident 55 who yelled and threw things in his room. CNA 3 stated she felt bad that residents sleep was interrupted when Resident 55 yelled.During an interview on 4/8/26, at 11:06 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the expectation was to have a calm homelike environment for the residents. The ADON stated residents could have a headache when they were not able to sleep properly due to Resident 55 yelling. The ADON stated resident could get scared when Resident 55 yelled. The ADON stated staff were expected to redirect Resident 55 when Resident 55 made loud noise. The ADON further stated she felt sad for Resident 98 that Resident 98 could not stay in his room due to loud noise.During a concurrent interview and record review on 4/8/26, at 3:45 p.m., with LN 8, LN 8 stated Resident 55 yelled loudly at staff when Resident 55 did not get what Resident 55 wanted. LN 8 stated staff would move Resident 98 outside his room when Resident 55 got loud. LN 8 stated staff tried to reorient Resident 55 by providing Resident 55 with snacks and activities in Resident 55's room when Resident 55 yelled. LN 8 stated Resident 55 had behaviors of agitation.During an interview on 4/9/26, at 11:51 a.m., with the Administrator, the ADM stated the expectation was to have a comfortable homelike environment for the residents. The ADM stated residents should have been assigned with other compatible residents. The ADM stated when a resident yelled other residents could possibly get irritated and have lack of sleep due to constant noise. The ADM stated sometimes staff offered ear plugs to residents when there is noise. The ADM stated it was not fair for Resident 98 to sit outside his own room when Resident 55 was yelling. The ADM stated Resident 98 could have felt frustrated and upset when Resident 98 was not able to rest due to Resident 55 yelling. The ADM stated the facility was looking for a placement for Resident 55.2.During an observation on 4/6/26, at 9:35 a.m., in Resident 98's room, a bottom drawer was missing the front drawer cover.During a concurrent observation and interview on 4/6/26, at 2:10 p.m., in Resident 51's room, bottom drawer face was missing. Resident 51 stated her room drawer had been broken for a long time. Resident 51 stated she would like her drawers to be fixed.During an observation and interview on 4/7/26, at 8:05 a.m., in Resident 24's room, bottom 2 drawers were broken. The bottom 2 drawers were open and unable to close with Resident 24's personnel belonging in the drawers. Resident 24 stated she could not open and close the bottom drawers to get her personal belongings. Resident 24 confirmed the bottom 2 drawers were not closed all the way.During a concurrent observation and interview on 4/7/26, at 8:08 a.m., with LN 2, LN 2 confirmed Resident 24's room drawers were broken and not closed. LN 2 stated he could see Resident 24's personal belongings. LN 2 stated the drawers should be fixed. LN 2 stated the drawers should be closed all the way. LN 2 stated Resident 24 could get hurt if she had tried to close the bottom 2 drawers.During a concurrent observation and interview on 4/8/26, at 10:15 a.m., with the Maintenance Director (MD), the MD stated the bottom drawer for Resident 51 and Resident 98 was missing the drawer face and the bottom 2 drawers were broken for Resident 24. The MD stated he did not remember when the drawer for Resident 98 was last fixed. The MD stated Resident 98 and staff would not be able to open the drawer with the drawer face missing. The MD stated the bottom two rails that held the drawers for Resident 24 were bent. The MD stated Resident 24, Resident 51, and Resident 98's drawers should have been fixed. The MD stated he was not aware that how long the drawers were broken for Resident 24, Resident 51, and Resident 98. The MD stated staff did not notify him that the drawers for Resident 24, Resident 51, and Resident 98 needed to be repaired.During a concurrent interview and record review on 4/8/26, at 11:10 a.m., with the MD, the MD stated there was no request made by staff from 3/8/26 to 4/8/26 to get Resident 24, Resident 51, and Resident 98's drawers fixed.During an interview on 4/8/26, at 11:13 a.m., with the ADON, the DON stated residents should not have broken drawers in their rooms. The ADON stated broken drawers was a safety issue and resident could get hurt when trying to open the broken drawers. The ADON stated when the drawers are broken residents' personal belongings could be exposed. The ADON stated staff were expected to notify the maintenance director when something needed to get fixed.During a concurrent observation and interview on 4/9/26, at 8:50 a.m., with CNA 4, CNA 4 confirmed Resident 24, Resident 51, and Resident 98's drawers were broken. CNA 4 stated staff were expected to notify the maintenance director when something needed to be fixed verbally and electronically using TELS system online (a specialized electronic building management platform that provides tools for maintenance work orders). CNA 4 stated she did not know Resident 24, Resident 51, and Resident 98's drawers were broken before.During an interview on 4/9/26, at 9:02 a.m., with CNA 5, CNA 5 stated she had notified the MD verbally on 4/7/26 that Resident 24, and Resident 51's drawers were broken. CNA 5 stated the MD notified CNA 5 that he had ordered new drawers for Resident 24, and Resident 51 and the drawers would be fixed soon. CNA 5 stated when residents' drawers were broken residents could have felt bad because they needed a place to store their belongings. CNA 5 stated residents' personal belongings could have fallen out of the broken drawers.During an interview on 4/9/26, at 11:51 a.m., with the ADM, the ADM stated the facility had been trying to get residents drawers fixed. The ADM stated staff were expected to notify the MD verbally and use TELS system when something needed to be fixed. The ADM stated every morning the department heads, including the MD, made room rounds to check residents' rooms. The ADM stated homelike environment is not being provided to a resident when a resident's drawer is broken. The ADM further stated a resident could potentially get hurt when trying to open a broken drawer.During a review of the facility policy and procedure (P&P) titled, Homelike Environment revision date 2/2021, the P&P indicated,.Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.These characteristics include:.personalized furniture and room arrangements.comfortable sound levels.During a review of the facility policy and procedure (P&P) titled, Maintenance Service revision date 12/2009, the P&P indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment.The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.The maintenance director is responsible for maintaining the following records/reports: k. Inspection of building.

Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from verbal abuse (using negative words and language that cause harm including demeaning, disrespecting, frightening, and threatening words) for one of thirty-two sampled residents (Resident 68) when Licensed Nurse (LN) 3 and Certified Nurse Assistant (CNA) 1 witnessed a contracted staff (staff who are usually not considered official company employee and are not on the traditional payroll but hired by another company for a specific responsibility) from the housekeeping department who made inappropriate and threatening remarks toward Resident 68 on 3/28/26. This failure had the potential to cause emotional distress and could negatively affect Resident 68's psychosocial well-being.Findings:On 3/29/26, at 10:02 a.m., the Department received a facility reported incident regarding an alleged employee to resident verbal abuse. This reported incident was investigated during the facility's annual recertification with a start date on 4/6/26.During a record review of Resident 68's admission RECORD, dated 4/9/26, the record indicated, Resident 68 was admitted to the facility with diagnoses including absence of right leg above knee, abnormal posture, and muscle weakness.During a record review of Resident 68's Minimum Data Set, (MDS, an assessment tool) dated 1/27/26, the MDS revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating Resident 68 had moderate problems with thinking and memory.During a record review of Resident 68's Care Plan Report, (summarizes a person's health conditions, specific care needs, and current treatments for care) dated 1/22/26, the report indicated, Resident 68 presents with lower extremities weakness due to impaired balance affecting functional mobility, and Resident 68 will achieve modified independence (patient can perform task safely and independently) with wheelchair mobility.During a concurrent observation and interview on 4/6/26, at 12:42 p.m. with Resident 68 in the South Unit, Resident 68 was in his wheelchair and wheeling around the facility with his right leg amputated (loss or removal of a body part through surgery) above the knee. Resident 68 stated he was doing well and had no concerns.During a review of Resident 68's clinical record titled, Interdisciplinary Care Conference, dated 3/30/26, the record indicated, .Notified by Primary nurse of contracted staff member spoke inappropriate language towards resident while self-propelling in wheelchair across wet floor that staff member had completed mopping.Explained to staff of not to use inappropriate language towards residents.During a record review of Resident 68's Care Plan Report, dated 3/29/26, the report indicated, .Staff to resident abuse [on] 3/28/26.Resident will indicate and/or staff will observe resident to experience no psycho-social distress.Encourage resident to verbalize feelings.Give support and reassurance.During an interview on 4/9/26, at 7:36 a.m. with Resident 68, Resident 68 stated he did not recall any staff member treating him inappropriately. Resident 68 also stated no one was bothering him and that he felt safe here.During a phone interview on 4/9/26, at 10:18 a.m. with CNA 1, CNA 1 stated that it was during the evening shift and was about to clock out for his lunch when CNA 1 heard the contracted housekeeper (HSK) 1 saying profanity and cursing at Resident 68. CNA 1 stated HSK 1 had indicated Resident 68 to get off the floor because he was going to mop it. CNA 1 stated she heard HSK 1 verbally abusive towards Resident 68.During an interview on 4/9/26, at 10:34 a.m. with the Environmental Services District Manager for Health Care Services Group (EVS DM) together with the Housekeeper Supervisor (HSK), the EVS DM stated that their group oversees all their employees and had gone through extensive hiring processes. The HSK stated that she reviews applicants that would be a potential fit to the needs of the facility. The HSK also stated applicants would go through onboarding orientation and through this orientation a background check and health examination would be executed before hiring. The EVS DM stated this process would ensure that applicants were clear and promote safety among the residents in the facility. The EVS DM stated that she expected all contracted employees hired under their group should respect resident rights and all educational training related to working in a nursing home environment including prevention of any abuse should be observed and any broken practices will be addressed. The HSK stated HSK 1 should have respected resident rights and should have worked well with the facility staff and residents.During an interview on 4/9/26, at 10:49 a.m. with the Administrator (ADM), the ADM stated HSK 1 did not follow the proper process of mopping the floor. The ADM stated the rule was to mop the floor one side at a time and HSK 1 got frustrated when Resident 68 passed through the mopped floor. The ADM stated residents felt unsafe and their rights violated when residents were treated inappropriately. During a phone interview on 4/9/26, at 11:03 a.m. with LN 3, LN 3 stated the incident happened at about 7 pm and just came back from her lunch. LN 3 stated she noticed HSK 1 was mopping the floor and she had commented to HSK to mop half of the floor first and not the entire floor in case of emergency to prevent staff from slipping. LN 3 stated HSK 1 responded aggressively that the floor would dry up quickly. LN 3 explained HSK 1 continued mopping the floor while Resident 68 was in wheelchair wheeling himself on the mopped floor at the South Unit close to the nurses' station. LN 3 continued to explain that she then heard HSK 1 saying to Resident 68 to move his ass and to get off the f*** floor. LN 3 stated she removed Resident 68 from the scene. LN 3 also stated that Resident 68 had indicated he was aware of what had happened. LN 3 further explained that she approached HSK and told him to act professionally and not to talk to residents rudely because this was their home and they have the right to be treated well and not to say profanity. LN 3 stated HSK responded and had indicated that the residents frustrated him and added the residents were lucky this was not a prison and if he was the correctional officer that he would beat them. LN 3 stated the residents have the right to be treated well and to feel safe because this place was their home.During a facility record review titled, Follow-Up Interview with [HSK 1], dated 4/2/26 at 12 p.m., the written statement by HSK 1 indicated, .[HSK 1] was asked whether he understood that speaking aggressively to a patient could be considered abuse. He responded, Yes.[HSK 1] was then asked to confirm whether, in his written statement, he indicated that he aggressively told [Resident 68] to move out of the way, [HSK 1] confirmed that those were his exact words. This written statement by HSK 1 was signed by the ADM and the Director of Nursing (DON).During a review of the facility's Policy & Procedure (P&P) titled, Abuse Prohibition, dated 2/23/21, the P&P indicated, .HealthCare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents.Verbal abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients.Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a patient.

Based on observation, interview, and record review the facility failed to assess a change in condition for one of 32 residents (Resident 1) and notify the physician when Resident 1's arteriovenous (AV) fistula (a surgically created connection of an artery directly to a vein allowing high blood flow during hemodialysis (HD), a life-saving treatment that acts as an artificial kidney that removes waste and extra fluid from the blood and regulates blood pressure) was not properly functioning. These failures placed Resident 1 at risk of missing hemodialysis as scheduled.Findings:A review of Resident 1's admission Record, indicated he was admitted to the facility with diagnoses that included but not limited to hypertension (a chronic condition where the force of blood pushing against artery walls is consistently too high, forcing the heart to work harder), chronic kidney disease (a long term, irreversible loss of kidney function where the kidney cannot effectively filter waste and excess water from the blood), and dependance on renal (kidney) dialysis.A concurrent interview and record review on 4/9/26, at 9:40 a.m., with the Director of Nursing (DON), Resident 1's MEDICATION ADMINISTRATION RECORD dated March 2026 was reviewed. The DON verified on dates 3/14, 3/24, 3/25, 3/26, 3/27, 3/28, and 3/31 licensed nursing staff documented negative for thrill and bruit (the nurse performed a physical exam and did not feel a thrill (vibration) or bruit (buzzing or swishing sound) over a blood vessel indicating a blockage or failure). The DON also verified that a change of condition assessment or informing the physician was not done. The DON stated it was her expectation of licensed nursing staff to notify the MD of the change in condition. The DON further stated this placed Resident 1 at risk of missing hemodialysis.A review of the facility's policy and procedure (P&P) titled, Change in Condition: Notification of dated 8/25/21, the P&P indicated, .physicians are informed of changes in condition.a significant change in the Resident's physical. status.A review of the facility's P&P titled, DIALYSIS CARE dated 8/25/21, the P&P indicated, .to provide dialysis care for residents in renal failure and those residents who require ongoing dialysis treatments.AV.Site will be inspected for functionality and sign and symptoms of complications.Nursing Staff will keep the Attending Physician, the resident and the resident's family informed of any change in conditions.

Based on observation, interview, and record review the facility failed to implement an adequate activities program for two of 32 sampled residents, Resident 15 and Resident 54 when:1.Resident 15 was not provided with one-to-one activities from 3/11/26, to 3/17/26, and2.Resident 54 was not provided with one-to-one activities from 3/19/26, to 3/29/26.These failures had the potential to negatively impact the psychosocial wellbeing of Resident 15 and Resident 54.Findings:1. A review of Resident 15's admission Record indicated Resident 15 was admitted to the facility with diagnoses that included but not limited to traumatic brain injury, schizophrenia (chronic brain disorder that causes people to lose touch with reality, making it difficult to distinguish what is real from what is not), and insomnia (chronic inability to get enough sleep).A review of Resident 15's activity care plan dated 5/5/25, indicated, .the resident needs 1 to 1 bedside/in-room visits and activities if unable to attend out of room events.A review of Resident 15's Participation Record dated March 2026, indicated Resident 15 did not participate in group activity and between 3/11/26 to 3/17/26 Resident 15 did not receive one to one activities.2. A review of Resident 54's admission Record indicated Resident 54 was admitted to the facility with diagnoses that included but not limited to adult failure to thrive (rapid or gradual decline in an older person's physical, mental, or social functioning, often characterized by unexplained weight loss, poor appetite, exhaustion, and loss of independence), delusional disorders (mental health condition where a person holds a firm, unshakable belief in something that is untrue, despite clear evidence to the contrary), and insomnia.During an interview on 4/7/26, at 8:25 a.m., with Resident 54, Resident 54 stated she used to get one to one visits from activities once or twice a week, but since last couple of weeks the one-to-one visits had stopped. Resident 54 stated she was no longer getting activity visits. Resident 54 further stated she was a little sad about it and she used to look forward to one-to-one activity visits since she was bedbound.A review of Resident 54's activity care plan dated 1/4/26, the care plan indicated, .one to one room visits 1-3 x [times] per week.the resident's preferred activities are writing, conversing.During a concurrent interview and record review on 4/8/26 at 10:30 a.m., with the assistant director of activities (ADA) Resident 54's, Participation Record dated March 2026, was reviewed. The ADA verified the record indicated between 3/19/26 to 3/29/26, Resident 54 did not receive a one-to-one visit or attended group activity. The ADA stated Resident 54 only participated in one-to-one activities. The ADA further stated if residents did not receive one to one activities when unable to attend group activity, it could negatively impact resident's mood and potentially resident could experience loneliness.A review of the facility's policy and procedure (P&P) titled, Individual Activities and Room Visit Program dated 6/2018, the P&P indicated, .Individual activities will be provided for those residents whose situations or conditions prevent participation in other types of activities, and for those residents who do not wish to attend group activities.individualized activities offered are reflective of the resident's activity interests, as identified in the Activity Assessment, progress notes, and the resident's Comprehensive Care Plan.It is recommended that residents with in-room activity programs receive, at a minimum, three in-room visits per week.

Based on staff interview and clinical record review, the facility failed to ensure that 1 of 32 sampled residents (Resident 8) was provided with education regarding the risks and benefits of prescribed psychotropic medications (medications used to treat mental health diagnosis) when the facility administered ordered psychotropic medications without confirming that consent had been obtained by the prescribing physician. This failure had the potential to cause Resident 8 to experience unnecessary side effects and duplicate therapy based on the number of psychotropic medications that had been ordered. Findings:During a record review of Resident 8's admission RECORD, dated 4/9/26, the record indicated that Resident 8 was admitted to the facility with diagnosis that included schizophrenia (a serious, chronic brain disorder that disrupts how a person thinks, feels, and acts, making it difficult to distinguish reality from imagination) and major depressive disorder (a serious mental health condition characterized by persistent, overwhelming sadness, hopelessness, or loss of interest in activities for at least two weeks.) The admission RECORD also indicated that Resident 8 was under conservatorship (a legal arrangement where a judge appoints a responsible person or organization (the conservator) to take care of another adult (the conservatee) who can no longer manage their own personal or financial affairs).During a record review of Resident 8's Minimum Data Set, (MDS - a federally required assessment tool) dated 3/10/26, the MDS revealed a Brief Interview for Mental Status (BIMS - a quick, 0-15-point test used in nursing homes to measure a person's memory and thinking ability) score of 3 (the score indicates a person's level of memory impairment with a score of 0-7 indicating severe impairment, 8-12 indicating moderate impairment, and 13-15 indicating no impairment.)During a record review of Resident 8's Order Summary Report, dated 4/9/26, the report indicated that Resident 8 had the following physician ordered psychotropic medications:fluoxetine (an antidepressant medication used to treat depression) 20 mg (milligram - a unit of measurement) once a day with a start date of 3/4/26lithium 600 mg (a mood stabilizing medication used to treat and reduce intense mood swings) two times a day with a start date of 3/4/26oxcarbazepine 300 mg (a medication used to treat seizures but is may also be used as a mood stabilizer for mental health disorders) two times a day with a start date of 3/4/26. The same medication was discontinued on 3/28/26 and a new order for oxcarbazepine 300 mg three times a day was started.risperidone 3 mg (an antipsychotic medication used to treat schizophrenia) with a start date of 3/5/26 then discontinued on 3/27/26quetiapine 400 mg at bedtime with a start date of 3/4/26During a record review of Resident 8's clinical document titled PSYCHOTROPIC MEDICATION ADMINISTRATION DISCLOSURE (Anti-Depressant), [a form used by skilled nursing facilities to document that the mandated process for ensuring residents or the resident's representative understand the risks, benefits, and alternatives to a psychotropic medication before the medication is initiated or the dose is increased], the document indicated that the NP had not obtained consent for the use of the medication fluoxetine 20mg one time a day from Resident 8's conservator until 3/15/26, and the facility had not confirmed that Resident 8's representative had given consent for the medication until 4/9/26.During a record review of Resident 8's clinical document titled PSYCHOTROPIC MEDICATION ADMINISTRATION DISCLOSURE (Anti-Psychotic), the document indicated that the NP had not obtained consent for the use of the medication lithium 600 mg two times a day from Resident 8's conservator until 4/5/26 and the facility had not confirmed that Resident 8's representative had given consent for the medication until 4/9/26.During a record review of Resident 8's clinical document titled PSYCHOTROPIC MEDICATION ADMINISTRATION DISCLOSURE (Anti-Psychotic), the document indicated the NP had not obtained consent for the use of the medication risperidone 3 mg one time a day from Resident 8's conservator until 3/14/26 and the facility had not confirmed that Resident 8's representative had given consent for the medication until 4/9/26.During a record review of Resident 8's clinical document titled PSYCHOTROPIC MEDICATION ADMINISTRATION DISCLOSURE (Anti-Psychotic), the document indicated the NP had not obtained consent for the use of the medication quetiapine 400 mg one time a day from Resident 8's conservator until 3/14/26 and the facility had not confirmed that Resident 8's representative had given consent for the medication until 4/9/26.There was no indication that a PSYCHOTROPIC MEDICATION ADMINISTRATION DISLOSURE form had been completed for the administration of oxcarbazepine 300mng twice a day.During a record review of Resident 8's clinical document titled MEDICATION ADMINISTRATION RECORD, (MAR) dated 3/1/26 through 3/31/26, the MAR indicated that Resident 8 was administered the following medications during the indicated period without informed consent:fluoxetine 20 mg every day from 3/5/26 through 3/14/26lithium 600 mg twice a day from 3/5/26 through 3/31/26oxcarbazepine 300 mg twice a day from 3/5/26 to 3/27/26 then three times a day from 3/28/26 through 3/31/26risperidone 3 mg at bedtime from 3/5/26 through 3/14/26quetiapine 400 mg at bedtime from 3/5/26 through 3/14/26During a record review of Resident 8's clinical document titled MAR, dated 4/1/26 through 4/30/26, the MAR indicated that Resident 8 was administered the following medication during the indicated period without informed consent:lithium 600 mg twice a day from 4/1/26 through 4/5/26oxcarbazepine 300 mg three a day from 4/1/26 through 4/7/26, held all three doses on 4/8/26 due to hospital stay, then given on 4/9/26 without documented consent.During a review of Resident 8's clinical document titled Visit Type: APP Initial Stabilization, dated 3/31/26, entered by NP 1, indicated that psychotropic medications fluoxetine, mirtazapine, oxcarbazepine, quetiapine and lithium were all to continue to treat Resident 8's diagnosis of schizophrenia and depression but did not indicate that informed consent had been obtained prior to the administration of the listed psychotropic medications.During a review of Resident 8's clinical document titled Visit Type: Follow Up, dated 4/1/26 and entered by Nurse Practitioner (NP) 1 review of the note revealed that there was no documentation that consent had been obtained by NP 1 from Resident 8's representative any the ordered psychotropic medications.During a review of Resident 8's clinical document titled Note Text: Progress Note, dated 4/2/26, entered by NP 2, indicated that the psychotropic medications had been ordered to treat Resident 8's diagnosis of schizophrenia and depression, but did not indicate that informed consent had been obtained prior to the medications being administered.During an interview on 4/8/26 at 11:42 AM with Licensed Nurse (LN) 1, LN 1 stated that informed consent for the use of psychotropic medication was required to be obtained by the MD and then confirmed by the nurse with the resident or the resident's representative that they had given consent to the MD and had agreed to the psychotropic medication order. LN 1 stated this process was to be completed before a psychotropic medication was to be administered. LN 1 stated they use the form titled PSYCHOTROPIC MEDICATION ADMINISTRATION DISCLOSURE to have the prescribing practitioner sign and date that the risks, benefits, and alternatives were discussed, the resident or their representative sign and date when the consent was given, and the nurse speaks to the resident or the representative to confirm that consent was given and then signs and dates the form when that is done. LN 1 stated the form then goes to the medical records department so it can be electronically uploaded into the resident's electronic health record.During a concurrent interview and record review on 4/8/26 at 12:07 PM with the Director of Nurses (DON), the DON reviewed Resident 8's psychotropic medication orders and Resident 8's MAR for March 2026 and April 2026. The DON stated that when psychotropic medications were ordered, the prescribing practitioner was responsible for obtaining consent from the resident or the resident's representative before the facility could administer a medication. The DON confirmed that facility used the form titled PSYCHOTROPIC MEDICATION ADMINISTRASTION DISCLOSURE form to document that the prescribing practitioner obtained consent from the resident or the resident's representative. The DON confirmed that Resident 8 had been administered fluoxetine, lithium, oxcarbazepine, risperidone, and quetiapine in March 2026 and lithium and oxcarbazepine in April 2026 without consent being obtained by the prescribing practitioner or confirmed by the facility. The DON stated that the psychotropic medications should not have been administered without the informed consent being obtained by the prescribing practitioner from the resident or the resident's representative. During a review of the facility's policy and procedure titled Psychotropic Medication Use, dated 7/22, the P&P indicated .Categories of medications which affect brain activity such as.central nervous system medications that are prescribed as a substitute for or an adjunct to a psychotropic medication are monitored and managed as psychotropic medications.Residents (and/or representatives) have the right to decline treatment with psychotropic medications.the staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.During a review of the facility's undated policy and procedure titled Informed Consent for Psychotropic Drugs, the P&P indicated .It outlines responsibilities for obtaining, verifying, and documenting informed consent to protect resident rights, promote safety, and facilitate appropriate use of these medications for residents with behavioral or psychotic symptoms.Informed Consent: Disclosure of material information (e.g., reasons for use, benefits, risks including black box warnings, alternatives including nonpharmacological approaches) to the resident or their representative/surrogate, allowing them to accept, refuse, or revoke consent. Consent must be obtained prior to initiation or increase.Responsibilities Prescribing Practitioner.obtain informed consent for all psychotropic medications prior to initiation or dose increase.document the discussion, resident/representative's understanding, and consent/refusal in the medical record.Facility Role verify (but not obtain) informed consent; ensure documentation in the medical record.

Based on observation, interview and record review the facility failed to provide one to one supervision (a designated staff to provide constant monitoring to prevent or redirect resident from engage in harmful act) to one of three sampled residents (Resident 2, with known behavioral issues), to prevent the physical altercation between Resident 1 and Resident 2 on 6/7/25.This failure resulted in Resident 2 suffering multiple bruises and a laceration to the right side of his face and Resident 1 suffering two fractures in his left hand.Findings:Review of Resident 1's admission RECORD indicated that Resident 1 was admitted to the facility with diagnoses that included but were not limited to unspecified mental disorder to known physiologic condition (a clear link between a physical condition and the mental symptoms, but the exact nature of the mental disorder is not clear), unspecified other stimulant abuse (continued use of amphetamine-type substances, cocaine, and other stimulants that can impact health), and cognitive communication deficit.Review of Resident 1's eINTERACT Change in Condition Evaluation dated 6/7/25, indicated that Resident 1 was involved in a resident-to-resident physical altercation and indicated the following, .AFTER THE RESIDENT WAS PUNCHED IN THE FACE, HE PROCEEDED TO GET UP FROM HIS WHEELCHAIR AND PUNCH ANOTHER RESIDENT X 5 ON THEIR FACE.RESIDENT HAD SWELLING TO HIS R [Right] EYE AND SWELLING TO HIS LEFT KNUCKLES.Review of Resident 1's Interdisciplinary (IDT - a group of professionals from various disciplines who work together to provide comprehensive care to a patient or group of patients) Care Conference Note - V 5 dated 6/8/25, indicated, Resident 1 had a Brief Interview for Mental Status (BIMS - a test used to get a snapshot of how well you are functioning cognitively at the moment the test is taken) score of 12, indicating Resident 1 had mildly impaired cognitive function. Review of Resident 2's admission RECORD indicated that Resident 2 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it), hemiplegia and hemiparesis following a cerebral infarction on the left, non-dominant side (paralysis and weakness of left side of the body after stroke), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), unspecified psychosis not due to a substance or known physiological condition (condition with symptoms that involves a disconnection from reality and the world, but does not fit into established categories of mental health disorders) and anxiety disorder. Review of Resident 2's eINTERACT Change in Condition Evaluation dated 6/7/25, indicated that Resident 2 was involved in a resident-to-resident physical altercation and indicated the following, .STAFF WITNESSED SEEING THE RESIDENT GETTING PUNCHED X 5 ON THE FACE BY ANOTHER RESIDENT.RESIDENT HAD IMMEDIATE SWELLING AND CONTUSION [bruise].Review of Resident 2's Interdisciplinary Care Conference-V5 note completed on 6/8/25, indicated that Resident 2 had a BIMS score of 13, indicating that Resident 2 was cognitively intact.During a concurrent observation and interview on 8/1/25, at 9:55 a.m., Certified Nursing Assistant (CNA) 1 was noted to be sitting outside of Resident 2's bedroom within visual site of Resident 2, who was asleep in his bed. CNA 1 stated she was providing one-to-one supervision for Resident 2. CNA 1 stated that Resident 2 was receiving one-to-one supervision on all shifts due to Resident 2's history of physical and verbal aggressive behaviors with other residents. CNA 1 stated the risk of not having Resident 2 on one-to-one supervision, was that Resident 2 could become aggressive with another resident and there would be no one closely monitoring him to step in and redirect Resident 2 before the altercation escalated. CNA 1 stated that her role in providing Resident 2 with one-to-one supervision was to monitor and ensure she watched Resident 2, to make sure he didn't start a fight with anyone.During an interview with Resident 2 on 8/1/25, at 11:15 a.m., Resident 2 was sitting up on the right side of his bed. Resident 2 was noted to have a small amount of discoloration under his right eye. Resident 2 stated that the eye was still tender and painful at times. Resident 2 stated that he was in the hallway when Resident 1 came up to him and asked him for a cigarette. Resident 2 stated that when he told Resident 1 that he did not have any cigarettes, Resident 1 said to him f. y., so Resident 2 said he said the same thing back to Resident 1. Resident 2 stated that when he did that, Resident 1 stood up and hit him. Resident 2 stated he then hit Resident 1 back but could not remember where he hit him. Resident 2 stated that Resident 1 then started to hit him repeatedly, causing a right black eye. Resident 2 stated that Resident 1 was a bad man, and he was glad Resident 1 was no longer in the facility. During a phone interview on 8/1/25, at 11:48 a.m. with Licensed Nurse (LN) 1, LN 1 stated that on 6/7/25 at approximately 11:00 p.m. she heard a loud commotion in the hallway while she was at the center nurse's station. LN 1 stated that she heard what sounded like a POW and when she came out from behind the station, she saw Resident 1 and Resident 2 in front of each other and yelling at each other. LN 1 stated that she and two other LNs ran towards the two residents and separated them upon arrival. LN 1 stated that Resident 2 had an obvious injury to his face as his right eye started to swell and was red and there was blood on his face. LN 1 stated she did not see any injury to Resident 1. LN 1 stated that Resident 1 was not on any specific monitoring prior to the altercation but was placed on one-to-one supervision after the altercation. LN 1 stated that Resident 2 was on one-to-one supervision but only on the morning and evening shifts due to his history of being verbally and physically aggressive with other residents, but that level of supervision was not in place on the night shift. LN 1 stated that the altercation might not have happened had Resident 2 been receiving one-to-one supervision on the night shift.During a phone interview on 8/1/25, at 12:04 p.m. with LN 2, LN 2 stated that she heard yelling and screaming while she was at the facility's north nurses' station. LN 2 stated she and two other LNs started running to the area. LN 2 stated while enroute to the altercation, she could see Resident 1 standing over Resident 2, who was in his wheelchair, and Resident 1 was punching Resident 2. LN 2 stated that when they arrived at the scene Resident 1 was still hitting Resident 2. LN 2 stated that one of the other LNs got in between the two residents and LN 2 pulled Resident 2 back from Resident 1. LN 2 stated Resident 2 had swelling to his right eye, redness around the orbital area (eye socket) and blood coming from a cut over his eye, while Resident 1 had a red face and knuckles but no indication of bleeding anywhere. LN 2 stated that Resident 2 did have a history of becoming physically and verbally aggressive with other residents. LN 2 stated Resident 2 had been receiving one-to-one supervision on the morning and evening shifts but not the night shift. LN 2 stated that the altercation might not have happened had Resident 2 been receiving one-to-one supervision on the night shift.During a phone interview on 8/1/25, at 12:39 p.m., with LN 3, LN 3 stated that the altercation between Resident 1 and Resident 2 occurred on 6/7/25 around 11:00 p.m. LN 3 stated she did not see the event or respond to the event but was the receiving nurse for Resident 1 when one of the other LNs brought him back to his primary nurses' station. LN 3 stated that Resident 1 stated that the guy swung at me, so I swung back. LN 3 stated that Resident 1 had no bruise or cuts on his face, but there was redness to his knuckles. LN 3 stated that Resident 1 had no history of aggressive behaviors prior to this altercation, but Resident 2 did have a history of physical and verbal aggression towards other residents. LN 3 stated that Resident 1 and Resident 2 were placed on one-to-one supervision after the altercation. During a concurrent interview and record review with the Administrator (ADM) on 8/1/25, at 10:48 a.m., the ADM stated that the Director of Nurses notified her of the altercation between Resident 1 and Resident 2. A review of Resident 1's radiology report dated 6/8/25 with the ADM, confirmed that Resident 1 sustained, . a fracture involving the 5th metacarpal [finger] and 5th proximal phalanx [the bone at the base of the little finger] distally with minimal callus [a temporary formation of new bone and cartilage that develops at the fracture site during initial stages of healing] and displacement. There is associated soft tissue swelling. The ADM stated that Resident 2 had a history of physical and verbal aggressive behaviors towards other residents and had been placed on one-to-one supervisor on the morning and evening shifts because of those behaviors. The ADM stated that Resident 2 had not received one-to-one supervision on the night shift prior to the 6/7/25 event. The ADM stated that the altercation might have been avoided had Resident 2 been receiving one-to-one supervision on the night shift prior to 6/7/25. Review of Resident 2's Care Plan Report, with a last care plan review completed date of 7/15/25, indicated Resident 2 had resident to resident altercation on the following dates: 1/24/25; 1/29/25; 2/26/25; 3/5/25; 3/10/25; 3/19/25; 3/24/25; 4/17/25; 4/23/25; 5/9/25; and 6/7/25.Review of a facility policy titled, Safety of Residents dated 6/27/22, indicated, .maintain one-on-one supervision of the resident until the behavior has subsided.Review of a facility policy titled, Resident Rights with a revised date of December 2021, indicated, .Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.be free from abuse.Review of a facility policy titled, Abuse Prohibition - Administrative Policies with a revised date of 10/25/24, indicated, Health Care Center prohibits abuse.for all residents.Physical abuse includes hitting, slapping, pinching, kicking, etc.Identifying, correcting and intervening in situation in which abuse.is more likely to occur.The Center will provide adequate supervision when the risk of resident-to-resident altercation is suspected. The Center is responsible for identify residents who have a history.or who exhibit other behaviors that make them more likely to be involved in an altercation.

Based on interview and record review, the facility failed to provide necessary care and services to prevent a pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with friction) from developing and/or worsening for one of two sampled residents (Resident 2) when: 1. Resident 2 developed a wound on the lower back/coccyx (tail bone) on 4/25/23, and the wound nurse was not notified per Resident 2's care planned interventions; and, 2. Licensed nurses did not monitor Resident 2's lower back/tailbone wound according to physician orders, facility policy, and per standard of nursing practice. These failures resulted in delayed identification and treatment of a pressure ulcer for Resident 2. Resident 2' s lower back/coccyx wound was identified on 5/8/23 as an unstageable pressure ulcer (the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown or black. The medical professional cannot see the base of the wound to determine the extent of damage) and on 5/10/23, Resident 2's wound was determined to be a stage 4 pressure ulcer (deep wound with exposed bone, tendon, and/or muscle). Findings: 1. Review of Resident 2's ADMISSION RECORD indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included fusion of the spine (surgery to permanently join two or more bones in the spine to prevent movement between them), paraplegia (paralysis of the legs and lower body), polyneuropathy (many nerves in different parts of the body are damaged), abnormalities of gait and mobility, and muscle weakness. During a review of Resident 2's Minimum Data Set (MDS, an assessment and care planning tool), dated 4/20/23, the functional status section of the MDS indicated Resident 2 required extensive assistance to move in bed, and total dependence to transfer between surfaces. Further review of the skin conditions section of the MDS indicated Resident 2 was at risk for pressure ulcers and had no existing pressure ulcers. Review of Resident 2's Admission & baseline care plan/summary, dated 4/13/23, in the BRADEN SCALE [a tool used to assess risk] FOR PREDICTING PRESSURE SORE [ulcer] RISK, indicated Resident 2 scored 13 and was at moderate risk for developing pressure ulcers. Review of Resident 2's care plan titled, 48 HOUR INITIAL CARE PLAN: has potential for and actual altered skin integrity related to multiple comorbidities (two or more diseases or medical conditions). Bed bound, current health condition, surgical orthopedic [surgery involving bones] aftercare . initiated on 4/17/23, indicated a goal for Resident 2 was, Resident will have no s/s [signs and symptoms] of skin breakdown at all times through next 90day [sic] review. The care plan interventions included, .Document any beginning stages of breakdown, notify wound consultant/nurse and MD [Medical Doctor] . Review of Resident 2's care plan titled Skin integrity impaired . Skin abrasion to lower back/upper coccyx . initiated on 4/25/23, indicated a goal for Resident 2 was to, .show s/s [signs and symptoms] of healing wound. The care plan interventions included, .Daily assessment and documentation by residents nurse .area of body .odor present .drainage color and amount .If tissue breakdown occurs: notify appropriate health care provider (e.g. [examples] physician, wound care specialist) .Notify MD as needed .Weekly skin assessments . During a concurrent interview and record review on 6/8/23, at 2:06 p.m., with the Wound Nurse (WN), Resident 2's Nurses Note, dated 4/25/23 was reviewed. The WN stated he was not notified about Resident 2's skin abrasion and had no knowledge of it. The WN further stated he should have been notified. The WN stated he learned of Resident 2's wound when a CNA notified him of a dressing change needed on 5/8/23. The WN stated he was unaware Resident 2 had a wound which needed a dressing. The WN stated he observed Resident 2's coccyx on 5/8/23 and described the skin as necrotic (dead tissue that can be dry, thick, leathery usually a tan, brown, or black color) The WN stated had he been notified of Resident 2's wound on 4/25/23, the progression of a small wound to a stage 4 pressure injury could have been prevented. During a concurrent interview and record review on 6/8/23, at 4:07 p.m., Licensed Nurse (LN) 8 reviewed Resident 2's clinical record, Nurses Note, dated 4/25/23, which indicated, .CNA [Certified Nurse Assistant] notified writer about skin abrasion in lower back, upper coccyx. Upon assessment, writer noted 4.06 cm [centimeters, unit of measurement] x 1.27 cm [approximately 1.5 by 0.5 inches] skin abrasion in lower back/upper coccyx .MD INFORMED: Yes . LN 8 stated he wrote the Nurses Note regarding Resident 2's wound. LN 8 stated when residents developed skin problems, nurses would report to the doctor and wound nurse. LN 8 further stated he notified the doctor and should have also informed the wound nurse (WN). Review of Resident 2's clinical record, Nurses Note, dated 5/8/23, written by the WN, indicated, Writer was notified by the nurse on duty that [Resident 2] has a wound on his bottom. sacrum [lower back] unstageable d/t [due to] necrosis . Review of Resident 2's Weekly Wound Review, dated 5/8/23, completed by the WN indicated, .Sacrum [lower back] .Pressure .centimeters .Length .12 .Width .7 [approximately 5 x 3 inches] .Unstageable . Review of Resident 2's INITIAL WOUND EVALUATION & MANAGEMENT SUMMARY, dated 5/10/23, completed by the Wound Physician (WP) indicated, .Etiology [cause] .Pressure .Wound Size (L x W x D) [length times width x depth] .11 x 6.5 x 0.1 cm .Surface Area .71.50 cm^2 [centimeter squared, a unit of an area] .Post-debridement [removal of damaged tissue from a wound] assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage 4 pressure injury [pressure ulcer, both terms used interchangeably] . During an interview on 7/6/23, at 1:16 p.m., the Unit Manager (UM) stated the expectation was if the licensed nurse saw a skin change on a resident, the licensed nurse would assess the resident, complete a change of condition form, initiate a care plan, notify the Doctor, responsible party, and inform the wound nurse. 2. Review of Resident 2's physician orders with a start date of 4/25/23, indicated, Monitor skin abrasion to lower back/upper coccyx. Notify MD for worsening changes, D/C [discontinue] when resolved. every shift . Review of Resident 2's Treatment Administration Record [TAR], for the month of April 2023 and May 2023, with a start date of 4/25/23, indicated, Monitor skin abrasion to lower back/upper coccyx .every shift . Review of Resident 2's care plan titled Skin integrity impaired . Skin abrasion to lower back/upper coccyx . initiated on 4/25/23, with interventions which included, .Daily assessment and documentation by residents nurse .area of body .odor present .drainage color and amount .If tissue breakdown occurs: notify appropriate health care provider (e.g. [examples] physician, wound care specialist) .Notify MD as needed .Weekly skin assessments . During a concurrent interview and record review on 6/8/23, at 9:34 a.m., with LN 7, Resident 2's clinical record, Weekly Assessments, dated 5/7/23 was reviewed. In the section SKIN CONDITION, LN 7 stated she entered the documentation under .Skin concerns . a check, .yes . and a check mark in the box for Surgical Wound. No other check mark or comment about any other skin concerns was documented. When asked if LN 7 looked at Resident 2's lower back or coccyx, LN 7 confirmed Resident 2 had a wound on the lower back/coccyx and LN 7 did not document this on the weekly assessment. LN 7 further stated she did not look at Resident 2's lower back/coccyx because she was not able to turn Resident 2 without help. LN 7 stated she should have had someone assist in turning Resident 2, in order to assess Resident 2's wound. During a concurrent interview and record review on 6/8/23, at 6:02 p.m., with LN 9, Resident 2's TAR for May 2023 was reviewed. In the section, Monitor skin abrasion to lower back/upper coccyx ., LN 9 stated he entered a check mark and his initials for the evening shifts on 5/1/23, 5/2/23, 5/5/23, 5/6/23, 5/7/23 and the night shift on 5/7/23. LN 9 stated Resident 2 had a dressing on his lower back/coccyx which was always clean and without any drainage evident. When asked if LN 9 removed the dressing to look at the skin, LN 9 stated he did not, as the dressing was dry. LN 9 further stated he assumed the wound nurse was doing the dressing changes and monitoring Resident 2's wound. LN 9 stated he should have checked Resident 2's skin on the lower back/coccyx area. During a concurrent interview and record review on 6/9/23, at 1:28 p.m., with the WN, Resident 2's TAR for May 2023 was reviewed. In the section, Monitor skin abrasion to lower back/upper coccyx ., the WN stated he entered a check mark and his initials for the day shift on 5/1/23, 5/2/23, 5/3/23, 5/4/23 and 5/8/23. The WN stated Medical Records gave him an audit of the overdue tasks for Resident's 2 TAR, which contained missing documentation, and he signed them off. The WN further stated the staff expected him to sign them off. The WN stated the documentation was inaccurate, as he did not monitor the wound on Resident 2's lower back/coccyx and was unaware of Resident 2's wound. During a concurrent interview and record review on 6/9/23, at 2:44 p.m., with LN 10, Resident 2's TAR for May 2023 was reviewed. In the section, Monitor skin abrasion to lower back/upper coccyx ., LN 10 stated she entered a check mark and her initials for the evening shift on 5/3/23 and 5/4/23. LN 10 stated monitoring the skin abrasion would consist of looking at the wound for signs of healing or complications, drainage, signs and symptoms of infection (redness, drainage, swelling, smell, and pain) and if there was a dressing, to remove it and look at the wound. LN 10 stated Resident 2 had a wound on the lower back/coccyx. LN 10 further stated LN 10 never looked at Resident 2's lower back/coccyx, because the wound nurse did the dressing change and signed off on it. When asked where it was documented to show the wound nurse signed off on dressing changes during the monitoring period prior to 5/8/23, LN 10 was unable to find the documentation. Review of Resident 2's clinical record, Nurses Note, dated 5/8/23, written by the WN, indicated, Writer was notified by the nurse on duty that [Resident 2] has a wound on his bottom. sacrum [lower back] unstageable d/t [due to] necrosis . During a telephone interview on 6/16/23, at 8:56 a.m., the Wound Physician (WP) stated if a wound was identified early, it had a better chance of healing. He stated once a wound became larger, it took longer to heal. The WP stated covering the wound with a dressing also decreased the opportunities of visualizing the wound. The WP stated, .would see changes in the coccyx if they were monitoring, looking at the skin. A wound can change to stage 4 in 24 hours . The WP stated if monitoring had occurred during the time period between 4/25/23 and 5/8/23, changes would have been identified and the progression to a stage 4 pressure ulcer could have been avoided. During a concurrent interview and record review on 7/6/23, at 1:16 p.m., Resident 2's clinical record was reviewed with the Unit Manager (UM) and the Administrator (ADM). The UM and the ADM stated there was no documentation stating the skin abrasion on Resident 2's lower back/coccyx was healed by 5/8/23. The UM and ADM indicated the physician order to, Monitor skin abrasion to lower back/upper coccyx .D/C when resolved. every shift, with a start date of 4/25/23, and an end date of 5/8/23, would have been discontinued if the skin abrasion had healed. The UM stated the expectation was for the licensed nurse to monitor for signs and symptoms of infection, to look at the skin on Resident 2's lower back/coccyx and not the dressing if there was one. The UM further stated not monitoring the wounds but documenting the task completed was inaccurate and falsified documentation and would result in inadequate treatment and worsening of the wound. The UM stated nurses should not rely on the WN for assessments they were expected to complete. The UM reviewed Resident 2's clinical record, Weekly Assessments, dated 5/7/23, and stated Resident 2's wound on his lower back/coccyx was not assessed. The UM stated she expected staff to complete a full assessment. During a telephone interview on 7/7/23, at 5:43 p.m., with the Medical Director (MD), the MD stated he was unaware the skin abrasion on Resident 2's lower back/coccyx reported to him on 4/25/23, measured, 4.06 cm x 1.27 cm. The MD stated the size was too large to have been an abrasion, and stated the initial evaluation was not correct, and may have been a stage 1 or stage 2 pressure ulcer at the time. The MD stated in that case, a physician would have looked at the wound and provided orders for wound care. The MD stated he did not order the dressing which was in place on Resident 2's lower back/coccyx described by LN 9, and best practice was to obtain physician orders for wound care. The MD stated he expected licensed nurses to be alert to new changes in the residents and expected them to notify the physicians. The MD stated licensed nurses would have seen a worsening in Resident 2's lower back/coccyx wound during the time period from 4/25/23 to 5/8/23, if they had looked at the wound every shift. The MD stated he expected the nurse to see or identify the wound before it became unstageable. He expected the nurses to document according to regulations and the clinical condition of the resident. He stated staff should not document a task they did not complete and stated, If a nurse signs off, I assume it was done. Review of an undated John Hopkins Medicine online article titled, Bedsores, in the section, What causes bedsores?, indicated, A bedsore develops when blood supply to the skin is cut off for more than 2 to 3 hours. As the skin dies, the bedsore first starts as a red, painful area, which eventually turns purple. Left untreated, the skin can break open and the area can become infected. A bedsore can become deep. It can extend into the muscle and bone . In the section, Can bedsores be prevented?, indicated, Bedsores can be prevented by inspecting the skin for areas of redness (the first sign of skin breakdown) every day with particular attention to bony areas . (https://www.hopkinsmedicine.org/health/conditions-and-diseases/bedsores) Review of a facility policy and procedure (P&P) titled Prevention of Pressure Ulcers/Injuries, undated, indicated, .Inspect the skin on a routine basis when performing or assisting with personal care or ADLs [activities of daily living, task of everyday life include eating, dressing, bathing or showering, and using the bathroom] .Monitoring .Evaluate, report and document potential changes in the skin . Review of the American Nurses Association online publication titled, Nursing: Scope and Standards of Practice, Third Edition, dated 7/2015, in the section, Standards of Practice, indicated, .The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation . In the section, The What and How of Nursing, indicated, .Nursing actions are intended to produce beneficial effects, contribute to quality outcomes, and above all, do no harm . (https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf)

Based on interview and record review, the facility failed to provide services that are necessary to avoid physical harm and pain when one of three sampled residents (Resident 1) demonstrated bruising, persistent pain in her left hip and leg, and a left hip fracture which limited her mobility and activity. This failure resulted in Resident 1 not receiving necessary nursing and medical treatment including positioning, pain management, surgical intervention and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Face sheet indicated Resident 1 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Brief Interview of Mental Status (BIMS) dated August 18, 2022 indicated Resident 1 has a BIMS of three which indicated cognitive impairment (trouble in thinking clearly). A review of Resident 1's Nurse's Admission notes by Licensed Nurse (LN) 1 dated 8/16/22 indicated Resident 1 had skin intact. A review of Resident 1's Nurse's note by LN 7 dated 8/17/22 at 9:36 a.m. indicated head to toe skin assessment upon admission. Skin intact no skin issue noted will continue to monitor. A review of Resident 1's nurse's note indicated the following on: - 8/17/22 at 1718 pm (5:18 pm) a late entry by LN 3 documented bruise noted to L [left] hip. - 8/18/22 by LN 8 documented .0/10 pain . - 8/20/22 by LN 4 documented bruise noted on L hip no swelling noted. - 8/20/22 by LN 5 documented .no c/o pain or discomfort at this time . -8/21/22 by LN 5 documented .noticed bruises on left hip . -8/22/22 by LN 5 documented .denied any pain or discomfort . - 8/22/22 by LN 3 documented .bruise noted to . L hip . -8/22/22 by LN 9 documented .resident is soundly sleeping .no c/o (complaint of ) pain . -8/23/22 by LN 3 documented .denies pain . - 8/24/22 by LN 10 documented .no manifestation of pain or any discomfort . - 8/25/22 there was no nurse's note documented on nursing care. -8/26/22 by LN 11 documented .denies pain . - 8/27/22 by LN 10 documented .no c/o pain or any discomfort . -8/28/22 by LN 10 documented .on monitoring for skin discoloration . -8/28/22 by LN 2 documented .on monitoring D3S1 (day 3 shift 1) to l (left) hip skin discoloration . -8/28/22 by LN 2 documented .on monitoring D3S2 to L hip discoloration . -8/29/22 by LN 10 documented . on monitoring for skin discoloration on L hip D3S3 . A review of Resident 1's Physical Therapy (PT) Progress Report dated from 8/17/2022 to 8/30/2022 indicated Resident 1 was not evaluated on the following functional skills assessments sit to stand .chair/bed-to-chair transfer . toilet transfer . car transfer . walk 10 feet .due to medical conditions or safety concerns .pending on CT [Commuted Tomography; noninvasive medical exaination that uses equipment to produce cross-sectional images of the body] scan results . A review of Resident 1's Occupational therapy (OT) Evaluation and Plan of treatment dated 8/22/2022 by OT 1 indicated Resident 1 had .observable L [left] lateral thigh bruise noted. (LN 3) made aware. The patient grimaced with slight movement on the L LE [left lower extremity] . A review of Resident 1's OT Treatment Encounter Notes dated 8/23/22 by OT 2 indicated Resident 1 Pt (patient) significantly limited by pain in L hip where bruise is, pt was premedicated however cont [continue] to c/o [complain of] pain . A review of Resident 1's PT Treatment Encounter Notes indicated the following: - 8/23/22 by PT 1 .Pt leans significantly towards R [right] side, possibly due to bruise on L hip . - 8/24/22 Resident 1 participates in, completes all skilled therapeutic interventions this visit with patient participation limited by pt's cognition. Pt also complains of LLE pain during hip and knee flexion (bending of a limb or joint) says it hurts. Pt does not elaborate. - 8/25/22 by PTA 2 indicated Resident 1 . all maximum A [assistance] due pt confusion and limited ROM [range of motion; measurement of the amount of movement around a specific joint or body part] at L hip due to pt c/o pain . A review of Resident 1's Change in Condition Evaluation form dated 8/26/22 at 10:19 am indicated skin discoloration in the left hip about 10 cm (type of measure; centimeters) long. Informed PT around 8 a.m. around 8:30 a.m. informed the MD [Medical Doctor]. A review of Resident 1's OT Treatment Encounter Notes dated 8/26/22 by OT 1 indicated patient was fully agreeable to the OT session .better tolerated but still complained of pain on the L LE with slight movement . A review of Resident 1's Physician Note dated 8/26/22 indicated MD 1 documented Discoloration of lef [sic] hip and pain as chief complaint/ nature of presenting problem. MD 1 further indicated, Today RN [Registered Nurse] asks me to look at pt left hip which is discolored per her [sic]. No hx [history] of fall . A review of Resident 1's MD orders dated 8/26/22 indicated stat [at once; without delay] left hip xray was ordered. A review of Resident 1's Radiology report dated 8/26/22 indicated linear lucency [a dark spot or region on an xray] involving left-sided intertrochanteric area [between bony protrusions on the thigh bone] overlying shadow versus fracture [the cracking or breaking of a bone]. A review of Resident 1's PT Treatment Encounter Note dated 8/29/22 by PTA 1 indicated communicated with Pt's nurse regarding pt's L hip; nurse reports [name of doctor; MD 1] suspects possible fracture and CT scan has been ordered for pt. PT not transferred to WC [wheelchair] out of abundance of caution until further imaging results available . A review of Resident 1's Nurse's note dated 8/29/22 by LN 2 indicated Results of Xray given to MD [Medical Doctor]. MD notified and made aware. No new orders at this time. A review of Resident 1's PT Treatment Progress Report dated 8/30/22 by PT 1 indicated patient has not made significant gains due to pain L [left] hip. Patient unable to tolerate any wb [weight bearing] rle [right lower extremity]. Xrays completed, however, further work up is recommended. Pending CT scan results. A review of Resident 1's discharge notes by LN 1 on 8/30/22 indicated Resident 1 was discharged to (name of facility; Facility B) and brought by family member to facility [B] by private transport. During a concurrent record review of Resident 1's nurse's notes and progress notes and interview with Assistant Director of Nursing (ADON) on 9/20/2022 at 11:40 a.m., ADON verified the following documentation: Nurses' Notes 8/17/22: LN 3 noted bruise on L hip 8/20/22: LN 4 noted bruise on L hip 8/21/22: LN 5 noted bruise on L Hip 8/26/22: LN 6 noted bruise on L hip 8/26/22: MD 1 noted mass on L hip Progress notes 8/26/22: Xray ordered Xray on Resident 1 was completed on 8/26/22 and resulted on 8/29/22. 8/26/22: change of condition documented by LN 6. (nurses' notes) 8/29/22: LN 2 informed MD of Xray results ADON also confirmed there were no documented evidence of assessment of Resident 1's bruise on the following dates: 8/18, 8/19, 8/22, 8/23, 8/24 and 8/25. During a concurrent record review of Resident 1's nurse's notes and interview with Director of Nursing (DON) 1 on 9/20/22 at 12:08 p.m., DON 1 stated Patient 1 was assessed and saw bruise on left hip. The bruise was present on admission. Pain level was 1 out of 10 [numeric level of pain status; 1= less pain; 10= severe pain] as indicated in the medical record. DON 1 also stated When abnormal findings assessed on admission, we do 72 hours monitoring . Family (husband) was notified on 8/26/22 at 10 a.m. MD was also notified. During a concurrent record review of Resident 1's Nurse's Admission summary note and interview with DON on 9/20/22 at 2:15 p.m., DON 1 confirmed there was no bruise assessment on 8/16/22 on Nurse's admission summary note. DON further stated the Admission Summary notes indicated skin intact. DON 1 also confirmed there was no care plan done on 8/16/22 for bruise. DON 1 confirmed a care plan was done for resident 1 on 8/26/22 for bruise. A review of Resident 1's care plan for monitoring anticoagulant medications dated 8/16/22 indicated at risk for complications related to anticoagulant (chemical substance that prevent or reduce coagulation [clotting; process by which blood changes from a liquid to a gel] of blood )or antiplatelet (medications that prevent platelets [component of blood] from sticking together) medication due to resident admitted with pre-existing left hip discoloration 10 cm and to notify MD for any significant changes in discoloration. During a concurrent record review of Resident 1's nurse's notes and interview with LN 1 on 9/20/22 at 2:55 p.m., LN 1 stated Resident 1 came from [name of hospital]. Got report. Talks a little bit, confused. On admission: skin assessment was done. Skin was intact. Noted a yellowish area on left hip, little bit bumped. I have not seen her walking. Never seen her walk. She was transferred from gurney to bed. LN 1 stated, I knew Xray was done. I didn't know what the results were . [name of family member] picked up the patient. I gave her report .I did not mention about the bruise. I handed the Xray to her . MD has seen the Xray results. There was no new order . During a phone interview with MD 1 on 9/21/22 at 9:33a.m., MD 1 stated Resident 1 has no bruise. She had a fall. She hurt herself. I will have to double check my notes .my 8/26/22 notes indicate she had a mass on left hip. Xray was done. The results were inconclusive [not leading to a firm conclusion] versus a fracture. In my assessment, she had no pain. In my clinical judgement, there was no need to do a CT based on her clinical symptoms. Xray was done on 8/26/22. I saw the results on 8/27/22 (sic; Xray resulted 8/29/22) .I am not aware of the fracture .She has no history of fall. She only has a bump/ mass on her left hip. I have no communication with nurses regarding the resident. During a concurrent record review of Resident 1's Nurse's notes and interview with the DON 2 of the receiving facility (B) on 9/21/22 at 10:16 a.m., DON 2 indicated Resident 1 was admitted in facility (B) coming from facility (A) on 8/30/22 and brought in by daughter. Nothing was mentioned about the bruise. During Resident 1's assessments on 8/31/22, the PT and the LN observed discomfort and pain on left hip. An Xray was done on 8/31/22. The Xray results showed acute nondisplaced intertrochanteric fracture. Resident 1 was sent again to the acute care hospital for an open reduction internal fixation [ORIF; surgery to fix severely broken bones] on the left hip on 9/1/22. A review of Resident 1's Radiology Results Report dated 8/31/22 indicated acute nondisplaced enter (sic) trochanteric fracture . A review of Resident 1's Computerized Tomography (CT; computerized Xray imaging in which three-dimensional (3-D) imaging is made possible) dated 8/31/22 indicated mildly displaced intertrochanteric fracture of the left proximal femur [thigh bone]. A review of Resident 1's Progress notes of the MD from the acute care hospital dated 8/31/22 indicated Resident 1 . presented .with evidence of left hip fracture. Patient apparently had an unwitnessed fall about a week ago. Since then, patient has been unable to bear weight so XRs (Xray's) were obtained which showed left hip fracture and she was taken to ED, Patient is unable to provide history . I personally spoke to patient's husband, who states that prior to fall and at baseline, patient was able to ambulate with a walker .I would recommend surgery, so she is not bedbound and to help with pain .plan for surgery tomorrow . During an interview with the Director of Rehab (DOR) 1 from facility (B) on 9/21/22 at 10:40 a.m., DOR 1 stated, I was with the PT when the resident was being evaluated. She was grimacing. I saw the bruise. So, I called the Rehab Director [RD] in facility [A] to verify about the bruise. RD said that they knew about the bruise, don't know when the nurse monitored it. They told the nurse about it. It was (name of OT) [OT 1] who reported to RD. DOR 1 further noted their assessment of Resident 1 showed the bruise was about 4 to 5 inches (10.16 cm to 12.7 cm). The bruise is more purplish inside and outside is light greenish. Patient 1 can say ouch and no during their assessments. During a concurrent record review of Resident 1's Physical therapists (PT) and Occupational therapists (OT) notes and interview with RD from facility (A) on 9/21/22 at 11:39 a.m., RD indicated Resident 1 was confused with a lot of pain. Resident 1 was not able to bear weight on her left leg. RD confirmed the following from the OT/ PT notes: 8/17: evaluated by OT 3; checked on bed mobility 8/19: evaluated by OT 2; observed pain, made nurse aware 8/22: evaluated by PT 1; (name of Nurse [LN3]) made aware of pain 8/23: noted resident complained of pain by OT 2 8/24: evaluated by OT 2; talked to Nurse; resident complained of pain hurts. Resident required maximum assistance to sit at side of bed. RD further stated that she had requested Xray to be done on Resident 1 during the interdisciplinary team (IDT) meeting. During an interview with the Administrator in facility (A) on 9/21/22 at 12:25 p.m., the Administrator stated Resident 1, had a bruise, not sure where. Not sure where she got it. She came from (name of general acute care hospital). When asked what the expectation is when a resident has a bruise, Administrator stated, nurses should have followed up on it. During a phone interview with LN 3 on 9/22/22 at 8:33 a.m., LN 3 stated, I took care of the resident (1) a day after the admission .Resident has no wounds but found bruising on the left hip. I wrote the addendum about it. I was made aware of the bruise the second time when the PT assisted me in changing the resident .I told her I have forgotten to write the note on the skin assessment. The resident was in the covid unit. I don't think I told anybody about it. I only made a note on the assessment .I gave report to (name of nurse) who was the night shift nurse .I don't remember if we monitor the bruising .she was not verbal on how she feels. She was confused. But she was protective every time she was moved . During a phone interview with LN 5 on 9/22/22 at 8:52 a.m., LN 5 stated I took care of her two days when she was in the covid unit. I don't remember much about her .I didn't do the skin assessment . During a phone interview with LN 2 on 9/22/22 at 9:30 a.m., LN 2 stated, I had taken care of (name of resident; Resident 1) once or twice. She had an Xray done. I briefly looked at the result. (Name of MD 1) was in the facility, so I handed it to him. He did not give any orders when he got the Xray results .The resident did not complain of pain. There was no grimacing. I did not turn her. It was the CNA who turned her. I did not give any pain meds to her .I can't recollect if there was communication regarding the bruising . A review of the policy titled Change in a Resident's Condition or status (version 2.3; no date) indicated, a significant change of condition is a major decline .that will not normally resolve itself without intervention by staff or by implementing standard .clinical interventions .the nurse will record in the resident's medical record information relative to changes in the resident ' s medical/ mental condition or status .

Based on observations, interviews and record review, the facility failed to provide monitoring and supervision to ensure safety of six residents (Resident 1, Resident 2, Resident 3, Resident 5, Resident 6, Resident 8) in a sample of 8 residents identified at risk for elopement (an act or instance when a cognitively impaired person leaves a safe area or premises unsupervised) when: 1.Resident 1 eloped and was found in a homeless shelter with altered mental status, dehydrated and with urinary tract infection ([CONDITION(S)]) 3 days later. 2. Staff failed to monitor the application and functioning of wanderguard (a monitoring device which beeps when residents go out of the building) bracelets for Resident 5, Resident 6, and Resident 8. 3. Staff failed to include Resident 2 and Resident 3 with wanderguards into the Elopement log binder for monitoring and have a Medical Doctor (MD) order for Resident 2 and 3. These failures resulted in Resident 1's elopement which caused harm when she experienced dehydration and possible exposure to extreme heat and had the potential for elopement of Resident 2, Resident 3, Resident 5, Resident 6, and Resident 8. Findings: 1.A review of Skilled Nursing Facility Admission Record (SNFAR) indicated, Resident 1 was admitted to the facility in February 2020, with diagnoses including stroke (a medical condition in which poor blood flow to the brain causes cell death) and muscle weakness. A review of the Minimum Data Set (MDS; an assessment tool) dated 6/4/2021, indicated Resident 1 has a Brief Interview of Mental Status (BIMS; an assessment tool in assessing mental cognition) score of 5 which indicated Resident 1 was cognitively impaired. A review of the Medical Doctor's (MD 1) order for Resident 1 dated 4/13/2020, indicated to monitor wanderguard (a monitoring device which alarms when resident goes out of the building) placement everyday shift. A review of the facility's incident report on 6/17/21 at 4:54 pm indicated Resident 1 eloped on 6/16/2021 (did not give exact time). The report indicated Resident 1 was discovered missing in the afternoon (early evening) of 6/16/2021. A review of the Nurses' Notes dated 6/16/2021 at 1345, Licensed Nurse (LN) 1 indicated Resident 1 was last seen in the resident's bathroom at 6/16/2021 at 1:30 p.m. to 1:45 p.m. by the CNA. A review of the Nurses' notes at 6/16/2021 at 22:52 p.m., LN 5 indicated Resident 1 was discovered missing on 6/16/2021 at 10:30 p.m., during nurse endorsement at shift change. A review of the Nurses' Notes dated 6/17/2021 at 17:11 p.m. (late entry for 6/16/2021), indicated LN 4 did not monitor Resident 1 and the functionality of the wanderguard during her shift. In an interview with the Director of Nursing (DON) on 6/18/2021 at 11:30 a.m., the DON stated that the Staff realized Resident 1 was missing during evening shift report on 6/16/2021 at 10:30 p.m., and that the resident was still missing. The DON also stated that Resident 1 had a wanderguard on when she eloped. During a concurrent interview and record review of the Medication Administration Record (MAR) for the month of June with Licensed Nurse 1 (LN1) on 6/18/2021 at 12 p.m., Resident 1's wanderguard bracelet was noted to be checked daily from June 1 to June 16, 2021. LN 1 stated Resident 1 was wearing a wanderguard bracelet when she checked Resident 1 on 6/16/21 at 8 a.m. During a document request with the Director of Nursing (DON) on 6/18/2021 at 1:10 p.m., the DON stated he will ask their Nurse Consultant for a policy on monitoring the wanderguard. A record review on the Emergency Documentation, dated 6/19/2021 at 4:45p.m. at the emergency room in a General Acute Care Hospital (GACH), MD 2 indicated that Resident 1 presented to the emergency room with altered mental status and diagnosed with dehydration (lack of total body water with an accompanying disruption of the metabolic process) and urinary tract infection ([CONDITION(S)]). The Complete Blood Count (CBC) results indicated Resident 1 had a white count of 13.7 thousand/unit liter (a measuring unit; normal values at 4-10). The Basic Metabolic Panel (BMP), dated 6/19/2021, indicated an elevated value (32.3) of Blood Urea [MEDICATION(S)] (BUN, a measure to evaluate kidney function and fluid balance; normal values at 9.8 to 20.1) and a potassium level of 3.1 mmol/L (a unit of measure; normal value at 3.5 to 5.1). MD 2 indicated the low potassium level was indicative of dehydration. The urinalysis results, dated 6/19/2021, indicated moderate presence of blood in the urine and moderate presence of leukocyte esterase (presence of white blood cells which indicate infection). MD 2 indicated the urinalysis results indicated urinary tract infection. During an interview with the SSD on 6/29/2021 at 2:40 p.m., SSD stated that Resident 1 has been wanting to return to the homeless camp. SSD also stated that the Psych MD indicated Resident 1 does not have the mental capacity to decide. SSD stated that this was the second time Resident 1 had eloped. During a phone interview with LN 4 on 6/29/2021 at 3:05 p.m., LN4 indicated she was busy on 6/16/2021 and did not check the wanderguard of Resident 1. LN 4 stated, she did not see Resident 1 that day and the CNA did not notice Resident 1. The DON confirmed there was no facility policy on wanderguard monitoring. In an email on 6/29/2021 at 3:58 pm, DON indicated that the facility has no policy on monitoring the wanderguard. In an email on 7/9/2021 at 2:05 p.m., DON indicated that the facility has no policy on monitoring the wanderguard as of 6/18/2021. During a phone interview with LN 4 on 7/9/2021 at 2:26 p.m., LN 4 confirmed LN 4 did not check Resident 1 on 6/16/2021 on her shift. LN 4 stated, I didn't expect her to leave like that . 2. During a concurrent interview with the DON on 6/18/2021 at 1:30 p.m. at the DON's office and record review of the Elopement Log binder, the DON showed a one-page resident file on each of the high-risk residents for elopement. There were five residents in the binder, namely Resident 4, Resident 5, Resident 6, Resident 7, and Resident 8. a. A review of Resident 5's SNFAR indicated he was admitted in the spring of 2021 with diagnoses including traumatic subarachnoid hemorrhage (bleeding in the brain) and [CONDITION(S)]. A review of the MDS indicated Resident 5 was cognitively impaired. During a concurrent observation and interview with LN 1 on 6/18/2021 at 1 p.m., Resident 5 was found not wearing his wanderguard and being wheeled by the Physical Therapist back to his room. LN 1 stated Resident 5 did not have his wanderguard on. During an interview with LN 2 on 6/18/21 at 1:47 pm, LN 2 stated that he checked the wanderguard of Resident 5 at 8 am and it was working. During a concurrent interview and record review with the DON on 6/18/2021 at 2:30 pm, DON confirmed there was no MD (MD 1) order for Resident 5 and there was no documentation of wanderguard monitoring in the MAR. DON stated Resident 5 was only a high potential for elopement and that was why he has no wanderguard. A review of MD 1's order for Resident 5, dated 6/21/2021, showed wanderguard for placement and monitoring was ordered 3 days after the facility visit. b.A review of Resident 6's SNFAR indicated he was admitted in April 2021, with diagnoses including dementia (a group of symptoms that make it hard to remember, think clearly, make decisions, and even control emotions). A review of the MDS, indicated Resident 6 has a BIMS score of 3 which indicated severely impaired. During a concurrent observation and interview on 6/18/2021 at 2:10 p.m., LN 3 brought Resident 6 to the front door to check the functioning of the wanderguard. There was an audible alarm when he reached the front door. During a concurrent interview and record review with the DON on 6/18/2021 at 2:20 p.m., the Medication Administration Record (MAR) for the month of June 2021 indicated, Resident 6 was being monitored for wandering behavior. DON stated there was no MD order to monitor wanderguard placement and monitoring. A review of the MD 1's order for Resident 6 dated 6/21/2021 indicated, monitor wanderguard for functioning every shift. The order was written 3 days after the facility visit. A review of the MAR for June 2021 indicated Resident 6 was monitored starting on 6/21/2021 on the p.m. shift. c. A review of Resident 8's SNFAR indicated she was admitted in November 2020, with diagnoses including Alzheimer's disease (a progressive disease characterized by memory loss and cognitive impairment), [CONDITION(S)] (a mental disorder characterized by hallucinations[hearing voices], and disorganized thinking. A review of the MDS, indicated Resident 8 has a BIMs score of 11 which indicated moderate impairment. A review of the MD (MD 1) order for Resident 8 dated 2/13/2021 indicated monitor for exit seeking behavior. A review of the MD 1 order, dated 2/16/2021, indicated monitor wanderguard to right wrist for placement and functioning every shift. During a concurrent observation and interview on 6/18/2021 at 2:15 p.m., Resident 8 did not have her wanderguard on. DON stated that LN 1 checked her wanderguard and it was on. DON stated that Resident 8 was able to remove the wanderguard bracelet. During a concurrent interview with the DON on 6/18/2021 at 2:30 p.m. at his office, and record review of the MAR for the month of June, DON indicated Resident 8 was noted to be checked for wanderguard from June 1 to 17, 2021. There was no documentation for June 18, 2021. The DON stated that that shift was not over yet and that the LN has not documented the monitoring. DON also confirmed the facility's list does not match the current identified residents who are at-risk for elopement. A review of the MD order (MD 1) for Resident 8, dated 6/18/2021 indicated, Resident 8 is on every 15 minutes whereabouts until wanderguard is available. A review of the documentation on Q 15 minutes Safety Checks on Resident 8, dated 6/18/2021 and 6/19/2021, indicated Resident 8 was monitored on 6/18/2021 and 6/19/2021 only. There was no documentation for Resident 8's Q 15-minute checks monitoring from 6/20/2021 to 6/29/2021. In an email from the DON dated 7/9/2021, DON indicated wanderguard was placed on the patient on 6/29/21 at 1 pm. A review of the facility's policy titled Wandering, Unsafe Residents dated Quarter 3, 2018, indicated .the staff will identify residents who are at risk for wandering . Resident 5 and Resident 8 were observed without wanderguard bracelets. Resident 5 and Resident 6 did not have an MD order for monitoring the wanderguard. 3, During a facility visit on 6/18/2021 at 12:15 a.m. with LN1, Resident 2 and Resident 3 were found wearing a wanderguard bracelet, but not included in the Elopement Log binder. Resident 2 was found with a non-functioning wanderguard bracelet. Resident 3 did not have an MD order for the wanderguard placement and monitoring. a. A review of Resident 2's Skilled Nursing Facility Admission Record (SNFAR) indicated Resident 2 was admitted in September 2014, with diagnoses including severe cognitive impairment and [CONDITION(S)] (a mental disorder characterized by hallucinations [hearing voices] and disorganized thinking). A review of Resident 2's MD (MD3) order dated 11/09/2019 indicated, may have wanderguard bracelet due to risk of wandering. During a concurrent observation and interview on 6/18/2021 at 12:15 p.m., LN 1 brought Resident 2 to the front door, the resident went out of the front door with the wanderguard on her, but there was no audible alarm heard. LN 1 stated the wanderguard was not functioning. During an interview with the DON on 6/18/2021 at 12:20 p.m., DON stated that Resident 2 is one of the residents deemed by the Interdisciplinary Team (IDT) for recommendations to MD to discontinue her wanderguard order as she does not have the risk for elopement. During an interview with the DON on 6/18/2021 at 1:45 p.m., DON stated that there was no IDT documentation on Resident 2's re-evaluation on wanderguard placement. During a concurrent interview and record review with the DON on 6/18/2021 at 2:20 p.m., the Medication Administration Record (MAR) for the month of June 2021 indicated Resident 2's wanderguard was noted to be checked from June 1-18, 2021 as functioning. DON stated that he does not know what time the wanderguard was checked, and maybe was working at that time. DON stated that the documentation indicated the wanderguard was checked. DON confirmed that Resident 2 was not included in the Elopement Log binder. b. A review of Resident 3's SNFAR indicated she was admitted in November 2016 with diagnoses including dementia (a group of symptoms that make it hard to remember, think clearly, make decisions, and even control emotions). A review of the MDS, indicated Resident 3 has a BIMS score of 3 which indicated severely impaired. During a concurrent observation and interview with LN 1 on 6/18/2021 at 12:35 p.m., Resident 3 was found standing in the lobby wearing a wanderguard. LN 1 led Resident 3 to the main door and there was an audible alarm. During a concurrent interview with the DON on 6/18/2021 at 1:30 p.m. in his office and record review of the Elopement Log binder, the DON confirmed Resident 3's file was not included in the Elopement Log binder. During a concurrent interview with DON on 6/18/2021 at 1:30 p.m. and record review of the MD 3's order for Resident 3, DON confirmed there is no MD order to monitor wanderguard for Resident 3. A review of MD 3's order for Resident 3 on 6/21/2021 indicated, monitor wanderguard for placement every shift. The order was written 3 days after the facility visit on 6/18/2021. A review of the care plan dated 6/22/2021 indicated Resident has wanderguard for wandering behavior. The Care plan was written 4 days after the facility visit on 6/18/2021. A review of the facility's policy titled Wandering, Unsafe Residents dated Quarter 3, 2018, indicated .the staff will identify residents who are at risk for wandering . The DON confirmed there was no facility policy on wanderguard monitoring. In an email on 6/29/2021 at 3:58 pm, DON indicated that the facility has no policy on monitoring the wanderguard. In an email on 7/9/2021 at 2:05 p.m., DON indicated that the facility has no policy on monitoring the wanderguard as of 6/18/2021.

Based on observation, interview, and document review, the facility failed to ensure 1 of 5 sampled residents (Resident 1), known to be at risk for elopement, was provided direct supervision to prevent him from leaving the facility through an unsecured door, unaccompanied and without staff knowledge. This failure resulted in Resident 1 leaving the facility unsupervised. Resident 1 was discovered dead two miles from the facility the following day, after being hit by a train. Findings: A review of the Skilled Nursing Facility Admission Record indicated, Resident 1 was admitted to the facility from the acute care hospital on [DATE] with [DIAGNOSES REDACTED]. Review of an undated acute hospital document titled, Discharge Planning Consult indicated a history of leaving his previous residence unsupervised. A review of the MDS (Minimum Data Set-assessment tool), dated 8/2/19, section G indicated, the resident required supervision. A review of the history and physical from the acute hospital dated 6/17/19, indicated Resident 1 had a [DIAGNOSES REDACTED]. The document indicated Resident 1 took [MEDICAL CONDITION] medications to help control aggressive and impulsive behavior. The report further indicated, Resident 1 had unpredictable wandering which posed a significant risk of unintentional self harm. Review of the undated Discharge Planning Consult note from the acute hospital, indicated while in the hospital Resident 1 was started on a new medication (Neudexta) to control his wandering. The report indicated with the new medication, the Resident's behavior was much improved. The hospital's discharge plan was for Resident 1 to be discharged to a locked facility. Review of a referral document from the acute hospital indicated on 7/18/19 the Skilled Nursing Facility (SNF) refused to accept Resident 1. On 7/24/19 the SNF refused to accept Resident 1. On 7/29/19 the SNF accepted the Resident 1 for admission and he was admitted to the facility on [DATE]. A review of the Baseline Care Plan and Wandering Assessment, performed 8/1/19 by the SNF, indicated Resident 1 was at High risk for wandering and was, An elopement risk (at risk for leaving the facility without staff knowledge). Review of a SNF Care Plan titled, At risk for elopement related to: Wandering and dated as initiated 8/2/19, included interventions such as, Educate family/responsible party on talking positively about Living Center Placement and I wish to have a wanderguard d/t (due to) potential elopement episodes. A review of the SNF Progress notes for Resident 1, dated 8/2/19 at 3:55 a.m., indicated Wanders in and out of unit at the beginning of the shift, redirected resident . A review of a Physician's Progress Note for Resident 1, dated 8/2/19, indicated the resident is aggressive and the Neudexta (a medication used to treat neurological disorders i.e.; aggression, wandering) was not effective. In an interview with the Administrator (ADM) on 8/5/19 at 4:30 p.m., the ADM stated Resident 1 was admitted to the facility on [DATE]. On 8/2/19, Resident 1 was last seen by unit staff completing every 30 minute checks at approximately 8:30 p.m. Resident 1 left the facility and the search for Resident 1 was unsuccessful. On 8/3/19 Resident 1 was found approximately 2 miles from the facility, dead, after being struck by a train. The ADM confirmed the facility is not a locked facility. In an interview with Licensed Nurse 1 (LN 1) on 8/5/19 at 5 p.m., LN 1 stated Resident 1 was at a high risk for elopement due to his ability to walk without assistance, a previous history of elopement, and confusion. LN 1 further stated on 8/1/19, Resident 1 was wandering throughout the facility and required redirection several times. In an interview with Certified Nursing Assistant 1 (CNA 1) on 8/5/19 at 5:20 p.m., CNA 1 stated Resident 1 was able to walk on his own without assistance, and due to his confusion required redirecting. CNA 1 further stated, she saw Resident 1 attempting to go outside the facility several times during the PM shift on 8/2/19. In an interview with the Director of Nursing (DON) on 8/5/19 at 5:30 p.m., the DON stated, He should have had a staff member with him at all times until we got to know him better due to his mental status and physical ability. On 8/5/19 at 5:40 p.m., a request was made for the facility policy on direct (1:1) supervision (1:1 supervision is an intervention where one staff person is assigned to one resident to ensure the resident's safety.) The DON stated the facility did not have a policy on 1:1 supervision. In an interview with Certified Nursing Assistant 2 (CNA 2) on 8/15/19 at 12:30 p.m., CNA 2 stated on 8/2/19 Resident 1 was walking throughout the building and required redirecting several times during her shift. In an interview with Licensed Nurse 2 (LN 2) on 8/15/19 at 1 p.m., LN 2 stated she was working on the evening of 8/2/19 when Resident 1 eloped. LN 2 further stated Resident 1 was last seen at 8:30 p.m. At 9 p.m. the CNA reported to her that Resident 1 could not be found. The staff then searched the facility for the resident but he could not be found. After approximately 10 to 15 minutes, LN 2 notified the police, administrator, physician, and the resident's family. In a concurrent video review and interview with the ADM on 8/22/19 at 10 a.m., (video footage with no audio) taken by the facility on 8/2/19 and verified by the ADM, showed Resident 1 leaving the facility at 8:42 p.m., through the north-east exit door that was unattended and unsecured. According to the ADM, the door was locked at all times and requires a code in order to exit the building. The door had opaque glass as well as an alarm code panel on the inside. Prior to exiting the facility, Resident 1 is seen pushing on the door, the door then opened and he walked out. At no point prior to leaving the facility was Resident 1 seen attempting to use the code panel on the right side of the door. After Resident 1 left the facility, no staff were seen on video attempting to silence the alarm. The ADM further stated, The alarm must not be working since no one comes to the door. During an interview with the Psychiatrist (MD) on 9/16/19 at 1:30 p.m., the MD stated, Resident 1 was seen by him on the morning of 8/2/19. The MD further stated, Resident 1's behavior continued to be aggressive, so the Neudexta was stopped and [MEDICATION NAME] (a medication used as a mood stabilizer) was started. During an interview with the DON on 9/17/19 at 10 a.m., the DON stated if the resident was exit seeking they were to have direct 1:1 supervision. There was no documented evidence of monitoring the resident on direct 1:1 supervision. During an interview with Licensed Nurse 3 on 9/17/19 at 10:30 a.m., LN 3 stated she was working day shift on 8/1/19 and Resident 1 had required redirection several times during her shift. In an interview with the Director of Staff Development (DSD) on 9/17/19 at 11 a.m., the DSD stated it was her expectation for staff to place residents that are high risk of elopement on direct 1:1 supervision first, before advancing them to every 15 minute checks or every 30 minute checks. In an interview with the DSD on 9/18/19 at 9 a.m., the DSD stated, The exits should have been watched by staff at all times. A review of the undated facility document titled, Preventing Elopement indicated; Exits must be under visual supervision by designated associates. During an interview with the ADM on 9/18/19 at 2:30 p.m., the ADM stated, in reference to the video recording from 8/2/19 at 8:42 p.m., I didn't see him (Resident 1) use the key pad, he just opens the door and leaves. The ADM then stated, The door should be alarming but it must not be working since none of the staff are seen attempting to silence the alarm. The ADM further stated, The door must have been unlocked, because I didn't see him (Resident 1) reach over and use the key pad to unlock it. In an interview with Licensed Nurse 4 (LN 4) on 9/18/19 at 3 p.m., LN 4 stated Resident 1 was exit seeking as evidenced by him exiting out the back door into a fenced area on 8/1/19. LN 4 further stated if residents are exit seeking, they should be on direct 1:1 supervision (staff to resident continuous direct supervision). In a concurrent video review and interview with the ADM on 9/19/19 at 12 p.m., The ADM verified on 8/2/19 at 9:46 p.m., staff were seen walking into the building from the outside through the north-east entrance and no key was used. On 8/2/19 at 9:47 p.m., staff were seen walking out the door and no code was used. On 8/2/19 at 11:43 p.m., a resident in a wheelchair was seen going out the door and no code was used. A staff member then points to the top of the door. On 8/2/19 at 11:44 p.m., a staff member was seen jumping up and hitting the top of the door. There was no evidence of the staff silencing the door alarm when no key or code was used to enter through the door. During an interview with the ADM on 9/19/19 at 1 p.m., the ADM stated there was a switch above the north-east exit door that turned the alarm on and off. The ADM further stated he was, Unsure why it was off. A review of the Certificate of Death, issued 8/12/19 for Resident 1, indicated he was discovered approximately 2 miles from the facility and the cause of death was multiple [MEDICATION NAME] force injuries due to pedestrian struck by a train.

Based on observation, interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) was treated with dignity and respect when an employee (Employee 1) deliberately took a cigarette from her mouth when Resident 1 was outside on the smoking patio. Resident 1 became upset with Employee 1, and in an attempt to get her cigarette back from Employee 1, she fell backwards and sustained a head injury that required treatment at the acute care hospital. Findings: Review of the 'Admission Record' the facility admitted Resident 1 last year with multiple [DIAGNOSES REDACTED]. The most recent assessment dated [DATE] indicated she scored 14 out of 15 in a Brief Interview for Mental Status (BIMS) indicating she was cognitively intact. The assessment under tobacco use was checked ,'Yes.' Resident 1's clinical record was reviewed as follows: A physician order [REDACTED]. Resident 1's 'Smoking Evaluation', dated 11/9/18 indicated she did not wish to quit smoking, remained alert during the course of smoking at all times, had no visual deficit, no tremors, had the ability to hold a cigarette safely and extinguish the cigarette safely. Resident 1 ambulated with a walker. A progress note dated 1/18/19 indicated Resident 1 reported she tripped at end of a hallway and, .hit head on brick wall .was going to smoke outside and staff member (Employee 1) removed cigarette and patient was going back inside to talk to .staff member (Employee 1) to obtain her cigarette back, and tripped in the doorway hitting her head .Laceration (a laceration is a cut through the skin) to the back of head measured .2.5 x 0.3 CM (CM-Centimeters, unit of measure) and 5th (finger) had abrasion .0.5 cm. A 'Change of Condition' assessment dated [DATE] indicated Resident 1 had head trauma related to a fall and the skin evaluation portion indicated, .Laceration .accompanied by significant pain or bleeding. Laceration requiring sutures. Back of head- Laceration 2.5 x 0.3 cm, Right hand back-Abrasion 0.5 cm. A head scan was done at the emergency room (ER) on 1/18/19 and the indication for the scan was, Head pain due to traumatic injury. The final [DIAGNOSES REDACTED].head trauma .a Laceration to scalp of head .This will require stitches .or staples if it is deep. A progress note dated 1/18/19 indicated Resident 1 returned to the facility from the ER and had 4 staples to laceration on the head. A Care Plan dated 1/18/19 indicated under problems, .laceration at the back of head: 4 staples noted after ER visit 1/18/19 .abrasion to the right 5th knuckle . The goal was that the affected area would heal without complications. The Interventions included neurological monitoring and, Reorient resident on smoking policy . During a concurrent observation and interview with Resident 1 on 1/29/19 at 3 p.m., she stated Employee 1 found her at the smoking patio about 10 days ago and as she was getting ready to light the cigarette, the employee pulled it out of her mouth. Resident 1 stated she felt humiliated and upset. Resident 1 further stated that in an attempt to get her cigarette back from the employee, she tripped backwards and hit the brick wall next to the entrance door and sustained a head injury. Resident 1 stated she went to the hospital and the cut at the back of her head was Stitched, you see the scar. Resident 1 further verbalized her frustration of not being able to smoke by herself and the staff's constant reminder that it was the facility's Rules. During an interview with a Certified Nursing Assistant 1 (CNA 1) on 1/29/19 at 3:15 p.m., she stated Resident 1 liked to smoke and she got mad if not allowed to smoke during non-scheduled times. CNA 1 stated the facility did not allow residents to smoke during non-scheduled times regardless of their ability to smoke independently. CNA 1 further stated staff had .no time to watch them .we got other work to do. An interview conducted with Licensed Nurse 1 (LN 1) on 1/29/19 at 3:20 p.m., she stated Resident 1's preferred activity was smoking and she was able to smoke independently. LN 1 stated Resident 1 can only smoke during designated times as per the facility's policy. LN 1 reported Resident 1 recently tripped backwards and hit her head on the brick wall after an employee took her cigarette away from her. LN 1 stated Resident 1 was angry with the employee and in an attempt to get back her cigarette, she lost her balance, tripped backwards and hit her head on the brick wall. LN 1 stated Resident 1 remained calm when staff were available to accompany her to smoke. During a concurrent interview and smoking patio observation with Employee 1 on 1/29/19 at 3:30 p.m., she stated she happened to go outside to the smoking patio to do some work on 1/18/19 at around 11 a.m. Employee 1 stated she observed Resident 1 on the smoking patio with a cigarette in her mouth ready to light it. Employee 1 stated residents were not allowed to smoke during non-scheduled times and she therefore removed the cigarette from Resident 1's mouth. Employee 1 stated Resident 1 got upset with her and followed her to the entrance door. Employee 1 observed the resident through the glass door as she tripped backwards and hit the brick wall. Employee 1 stated there was nothing wrong in stopping Resident 1 from smoking because it was the facility's policy that residents follow the smoking schedules. The facility's investigation report received by the Department on 1/23/19 indicated in part that Employee 1 had asked Resident 1 to put away the cigarette and when the resident refused, .employee removed the cigarette from the resident and turned around towards the back door of the facility when (Resident 1) started cursing at the employee and swinging at the employee in an attempt to hit her. At this point, the resident lost her balance, tripping herself backwards and hitting the back of her head on the outside wall of the facility causing a laceration . A review of the facility's 'Smoking and Tobacco Use' policy dated 12/17/16 indicated in part, While the facility leadership will attempt to accommodate those residents who desire to smoke, the primary obligation is to the safety of the population as a whole. Therefore, any resident or visitor who does not comply with rules regarding smoking will be asked to restrict or forfeit smoking or visiting privileges. If the smoking infraction or lack of compliance is serious enough, it will warrant discharge in accordance with state and federal law. Anytime the Executive Director or designee determines there is a reasonable suspicion of a violation of the smoking policy, such as a resident retaining their smoking materials or having others bring in smoking materials that are not retained according to policy, a room search may be conducted of all involved persons and areas .Smoking will be supervised by staff. Patients and Residents who smoke must be able to do so safely. Periodic assessment evaluates the individuals' ability to smoke safely in a supervised setting. An undated 'Resident Who Smoke' document indicated there were 6 smoking scheduled times spread between 8:30 a.m. and 8:30 p.m. This represented 12 hours without smoking in the hours between 8:30 p.m. to 8:30 a.m. Review of a facility policy titled Dignity, last reviewed 3/31/16, indicated All residents will be treated in a manner and in and environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality. Treating residents with dignity and respect maintains and enhances each resident's self-worth and improves his or her psychosocial well-being and quality of life. The facility's Administrator was interviewed on 1/29/19 at 4:15 p.m. She stated residents were educated on the facility's smoking policy and scheduled smoking times. The Administrator stated if Resident 1 was allowed to smoke during non-scheduled times, all other residents who smoked would like to do the same. This, she stated included all residents regardless of their ability to smoke independently. The Administrator stated Employee 1 should have approached Resident 1 in an appropriate manner instead of taking her cigarette away.

Based on observation, interview and record review, the facility failed to effectively manage pain symptoms for 2 of 11 sampled residents (41 and 38) and 1 random resident (47) as evidenced by the following: 1. Resident 41 had no revisions to her plan of care despite experiencing pain that had increased to "constant". This failure resulted in pain that interfered with her sleep and made it difficult for her to participate with therapy, which she needed to do in order to return home. 2. Resident 38 did not receive two sequential doses of pain medication during the survey. 3. Random Resident 47 had to wait more than 2 hours after requesting a pain medication. Findings: 1. Resident 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of a care plan for Resident 41, dated 11/24/11, indicated pain related to the [MEDICAL CONDITION] she sustained prior to being admitted to the facility. Further review of Resident 41's physician's orders [REDACTED]. ([MEDICATION NAME] is a narcotic pain medication). The order, as written on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The 11/24/11 pain assessment for Resident 41 indicated she was experiencing a pain level of "6" at the time the assessment was completed. This indicated her pain level was between "distressing" and "severe". The assessment indicated the pain was a stabbing pain in her hip. The resident had indicated the pain affected her mood. The assessment also indicated the resident was on a "moderate" pain management program that was effective at the time of the assessment. Resident 41's Admission Minimum Data Set (MDS-comprehensive assessment tool) dated 11/30/11, indicated the resident was cognitively intact, received scheduled and as-needed pain medications for frequent pain levels that were as high as an 8 during the prior 5 days. Review of a physician's orders [REDACTED]. Review of a 2/27/12 quarterly MDS indicated the resident experienced "Constant" pain which was as high as a "7" during the prior 5 days. The Progress Notes in the clinical record for Resident 41 included the following information: -A 3/19/12 note documenting the resident fell while standing in the shower. -A 3/25/12 note documenting the resident had fallen while transferring to her bedside commode. -A 3/26/12 note indicating the resident was complaining of pain to her lower back and left toes, and an x-ray had been ordered. -A 3/27/12 note indicating the resident had been found on the floor. -A 3/27/12 note documenting the resident requested her medications for breakthrough pain as soon as it could be given since the last dose. The note indicated the pain medications were not to be given if sedation was noted to prevent fall. -A 3/31/12 note indicating the resident had experienced a pain level of 10/10, the scheduled and breakthrough pain medication had been given, and the resident had reported the pain was relieved for 1 hour. A 3/25/12 update to the fall-prevention care plan identified the resident was at risk for injuries related to falling. The update indicated the resident had experienced falls on 3/18/12, 3/26/12 and 3/27/12 which were "mostly related to poor safety awareness and the use of ATC (around the clock) narcotic [MEDICATION NAME] for chronic pain. The care plan update included participation in the Restorative Nursing Program (RNA- a continuation of physical therapy performed by the certified nursing staff when a resident no longer received therapy from the physical therapists) to improve strength and her ability to stand. Although the care plan had directed the nursing staff to monitor for side effects of medications, the care plan did not include evaluating the escalating use of as-needed pain medication as a potential cause of the series of falls that had begun in March 2012. There were no other updates to the care plan for pain in response to the 3 additional falls the resident had experienced or the progression of the pain identified in the sequential MDS's (11/30/11 and 2/27/12). Further review of Resident 41's clinical record indicated: -A 4/5/12 weekly summary note that indicated the resident was in constant pain while taking her scheduled and as-needed pain medications. -A 4/16/12 note documented another x-ray had been ordered for the resident's spine and left foot due to complaints of pain from previous fall. -A 4/21/12 order for an x-ray of the resident's right thigh due to complaints of pain related to her previous fall. There were no notes indicating the Interdisciplinary Team had met to discuss Resident 41's continuing unresolved pain. Review of a fax dated 4/24/12 indicated the physician approved a faxed request to change the [MEDICATION NAME]/[MEDICATION NAME] from 1 tablet of 10/325 every 4 hours to 1-2 tablets of 5/325 every 4 hours. The change was made as a result of the payer no longer covering cost of the 10/325 dosages. There were no other changes in pain medications following a series of falls the resident experienced in March 2012. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -During the month of January 2012 the resident received the [MEDICATION NAME] 5 times. -During the month of February 2012 the resident received the [MEDICATION NAME] on 23 occasions. -During the month of March 2012 the resident received the [MEDICATION NAME] on 41 occasions. -During the month of April 2012 the MAR indicated [REDACTED]. The assessment record documenting the pain level reported by the resident at the time the resident had been medicated had only documented the resident's pain level on 26 occasions, failing to collect meaningful data to use to evaluate the resident's pain management program. -The April 2012 MAR indicated [REDACTED]. Progress notes from the RNA binder indicated the resident had been able to walk 100 feet with assistance and encouragement on 4/2/12. Subsequently, the notes were as follows: - On 4/3/12 the resident was unable to tolerate therapy because of pain "charge nurse notified." - On 4/4/12 the resident was unable to tolerate therapy because of pain and the "charge nurse was notified by the resident." - On 4/6/12 the resident was unable to tolerate therapy because of pain and the "charge nurse aware." -On 4/7/12 the resident was still unable to tolerate therapy because of pain and the "charge nurse aware." -On 4/8/12 the resident was unable to tolerate therapy because she did not feel well "charge nurse notified." - On 4/9/12 the resident was unable to tolerate therapy because of pain. - On 4/10/12 the resident refused exercises and the charge nurse was notified. - On 4/11/12 the resident continued to refuse exercises because of pain, "charge nurse notified. - On 4/12/12 the resident continued to refuse exercises because of pain, charge nurse notified." - On 4/13/12 resident unable to tolerate RNA program "still c/o pain" (complains of pain). - On 4/14/12 resident unable to tolerate RNA program today complaining of pain, "charge nurse aware." - On 4/17/12 "Resident continues to refuse all range of motion exercises, still c/o pain, charge nurse aware." - On 4/21/12 the resident was unable to tolerate any exercises, "c/o pain, charge nurse aware." - On 4/24/12 the resident was discharged from the RNA program until further notice. There was no evidence in the clinical record the charge nurse had documented the resident had not participated in the RNA program, or that she had been dropped from the program due to pain. There was no evidence the IDT had been made aware the resident was refusing to participate in the RNA program or had updated the care plan for falls when the resident had refused to participate for three weeks. In an interview with Resident 41 on 4/30/12 at 8:45 a.m. she reported she was in constant pain, despite the medication she was scheduled to receive, as well as the as-needed medication she could take for breakthrough pain. She reported the pain would be controlled for only "about 1 hour." She reported the pain was about an 8, but could be as much as 10 (Zero is no pain, and 10 is the worst pain imaginable.) She reported the pain was originally in her hip from the fracture, but she had experienced a series of falls since she had been admitted and she was also experiencing constant pain in her back, as well as increased pain in her hip. She also reported she had taken a pain medication at home for her [MEDICAL CONDITION], and they started giving her more of it, but it no longer seemed to be working. She reported the pain interfered with her sleep and made it difficult for her to participate with therapy, which she needed to do in order to return home. In an interview with Certified Nursing Assistant (CNA) 9 on 5/1/12 at 10:30 a.m. she reported Resident 41 had refused to participate in the RNA program due to pain and she verified the charge nurse had been notified whenever the resident had refused. She also verified the resident's refusal to participate was the reason she was dropped from the program on 4/24/12. In an interview with Resident 41 on 5/1/12 at approximately noon the resident reported she had wanted the 2 tablets of [MEDICATION NAME]/[MEDICATION NAME] on 4/30/12 at 8 p.m. but she had been told she could not have the second tablet because it would exceed the [MEDICATION NAME] limit for the day. Resident 41's narcotic control log for [MEDICATION NAME]/[MEDICATION NAME] 5/325 indicated 9 tablets had been removed as of 8 p.m. on 4/30/12. The last dose removed, at 8 p.m., was a single tablet. The sum of all sources of [MEDICATION NAME] came to 2,925 mg. The second tablet from the 8 p.m. dose would have exceeded the 3000 mg daily limit of [MEDICATION NAME]. There was no indication in the clinical record the LN had documented or reported she was unable to provide the full dose of medication on the 4/30/12 evening shift. The facility's January 2011 "Pain Management Guidelines" included the following directives: -"The functions of appropriate pain management include, but are not limited to: Ensuring involvement of resident in pain management." -"The licensed nurse/IDT periodically evaluates the frequency of PRN (as-needed) medication usage and consult physician regarding routine pain medication, if indicated." -"The licensed nurse updates the plan of care to reflect interventions for ongoing pain management" -"Following an acute change of condition when pain is suspected, (e.g. new fracture), the licensed nurse assesses the resident for pain, using the pain scale...and document findings on this record. A plan of care is developed/updated and the resident is monitored for pain with findings documented in the nurses' notes until stable." -"The interdisciplinary team evaluates the effectiveness of each resident's pain management plan at the time of the initial comprehensive assessment, quarterly, following a significant change, and annually. Findings and/or recommendations are documented in the medical record, as indicated. Update plan of care as needed." In an interview with the Administrator (ADM), the Director of Nurses (DON), and the Assistant Director of Nurses (ADON) on 5/1/12 at 3:25 p.m. the DON reported the nurses were expected to notify the physician when pain medications were not effective, and if the physician did not respond to the nurses' concerns the ADON or the DON were to be notified. The DON also reported the nurses were expected to report on the 24-hour report when pain medications were not effective so the issue could be reviewed at the "Clinical start-up" the next day. She could not report the ineffective pain management for Resident 41 had been discussed at the daily clinical start-up meetings. The ADM, DON, and ADON reviewed both the electronic and paper clinical records of Resident 41 and found no evidence the nurses had informed the physician of the ineffective pain relief she had been experiencing. The ADON and the DON reported they had not been made aware Resident 41 pain management needs had not been met. They were not aware Resident 41 had been dropped from the RNA program due to a lack of participation because of her pain. 2. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan titled, "Pain Management," dated 8/17/10, indicated, "Needs pain management and monitoring." Interventions included, "Administer pain medication as ordered." Review of the physician's orders [REDACTED]." In an interview with the resident on 5/1/12 at 1:35 p.m., the resident indicated she was in pain. She stated, "I'm having chest pains and it feels like I've been stabbed in my stomach. My pain level is about a 6 (On a scale between 0-10, where 0 equals no pain and 10 equals worst possible pain) I don't know when I had my last pain medication." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview with the DSD on 5/1/12 at 2 p.m., she verified she had missed the resident's 8 a.m. and 12 p.m. pain meds. 3. Random Resident 47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS, dated [DATE], described the resident as having no memory problems. Random Resident 47 was described as having occasional pain, described as a level 6 on a scale of 1 to 10 (10 being the worst). During an interview with Random Resident 47 on 5/1/12 at 7:50 a.m. she stated, "Last night I had to wait for 2 and a half hours for my pain medication. I was mad, it took a good hour to get it under control, then the phantom pain came..." Random Resident 47 stated she "asked for medication (on 4/30/12) at 11:20 p.m., and didn't receive it until 2 a.m." on 5/1/12. Review of the clinical record for Random Resident 47 included the following physician's orders [REDACTED]. -[MEDICATION NAME] 50 mg every six hours as needed for moderate pain, dated 4/4/12; -[MEDICATION NAME] 5-500 mg 1 tab every 4 hours as needed for moderate pain, dated 4/28/12; -[MEDICATION NAME] 5-500 mg 2 tabs every 4 hours as needed for severe pain, dated 4/28/12. Review of the clinical record for Random Resident 47 revealed: -A "Controlled Drug Record" for [MEDICATION NAME] 5-500, issued 4/15/12 documented 2 tablets were administered on 5/1/12 at 1:30 a.m. The record documented the resident had previously received a dose of [MEDICATION NAME] 1 tablet at 2 p.m. on 4/30/12, more than 4 hours before she made her request at 11:20 p.m. -A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"severe leg pain, 8/10." This described the pain as being an 8, on a scale of 1 (least) to 10 (worst). The clinical record did not contain a care plan for the resident's pain, despite "chronic pain" being listed 4 th on the resident's list of 13 diagnoses. Review of facility policy titled "Pain Management Guideline," dated January 2011, included "A plan of care is developed/updated and the resident is monitored for pain with findings documented in the nurses' progress note until stable." During an interview with LN 9 on 5/1/12 at 4:30 p.m. she stated, "I was really overwhelmed last night." LN 9 stated, "I was really sorry her pain medicine was given so late, last night." LN 9 was unable to recall how long the resident had to wait for her pain pills.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards, and failed to provide adequate supervision and assistance to prevent an accident that resulted in a leg fracture for 1 of 20 sampled residents (2). On 2/1/11 at 5:34 p.m. the Department called Immediate Jeopardy related to the hazardous driveway and lack of facility system to provide supervision and assistance to unattended residents as they exited the facility grounds via wheelchair. The Department Team Coordinator met with the Executive Director, DON, and Nurse Consultant to advise of the Immediate Jeopardy. Resident 2 was identified to be at risk related to the facility's failures. The Immediate Jeopardy was abated on 2/2/11 at 4:55 p.m. based on acceptance and implementation of the facility's immediate plan of correction. Findings: Resident 2 was an under [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual MDS, dated [DATE], indicated he had no behavior problems, memory problems, or problems with cognition. Review of a physician's orders [REDACTED]. During the Initial Tour on 2/1/11 at 9:15 a.m. Resident 2 was observed lying in bed with his left leg splinted and wrapped with cloth bandages. In an interview with Resident 2 on 2/1/11 at 9:15 a.m. he reported he had fractured his leg when he had left the facility by himself. He reported he was in a hurry to catch a bus and had left the building by self-propelling his wheelchair along the drive aisle of the parking lot out to the sidewalk. He reported he was not aware the driveway was as steep as it was and he gained too much speed. Where the driveway connected to the sidewalk, the wheelchair stopped suddenly and he was thrown out into the street. In an interview with the ED on 2/1/11 at 11:15 a.m. she stated Resident 2 was not supposed to leave the facility without assistance but that the Licensed Nurse let Resident 2 sign himself out on pass and he left the facility. She then reported the Licensed Nurse was suspended pending her investigation of the resident's fall. On 2/1/11 at 3:35 p.m. the DON and ED demonstrated where Resident 2 was found lying in the street, about 2 feet from the sidewalk, directly across from the steepest portion of the driveway entrance. The driveway was observed to slope down from the building to the street. The slope of the driveway became increasingly steep as the driveway neared the street, and then suddenly dropped off approximately 2 inches where the driveway connected with the sidewalk. The sidewalk in front of portions of the driveway was broken and cracked with small sections of concrete missing. A second driveway was observed on the other side of the parking lot. This driveway was not as steep, and the abutting sidewalk was not cracked. Observation noted no defined wheelchair path of travel to direct wheelchair-bound people to take the less-steep driveway, or any other signage to direct them away from the steeper driveway. On 2/1/11 at 5:34 p.m. the Department called Immediate Jeopardy related to the hazardous driveway and lack of facility system to provide supervision and assistance to unattended residents as they exited the facility grounds via wheelchair. The Department Team Coordinator met with the Executive Director, DON, and Nurse Consultant to advise of the Immediate Jeopardy. The clinical record for Resident 2 contained the following information: - A 9/11/09 care plan for "Risk of Injuries/Falls" due to [DIAGNOSES REDACTED]. - An H&P (History and Physical) from an acute hospital which indicated Resident 2 was admitted to the hospital on 1/25/11 due to a leg fracture. The H&P documented an X-ray of the right leg had revealed both lower leg bones had been fractured. - A nursing note written by LN 5, dated 1/26/11 at 7:27 a.m. documented "late entry for 1/25/11 . Resident signed out to go on pass to go to the hospital to see a friend by city line bus. Five minutes later resident found lying in street next to the front entrance sidewalk. Lying on his left side complaining of pain in his right leg..." - A nursing note written by LN 5 dated 1/26/11 at 1:13 p.m. which documented "late entry for 1/25/11 @ 10:45 a.m. Resident stated he was going to visit (friend) in the hospital. Writer asked if someone from this facility was going to drive him to the hospital. The resident said no, I'm going on the bus. The writer said 'can't you wait for another time to go to the hospital so someone can take you to the hospital.' Resident said, 'no, I am going now. I am able to go by myself. The bus stop is just over there on the corner.' Resident signed out and left the facility." Review of Resident 2's "Plan of Care" for "Risk of injuries/falls..." dated 9/11/09 indicated in part for interventions, "Monitor for factors causing falls..." Review of a "Temporary Plan of Care" dated 1/25/11, indicated the problem, "Fall" with the short-term goal of "free of injuries." The approaches indicated, "Send to the hospital for evaluation." There was no documented evidence that the facility updated Resident 2's plan of care regarding the resident's ongoing potential to use the unsafe driveway when leaving the facility to go out on pass. On 2/1/11, at approximately 12 noon, Resident 2 demonstrated he was still capable of self propelling his wheelchair despite having a fractured leg. This reflected that Resident 2 was still at risk due to the continued presence of the hazardous driveway and lack of updated plan of care. During a second interview with Resident 2 on 2/1/11 at 6:15 p.m. he reported he had gone out on pass before, but he was with another resident. He reported the staff were aware of his plan to leave the facility to catch a bus, and they had discussed with him the bus pick-up times. He reported nobody had offered to assist him down the driveway, and nobody had instructed him to use the less steep driveway to get to the sidewalk. During the Group Interview at 10 a.m. on 2/2/11, Random Resident 22 stated, "that driveway is a little treacherous". During a follow up interview with Random Resident 22 immediately after the group interview, he reported he had heard that Resident 2 had fallen from his wheelchair while going down the driveway and he then took his motorized wheelchair down the same driveway and videotaped it and stated, "it is one hell of a ride!" Furthermore, Random Resident 22 stated he was not aware of any other route to leave the property except "over the hump at the end of the driveway." During an interview with LN 3 on 2/2/11 at 11:05 a.m. she reported she had worked at the facility for more than one year. At the time she started employment she was instructed to assist wheelchair-bound residents down the driveway because several residents had reportedly expressed fear of going down the steep slope. In a telephone interview with LN 5 on 2/2/11 at 1 p.m. she reported Resident 2 had wanted to the leave the facility to visit a friend. She had tried to get him to wait for a facility staff person to drive him, but he did not want to wait. She reported that in the past staff members had assisted residents when they left the building, and she did not know why she did not remember to send someone with Resident 2 when he signed himself out. At the time of the fall, she had gone out to the resident while he waited for the ambulance, and she noted the driveway was not suitable for wheelchairs. On 2/2/11 at 5:30 p.m. the DSD reported that the staff orientation process did not include any training on escorting residents to the sidewalk to assist and ensure their safety while they navigated the sloped and uneven driveway when going out unattended on pass. Review of the facility's "Pass Procedure (sending residents out on pass)" dated 2006, indicated the "basic responsibility" for the procedure was with the "Licensed Nurse." Further review of the procedure indicated no documented evidence that the facility had a system in place to supervise and assist residents to exit the facility grounds safely down the sloped and uneven driveway surface. The Immediate Jeopardy was abated on 2/2/11 at 4:55 p.m. with the facility ED based upon the acceptance and implementation of the facility's immediate plan of correction. The plan included evaluation of the environmental hazard (driveway) by an engineering firm and plans to escort residents, who have independent pass orders and decide to leave the facility, through the parking lot to the sidewalk off facility property.