Every finding on record at Park Valley Inn Health Center

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 3 of 5 medication carts ( Treatment Cart #1, Treatment Cart #2, and Nursing Cart #3) reviewed for medication storage. The facility failed on 07/21/2026 to ensure Treatment Cart #1 & #2 and Nursing Cart #3 were locked, and medications were secure and not accessible to other staff, residents or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the-counter medications.Findings include: Observation on 07/21/20726 at 9:11 a.m. revealed TC #1 and TC #2 were unlocked against the wall by the common tv area near 600 Hall. The back of the carts was against a half wall with the top open to the tv common area. The drawers of the treatment carts were facing the area near the nurses' desk and 600 Hall. The locking mechanisms were protruding outward on the treatment carts. The State Surveyor opened the drawers and captured photos. The treatment nurse (LVN A) responsible for treatment carts was at the end of 600 hall administering medications while using a different medication cart. There was no nursing staff in the area of the unlocked treatment carts. Residents were observed walking around unlocked treatment carts without anybody trying to open them. During an interview on 07/21/2026 at 9:15 pm, LVN A/Treatment nurse stated she worked today on 600 hall as a charge nurse. She stated that she came to the facility around 8:30 a.m. this morning and was assigned to 600 hall as a charge nurse. She stated that she was not working on treatment carts this morning and night nurses were using TCs at night and were responsible for locking them before they left at 6 a.m. She stated that she was still responsible for checking on TCs and locking them if not using those carts. She stated she was in-serviced on locking medication carts when she was not obtaining medications from the cart. LVN A stated she had in-service on medication storage but did not recall the date of the in-service on locking medication carts. She stated that if treatment carts or medication carts were not locked, residents or visitors could be exposed to medications. Observation on 07/21/20726 at 12:36 p.m. revealed NC #3 was unlocked against the wall in the beginning of 300 hall and near the nursing station. The locking mechanism was protruding outward on the NC #3. The State Surveyor opened the drawers and captured photos. LVN B, responsible for NC # 3, was observed to come back from the dining room with a resident in 3 minutes. There was no nursing staff in the area of the unlocked NC #3. Residents were observed walking around unlocked NC #3 without anybody trying to open it. During an interview with LVN B on 07/21/2026 at 12:39 p.m., she stated she walked away from the NC #3 just for a minute. She had training on medication storage a few months ago. She stated that she knows that medication carts should not be left unlocked while unattended. She stated that potential risk if medication cart left unlocked while unattended could be residents opening it and taking medications that would harm them. During an Interview with ADON on 07/21/2026 at 1:22 p.m., she stated the medication carts were expected to be locked unless the nurse was standing at the cart administering medications. She stated if the medication carts were in the hallway and the nurse was not standing at the medication cart it was expected to be locked, no exceptions. She stated the staff were in-serviced on locking medication carts a month ago given to nurses and medication aids. She stated they have a keyless padlock on all medication carts and night shift nurses should lock treatment carts after using them. She stated that the Treatment nurse, LVN A, was responsible for checking if TCs were locked. She stated that if medication carts were not locked, there was a risk of unauthorized personnel including visitors and residents getting into the carts and taking medications. She stated that the director of nurses and ADON oversee carts were locked aside from the staff who worked on those carts. During an interview with ADM on 07/21/2026 at 2:29 p.m., he stated Medication storage training Inservice was provided to nursing staff in March this year and it was ongoing training by the clinical regional director. He stated that the Director of Nursing or his/her designee were responsible for monitoring that medication storage policy was followed. He stated whoever worked on medication cart was responsible for locking it. He stated that if TCs or medication carts were unattended, it should be locked before walking away. He stated that he expected that any of his staff could lock medication carts if saw them being unlocked and unattended. He stated that unauthorized personnel could access TCs or NC with medications. Record review of the facility's policy on Medication Storage in the Facility, dated 12/01/2025, reflected All drugs and biologicals will be stored in locked compartments (i.e., medication carts,.). Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (R#1) of 7 residents reviewed for falls. The facility failed to notify the NP from 6/12/26 through 6/14/26 when R#1's head injury worsened after her two incidents [PH1.1][SB1.2]on 6/11/26. R#1 was sent to the hospital on 6/15/26, diagnosed with traumatic subarachnoid hemorrhage and required care in the ICU. The facility failed to follow R#1's hospital discharge orders of discontinuing her Ticagrelor [PH2.1][SB2.2]when she returned to the facility on 6/18/26. R#1 was sent to the hospital and received stiches to her forehead because staff could not stop the bleeding from her laceration after sustaining a fall on 6/23/26. An IJ was identified on 6/27/26. The IJ template was provided to the facility on 6/27/26 at 2:47 p.m. While the IJ was removed on 6/29/26, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems.These failures could place residents at risk of delayed medical intervention, severe medical complications, or death. Review of R#1's admission Record, dated 6/26/26, reflected she was admitted to the facility on [DATE]. She had medical diagnoses of traumatic subarachnoid hemorrhage (bleeding in the fluid-filled space between the brain and the skull), difficulty walking, lack of coordination, muscle weakness, and Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills). Review of R#1's Quarterly MDS Assessment, dated 5/29/26, reflected she had a BIMS of 3, which indicated she had severe cognitive impairment. She had no falls since admission.Review of R#1's Discharge MDS, dated [DATE], reflected she had one fall with no injury since admission. She also required supervision or touching assistance when she walked. Review of R#1's Care Plan, revised 6/26/26, reflected she was at risk for falls related to her unsteady gait and history of falling and getting herself back up. She had a witnessed fall on 6/11/26 and 6/23/26. Interventions initiated on 6/15/26 included ensure she wore non-skid, well-fitting shoes. Interventions initiated on 6/19/26 included move her closer to the nurse's station. Interventions initiated on 6/26/26 included conduct purposeful staff rounding. Review of R#1's Progress Notes reflected: LVN A created a note on 6/11/26 at 11:48 a.m., While returning from morning meeting. This nurse was made aware from CNA that resident has a hematoma to eyebrow area. Complete assessment done. No other injuries noted. NP at facility at assessed resident. Received new order for facial x-ray stat, and Tylenol 650mg[PH3.1][SB3.2] po tid. Resident RP notified and voiced understanding. Neuros initiated per protocol. Resident keep in common area for close observation. care ongoing. LVN A created a note on 6/11/26 at 4:00 p.m., Complete assessment done. Hematoma (a collection of pooled, clotted blood that forms outside of a blood vessel) noted to Right side of forehead/eyebrow area. No other new injuries noted at this time. vss. Afebrile (normal body temperature). no s/s of distress or discomfort noted. [RP] notified. NP notified. Xray here to do Xray on face. neuros initiated per protocol. care ongoing. LVN B created a note on 6/12/26 at 5:09 a.m., Resident on a witnessed fall follow-up with neuro check & head injury. Large hematomas approximately golf ball-sized to bilateral forehead/eyebrow areas. Swelling and bruising noted around affected sites. No active bleeding observed. X-ray completed with negative results for fracture. Neurological status remains at baseline. Resident alert and responsive. Vital signs stable. No s/s of pain, headache, dizziness, nausea, vomiting, visual changes, or changes in mental status noted. Remains in bed this shift, bed at lowest position, call light within easy reach. Care ongoing. LVN B created a note on 6/13/26 at 4:45 a.m., F/u witnessed fall Day 3/3 with neuro check & head injury. Large hematomas approximately golf ball-sized to bilateral forehead/eyebrow areas healing well. Continues with swelling and bruising around affected sites. Neurological status remains at baseline. Resident alert and responsive. Vital signs stable. No s/s of pain, headache, dizziness, nausea, vomiting, visual changes, or changes in mental status noted. Remains in bed this shift, bed at lowest position, call light within easy reach. Care on going. LVN A created a note on 6/14/26 at 1:04 p.m., Aaox1- pleasantly confused. Wanders. Poor safety awareness. No s/s of distress or discomfort noted. Fall precautions in place. Kept at nurses station for close observation. VSS afebrile. Care ongoing. Cont. neuros WNL. F/u fall. Bruising noted to both sides of face with facial swelling noted to ous. Care ongoing. LVN C created a note on 6/14/26 at 5:45 a.m., Resident has increased orbital edema to right eye. Ice pack administered for comfort and to reduce edema (the abnormal accumulation of excess fluid within the interstitial spaces (the spaces between cells and tissues), which leads to swelling). LVN A created a note on 6/14/26 at 1:08 p.m., Aaox1- pleasantly confused. Wanders. Poor safety awareness. No s/s of distress or discomfort noted. Fall precautions in place. Kept at nurses station for close observation. VSS afebrile. Care ongoing. Cont. neuros WNL. F/u fall. Bruising noted to both sides of face with facial swelling noted to ous. Care ongoing. RN D created a note on 6/15/26 at 10:09 a.m., Resident arrived back to facility from appt. with orders. This writer notified NP of orders and received new orders to transfer to medical center for increased (R) eye orbital edema. RP aware.[TT4.1][SB4.2] RN D created a note on 6/15/26 at 10:36 a.m., EMS just left facility to transport resident to medical center. RN D created a note on 6/18/26 at 11:28 a.m., Resident arrived at facility via medical transport on a gurney accompanied by two EMS personnel. Transferred from gurney to bed by two-person slide. She is alert and oriented x 1. She denies pain or discomfort. Hospital wrist bands removed. Resident has discoloration around both eyes as expected from previous bruising. No new skin issues observed. Vital signs. 122/66 P 77 R 18 T 97.8 O2 Sat. 97% room air FSBS 121mg/dl[PH5.1][SB5.2]. No acute distress observed. Bed placed in lowest position, call light within reach. Care ongoing. RN E created a note on 6/20/26 at 5:15 p.m., Skilled for Traumatic subarachnoid hemorrhage. Noted bruises on both sides of the eyelids. Took all meds and tolerated well. Denies pain or discomfort. Even and unlabored breathing. Res stays on wheelchair. The DON created a note on 6/23/26 at 6:10 p.m., Resident was observed sitting on the couch in the common area watching television. Resident attempted to transfer from the couch to her wheelchair. While attempting to sit, resident realized the wheelchair was not properly positioned, with the seat not facing her. Resident attempted to correct her position and stand upright but lost her balance, stumbled several steps forward, and fell into the lower portion of an electric piano. During the fall, resident sustained a skin tear/abrasion to the left temple after making contact with the lower edge of the piano. RN D and Unit Manager, immediately responded to the scene and found resident on the floor. Pressure was applied to the left temple wound with gauze and an ABD pad to control bleeding. Resident remained awake, verbal, and responsive throughout the event. No loss of consciousness noted. PERRLA[PH6.1][SB6.2] 2+ bilaterally. Vital signs obtained and within normal limits. Resident alert and oriented x1, consistent with baseline cognitive status. DON notified and responded to the scene. Resident's (RP), notified by DON. EMS activated for evaluation and transport. EMS arrived at (4:25 p.m.) 1625[TT7.1][SB7.2]. Resident remained responsive and exhibited no signs of acute distress while awaiting EMS arrival. LVN F created a note on 6/23/26 at 9:00 p.m., Resident returned back to the facility transported by ambulance via stretcher post ER visit SPF[PH8.1][SB8.2] with laceration to the LF[PH9.1][SB9.2] side of the forehead, noted dry dressing to area of laceration, stable and situated in room, neuro checks cont., NP notified, RP notified, notified DON/Administrator.Review of R#1's NP Progress [PH10.1][SB10.2]Notes reflected: Visit note, dated 6/11/26, reflected, Patient is seen today for hematoma to the right forehead. Nurse reports hematoma was noted today. No reports of recent trauma. Patient is a poor historian due to dementia. Neurochecks unremarkable. Will obtain facial x-ray. Multimodal pain management. Discussed with nursing to closely monitor and notify for worsening. DON has been notified. Visit note, dated 6/23/26, reflected, R#1 was sent to ED on 6/15/26 due to worsening hematoma to the forehead. Hematoma to the forehead was initially detected on 6/11/26. I saw R#1 at that time and facial X-ray was ordered which resulted negative for fracture. Nurse called to report that patient had increased hematoma to the forehead and therefore patient was sent to ED for further evaluation on 6/15/26. ED workup included CT[PH11.1][SB11.2] of the head which was remarkable for minimal SAH[PH12.1][SB12.2] in the left sided high cerebral region. NSGY[PH13.1][SB13.2] was consulted and no acute intervention was recommended. Brilinta was discontinued and patient discharged back to facility on 6/18/26 in stable condition. On exam, patient is seen in the memory care unit up in wheelchair watching TV. She is awake and alert. No acute distress or discomfort. She has bruising and hematoma to bilateral forehead right slight larger than left side. She is a poor historian due to dementia. Neuro exam are unremarkable. Fall precautions per facility protocol. PT/OT to [PH14.1][SB14.2]eval and treat. Chart reviewed including nurses notes, recent labs and medications.Review of R#1's Facial X-Ray, created by LVN A on 6/11/26 at 9:15 a.m., reflected R#1 was examined on 6/11/26 at 4:33 p.m. The results were reported on 6/11/26 at 6:10 p.m. The NP reviewed the X-ray results on 6/18/26 at 11:38 a.m. The results reflected, Findings: Evaluated limited due to motion. The osseous structures demonstrate no acute fracture or destructive bone lesion.Conclusion: .Consider CT scan to best evaluate. Review of R#1's Hospital Records, dated 6/15/26, reflected, On presentation to the ER.CT head showing minimal SAH in L sided high cerebral region, no hematoma or mass effect, RT sided scalp trauma with hematoma and swelling.Review of R#1's Hospital Discharge summary, dated [DATE], reflected, Stop taking the following medications: Ticagrelor (Brilinta) 60mg tab oral twice daily.Review of R#1's Medication Administration Record for June 2026 reflected staff administered the 60mg Ticagrelor oral tablet by mouth two times daily from 06/01/26 at 8:00 a.m. through 6/15/26 at 8:00 a.m., from 6/18/26 at 8:00 p.m. through 6/19/26 at 8:00 p.m., and from 6/20/26 at 8:00 p.m. through 6/23/26 at 8:00 a.m. The medication was discontinued on 6/23/26 at 9:58 a.m. Review of R#1's Hospital Records, dated 6/23/26, reflected, Patient fell out of her wheelchair striking her head on a piano.noted to have a 4cm laceration to the left forehead, mild active bleeding.ED Laceration Face Stitches, follow-up with primary care doctor in 7 days for suture removal.return to the ER for any new or worsening symptoms.During a telephone interview with R#1's RP on 6/26/26 at 10:09 a.m., RP said R#1 often fell at home before she was admitted to the facility's memory care unit due to her severe dementia, severe cognitive impairment, and diminished capacity to make informed decisions. They said DON called and notified them on 6/11/26 that R#1 was walking fast without standby assistance, fell, hit her face and head on the floor, and sustained injuries to her head and face on 6/11/26 between 8:00 a.m. and 12:00 p.m. They did not know whether R#1's first fall was witnessed or not. They also said the DON also told them that a nurse assessed R#1, had an x-ray done, and the x-ray showed she did not sustain any fractures. They said the DON also called and notified them on 6/11/26 that she witnessed R#1 walking fast without standby assistance, fell and hit her face again on 6/11/26 between 1:00 p.m. and 6:00 p.m. They said R#1 was not sent to the hospital after the first and second fall on 6/11/26. They said they did not know why R#1 was not sent to the hospital. They also said they observed R#1 sitting at the nurse's station with a swollen eye and blood noticeable in her eyes on 6/13/26. They said R#1 was sent to the hospital on 6/15/26, was x-rayed again, CT scanned, the CT scan reflected she sustained internal bleeding to her eyes and brain and was sent to the ICU. They said R#1 was discharged from the hospital and returned to the facility with discharge paperwork and instructions from the hospital doctor to make sure she rest and not fall again on 6/18/26. They said the ADM and DON told them on 6/19/26 that the staff could not monitor her at all times. They said the ADM and DON did not mention anything to them about what interventions they were going to put in place to prevent and intervene when she fell. They said the DON called and notified them on 6/23/26 that R#1 wandered away during an activity, fell, hit her face and head on the floor, sustained a head laceration, bled, staff could not control her bleeding, and sent her to the hospital on 6/23/26. They said R#1 received stiches at the hospital and returned to the facility on 6/23/26. During an observation and interview of R#1 on 6/26/26 at 11:25 a.m., R#1 was sitting in her wheelchair at the memory care unit nurse's station. She had a dark red laceration on the left side of her forehead that had stiches. The surveyor attempted to interview R#1, but she was unable to answer any questions.During an interview with RN D on 6/26/26 at 11:29 a.m., he said R#1 had an unsteady gait and required a lot of redirection. He also said he tried to keep R#1 next to him at the nurse's station or in common areas where he could monitor her within eyesight. He said he was sitting and talking to hospice, heard a thump, and observed R#1 on the ground on 6/23/26. He said R#1 had no falls after she returned from the hospital with stiches to the left side of her forehead laceration on 6/23/26. During an interview with RN E on 6/26/26 at 11:43 a.m., she said R#1 required standby walking assistance. She also said staff were required to ensure R#1 was sitting next to them at the nurse's station or in a common area within eyesight to monitor her. She explained R#1 had a behavior of standing up by herself without assistance, walk and fell forward whenever no one watched her. She said she was working when R#1 fell on 6/11/26. She explained R#1 fell two times on 6/11/26. She said she did not know whether nor not R#1's first fall was witnessed. During an interview with CNA H on 6/26/26 at 12:01 p.m., she said she was changing a resident when R#1 fell on 6/23/26. She observed RN D apply pressure to R#1's head, R#1 bled nonstop, and the DON called EMS. During an interview with the ADM on 6/26/26 at 2:58 p.m., he said R#1's first fall was unwitnessed and occurred on 6/11/26. He said he initiated an investigation on 6/11/26 because R#1 had a hematoma observed on 6/11/26 around 9:45 a.m. He said R#1's second fall was witnessed and also occurred on 6/11/26. He said R#1 went to the hospital after the second fall. He said the Unit Manager in-serviced the memory care unit staff on 6/11/26. During an interview with the Physician on 6/26/26 at 3:07 p.m., he said he expected staff to monitor residents as often as possible and to sit with the resident at the nurse's station. He said he also expected staff to notify him and the NP whenever a resident had a fall. He said he expected staff to send a resident out for a CT scan if the resident could not stay still during the evaluation after a fall. He said he did not know why R#1 was sent out to the hospital on 6/15/26 and said, There might have been a delay in the facility sending her. He did not have any additional information to provide. During an interview with the NP on 6/26/26 at 3:20 p.m., he said he expected staff to frequently monitor residents and make sure residents were in common areas to be easily observed, seen by therapy to determine why there were falling, review medications and conditions that could contribute to residents' falls, and immediately call him whenever a resident fell and sustained an injury. He also expected staff to send the resident to the hospital ER if the resident's injury was bleeding out, had a worsening change in condition, resident had an altered mental status outside their baseline, pupils contracted, were restless, and if they hit their head, had a hematoma and radiology recommended a CT scan. He also expected staff to assess residents for any neurological deficits and monitor the resident at the facility if they sustained a minor injury or had an abrasion. He said he saw R#1 on 6/11/26, was not notified at the time that she fell when he observed her, he observed the hematoma to her forehead, asked the staff about the hematoma and they did not know what caused the hematoma on 6/11/26. He said he would have expected staff to notify him and said, So we can decide if additional treatment needed to be ordered for the resident and if the resident needed to be sent out to the hospital. He said he ordered a STAT facial x-ray on 6/11/26 and did not review the results until 6/12/26. He explained he was the only one who reviewed the x-ray results. He said he was not notified between 6/12/26 and 6/14/26 that R#1's swelling worsened. He said he would have sent R#1 out if he knew staff noted swelling and bruising worsened between 6/12/26 and 6/14/26 and as soon as he got the x-ray report that recommended CT scan. He said it was inappropriate to send a resident out four days later to the hospital after they had a fall and sustained a hematoma. He said R#1 was on antiplatelet (blood thinning medication) before she was transferred to the hospital on 6/15/26. He said staff notified him on 6/15/26 that R#1 swelling worsened. He knew it was important for staff to notify the physician of any or worsening changes in condition and said, Not sending residents out hospital timely could place them at risk of internal bleeding or hemorrhagic stroke, which was a stroke caused by bleeding in the brain. He said R#1 returned from the hospital on 6/18/26 with a discharge order to discontinue the antiplatelet. He said he could not recall attending care plan or IDT meeting between 6/18/26 and 6/22/26. He said he was notified of the fall on 6/23/26 and instructed staff to send R#1 to the hospital. He said he would have expected staff to have IDT meeting to discuss her falls and interventions that had been effective and ineffective, staff to be reeducated on fall prevention and response after a fall. During an interview with the DON on 6/26/26 at 3:51 p.m., she said she expected staff to ensure residents' rooms had no clutter, residents' pathways were clear and free from obstacles and debris, residents wore correct footwear and non-skid socks, and furniture was placed in familiar areas as preventative measures for residents at high risk of falls. She said she also expected staff to immediately notify her, the ADM, and the NP whenever a resident had a witnessed fall with head injury or an unwitnessed fall. She said staff told her that they did not know if R#1's first incident in which they observed she had a bruise on 6/11/26 was as a result of a fall, notified the NP, the NP ordered a STAT x-ray, and they initiated neurological monitoring. She said the ADM performed a soft investigation and found during staff interviews that staff suspected R#1 sustained the bruise as a result of hitting her head on furniture. She said the STAT x-ray results ordered for the first incident on 6/11/26 had not arrived yet when R#1 had her second incident on 6/11/26. She said R#1's second incident on 6/11/26 was a witnessed fall in which R#1 was in the activity area, leaned forward, and fell in front of her and another nurse. She said R#1's x-ray results arrived on 6/11/26 after the second incident, she reviewed the results, and the results showed R#1 had no abnormalities. She said the, Consider CT scan to best evaluate, was not a recommendation in the x-ray results and said, The radiology department puts that because hematomas cannot be evaluated using an x-ray. She said she did not send R#1 out to the hospital on 6/11/26. She said she asked the Unit Manager to reeducate the staff on resident rights, abuse and neglect, and incidents and accidents and was present when the Unit Manager present the in-services to the memory care staff. She said her and the staff did not notify the NP from 6/12/26 through 6/14/26 of R#1's bruise and head injury worsening and said, Bruises normally got bigger and darker before they go down. Unless the residents' neuros were off and their change in condition worsened, it would not prompt NP notification. What would prompt us to notify the NP would be a change. Her and the NP decided to send R#1 out to the hospital on 6/15/26 and said, Staff were not sure where the abrasion came from on her head. There was a bigger abrasion and it was worsening, and the hospital could sedate her and perform a CT scan. She said R#1 had internal bleeding and did not require surgery during her hospitalization. She said R#1 returned from the hospital on 6/18/26, had no changes or new interventions in treatment and care, staff moved R#1 to another room and placed her on 1:1 monitoring. She said staff told her that they observed R#1 sitting in the living room area, got up, tried to sit in her wheelchair next to her, fell forward, and scraped her head on the corner of the electric piano on 6/23/26, which tore the soft tissue from the hematoma she already had. She said RN D applied pressure to the hematoma because the bleeding did not stop, she notified EMS, R#1 went to the hospital, received stiches, and returned to the facility with no changes in treatment or care. During a telephone interview with the NP on 6/27/26 at 9:34 a.m., he said R#1's worsening hematoma and increased edema to the eye on 6/15/26 and head laceration on 6/23/26 were significant, major injuries, because the injury was severe enough for him to instruct the staff to send R#1 to the hospital for further evaluation and treatment. He also said R#1's blood thinner medication not being discontinued according to hospital discharge orders on 6/18/26 could cause R#1 to have persistent and serious bleeding that took significant time to stop if she sustained a laceration, cut or injury from an incident or fall and also cause her to easily bruise.During an interview with the ADM on 6/27/26 at 11:22 a.m., he said he expected the IDT (MDS, ADONs, DON, ADM, Wound Care and Social Worker) to meet every morning within the first 72 hours of admission, during initial baseline care plan, after care plan review, after each incident, and quarterly to review incidents, discuss interventions, and implement interventions for staff to follow. He said he also expected staff to immediately assess the resident, notify the NP, RP, DON, ADM, police, Corporate and Regional Director of Clinical Services, and follow the NP orders whenever a resident fell. He said he also expected staff to follow the change in condition policy, prepare an SBAR, notify the NP, and follow NP orders. He knew the importance of notifying the physician timely and following physician's orders and said, To treat the residents' change in condition. Residents could be at risk depending on what it is. He said LVN A notified him on 6/11/26 between 9:30 a.m. and 9:45 a.m. that R#1 had a bruise on her forehead. He explained that after he was notified, he had the Unit Manager initiate in-services on 6/11/26. He said he did not initiate in-services after the second incident on 6/11/26. He said the NP was also notified on 6/11/26, ordered a STAT x-ray, and instructed staff to closely monitor and report any worsening changes in the hematoma. He said the DON notified him on 6/11/26 that R#1 sustained a head injury and discoloration after a witnessed fall. He said the NP was also notified and did not know if the NP had new orders. He explained R#1's facial STAT x-ray results were received either the night of 6/11/26 or the morning of 6/12/26 and was unsure who reviewed the x-ray results. He said the NP was not notified of R#1's injury worsening from 6/12/26 through 6/14/26 and was not aware that staff did not notify the NP before 6/15/26. He said staff sent R#1 out to the hospital on 6/15/26 because her injuries worsened, R#1 sustained a subcranial hemorrhage, and the hospital did not recommend any new orders for treatments or care after she returned on 6/18/26. He said the IDT met after R#1's second incident on 6/11/26, but he could not recall when. He said he was not aware that the NP wanted R#1's antiplatelet discontinued when she returned from the hospital on 6/18/26. He said the NP did not visit R#1 from 6/18/26 through 6/23/26. He said the DON notified him on 6/23/26 that she witnessed R#1's fall and he observed R#1 lying on the ground with the laceration to her head. He also said the DON and RN D were providing care to R#1. He said R#1 went out to the hospital on 6/23/26 because she was bleeding on her forehead, received stitches at the hospital, and returned to the facility the same day. During a telephone interview with LVN A on 6/29/26 at 12:58 p.m., she said the nurses who admitted residents were required to review the discharge orders and verify with the physician any new or changes. She knew the importance of reviewing discharge orders with the physician and said, For resident safety. To prevent further injury and to ensure resident received continuity of care and to make sure physician was aware of residents' condition and care. Residents could be at risk of receiving improper treatment and medication error, which could result in death. She said CNA N notified her on 6/11/26 that R#1 had a bump on one of the sides of her head, she did not know where the injury came from, she notified the ADON, DON and NP, and the NP ordered her to start R#1 on scheduled pain medication, order a facial x-ray and to initiate neurological checks because it was a head injury. She said R#1's head area did not worsen during the shift, but she had a fall later that day. She said R#1's fall was witnessed in the activity area, she completed an incident report on the witnessed fall, notified all appropriate parties, the x-ray order results came in after this fall, and she was expected to continue monitoring. She said R#1 was not sent out to the hospital and she did not notice the injuries worsening after the fall incident on 6/11/26. She also said the CNAs and nurses did not notify her of any worsening changes in R#1's injuries. She said she did not work with R#1 after she returned 6/18/26 because she was transferred to another hallway. Review of the facility's in-services from 6/1/26 through 6/26/26 reflected the Unit Manager trained staff on Abuse, Neglect and Exploitation, Incidents and Accidents, and Resident Rights on 6/11/26. RN E, LVN F and LVN G were not listed. The in-service roster for resident rights and accidents and incidents in-services were photocopies from abuse, neglect and exploitation in-service. Review of the facility's Change of Condition policy, reflected 10/1/25, reflected, A significant change in Resident's status is any sign or symptom that is: Acute or sudden onset A marked change (i.e., more severe) in relation to usual signs and symptoms New or worsening symptomsWhen a change in condition occurs, the Licensed Nurse will:.2. Notify the Physician of the change in condition.3. Document date, time Physician, Responsible Party was notified of findings from the evaluation and any new orders obtained.5. If it is determined that there is no improvement or resolution in the Resident's condition change, the nurse will notify the Physician for further guidance and document response in the EMR.Review of the facility's Provision of Physician Ordered Services policy, implemented 12/1/25, reflected, .3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Ordering Provider will be notified of results upon receipt if deemed critical and/or require immediate attention.4. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record.Review of the facility's Consulting Physician/Practitioner Orders policy, implemented 11/1/25, reflected, 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will:a. Call the attending physician to verify the order.b. Document the verification order by entering the order and the time, date, and signature on the physician order sheet.c. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.These failures resulted in the identification of an IJ on 6/27/26 at 2:47 p.m. The ADM and DON were notified of the IJ and provided the IJ template on 6/27/26 at 2:54 p.m.The POR was approved on 06/28/26 at 6:52 p.m. and reflected the following, On 6/26/2026 an abbreviated survey was initiated at the facility. On 6/27/2026, the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety.The notification of Immediate Threat states as follows: The facility failed to ensure residents received treatment and care in accordance with professional standards of practice.1.) The facility failed to notify the NP when Resident #1 had had two incidents on 06/11/26 in which she hit her head and her injuries worsened 6/12/26 through 6/14/26. The NP sent her to the hospital on [DATE] where she was diagnosed with a traumatic subarachnoid hemorrhage and subsequently led to her needing care in the ICU.2.) The facility failed to follow the physician's instruction and hospital discharge orders by not discontinuing her blood thinner medication when she returned to the facility on 6/18/26, which subsequently resulted in another hospital visit on 6/23/26 requiring stitches to her forehead when staff could not stop the bleeding from Resident #1's laceration after sustaining another fall.Action: The nurse practitioner had been notified of the incidents on 6/11/2026, as evidenced by NP documentation on chart dated 6/11/26 (page 7 of 8) where facial x-ray was ordered. Another meeting with physician and NP was also conducted yesterday with administrator and director of nursing to review the case and as part of ad hoc QAPI.[PH15.1][SB15.2] A head-to-toe assessment and medication reconciliation was completed on 6/27/26. No additional findings were noted.Start Date: 6/27/26Completion Date: 6/27/26Responsible: Administrator and Director of NursingAction: The Director of Nursing and Assistant Director of Nursing will initiate a 100% audit of all residents who admitted /readmitted within the last 14 days to ensure orders were entered correctly by reconciling against the hospital discharge medication list, the provider and patient representative will be notified of any discrepancies.Start Date: 6/27/2026Completion Date: 6/27/2026Responsi

Based on observation, interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (R#1) of 7 residents reviewed for pain management. The facility failed to accurately assess R#1's pain levels. This failure could place residents at risk of functional decline, untreated physiological complications and mental health deterioration. Findings include: Review of R#1's admission Record, dated 6/26/26, reflected she was admitted to the facility on [DATE]. She had medical diagnoses of traumatic subarachnoid hemorrhage (bleeding in the fluid-filled space between the brain and the skull), difficulty walking, lack of coordination, muscle weakness, and Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills).Review of R#1's Quarterly MDS Assessment, dated 5/29/26, reflected she had a BIMS of 3, which indicated she had severe cognitive impairment. She also received a scheduled pain medication regimen. Review of R#1's Care Plan, revised 6/26/26, reflected she was at risk for pain and rarely/never understood in ability to express ideas and wants. Staff were required to assess for presence of pain at frequent routine intervals and before/after specific activities. Review of R#1's Order Summary Report, dated 6/26/26, reflected staff were required to assess for pain every shift by using non-verbal/noncognitive signs of pain to determine R#1's pain score. The report also reflected R#1's pain intensity score could not be verbalized and she had a cognizant deficit. Review of R#1's Pain Summary, dated 6/26/26, reflected staff used a pain numerical scale to assess R#1's pain levels on 6/1/26 at 11:16 a.m., 6/8/26 at 9:46 a.m., 6/19/26 at 11:27 p.m., 6/20/26 at 4:28 p.m., 6/22/26 at 3:40 p.m., 6/23/26 at 2:48 p.m. and 9:59 p.m., 6/24/26 at 3:49 p.m. and 6/25/26 at 1:11 a.m. and 1:12 p.m. The rest of the pain assessments performed from 6/1/26 through 6/25/26 were conducted using a PAINAD. During a telephone interview with R#1's RP on 6/26/26 at 10:09 a.m., RP said R#1 had severe dementia, severe cognitive impairment, and a diminished mental capacity. They explained R#1 was unable to verbalize and express her pain levels. During an observation and interview of R#1 on 6/26/26 at 11:25 a.m., R#1 was sitting in her wheelchair at the memory care unit nurse's station. She had a dark red laceration on the left side of her forehead that had stiches. The surveyor attempted to interview R#1, but she was unable to answer any questions.During a telephone interview with the NP on 6/26/26 at 3:20 p.m., he said he expected staff to use PAINAD for R#1 and said, Because a dementia resident could not tell you their numerical pain value. He also said he knew the importance of using the proper pain assessment when assessing residents for pain and said, Because the resident could have a new injury. Residents could be at risk of not having their pain assessed and managed.During an interview with the DON on 6/26/26 at 3:51 p.m., she said she expected staff to use PAINAD when evaluating R#1's pain levels because she was not able to verbalize her pain level. She also said she was not aware that staff used a pain numerical scale when assessing R#1's pain levels instead of PAINAD. She knew the importance of using the proper pain assessment when evaluating residents' pain levels and said, So their pain could be accurately assessed and treated.During an interview with the ADM on 6/26/26 at 11:22 a.m., he said he expected staff to evaluate residents like R#1 using PAINAD. He explained he expected staff to evaluate and identify nonverbal cues for pain for R#1. He also said he was not aware that staff used a pain numerical scale when assessing R#1's pain levels instead of PAINAD. He knew the importance of using the proper pain assessment when evaluating residents' pain levels and said, To determine if residents need further treatment and to treat the pain. Residents could be at risk of pain being unnoticed and facility not being aware of residents' pain. During an interview with LVN I on 6/29/26 at 11:17 a.m., she said the nurses assessed, treated and documented pain. She explained that staff used appropriate pain evaluation based on residents' BIMS. She said she was trained on pain administration. She said she would switch to PAINAD when evaluating R#1's pain levels. She also said R#1 sometimes could answer using a numerical pain scale. She said she knew the importance of using the proper pain assessment when evaluating residents' pain levels and said, It's important because to tell staff what the resident's pain level was. Residents could be at risk of pain. During an interview with the ADON on 6/29/26 at 11:43 p.m., she said nurses assess residents' pain levels. She also said nurses determined pain evaluation type based on residents' BIMS score and cognitive impairment. She said she knew the importance of using the proper pain assessment when evaluating residents' pain levels and said, So residents could communicate or staff could determine pain levels. Residents could be at risk of their pain levels not accurately being evaluated.During a telephone interview with LVN A on 6/29/26 at 12:58 p.m., she said nurses evaluated residents' pain. She also said nurses determined evaluations for pain based on residents being alert, oriented, their BIMS and verbal communication. She said she knew the importance of using the proper pain assessment when evaluating residents' pain levels and said, So we can get the correct assessment, evaluation and treatment for the resident. Residents could be at risk of not being effectively treated for injuries. Review of the facility's Pain Management policy, implemented 12/1/25, reflected, Facility staff will observe for nonverbal indicators which may indicate the presence of pain.The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain.

Based on interview and record review, the facility failed to administer in a manner that enables it to resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 13 of 19 staff reviewed for in-services. The facility failed to in-service who were assigned to work in the memory care unit on 6/11/26 on abuse, neglect and exploitation, incidents and accidents and resident rights on 6/11/26. This failure could place residents at risk of repeat safety failures, escalating neglect, and sustaining avoidable injuries. Findings include: Review of the facility's in-services from 6/1/26 through 6/26/26 reflected the Unit Manager trained staff on Abuse, Neglect and Exploitation, Incidents and Accidents, and Resident Rights on 6/11/26. The in-service roster for resident rights and accidents and incidents in-services were photocopied from the abuse, neglect and exploitation in-service. There were no other in-services given to staff in June 2026. Review of the facility's staff schedules, as of 6/26/26, reflected the following staff were assigned to work in the memory care unit and were not in-serviced: 6/11/26 6a-6p: CNA N, RN E, RA, ADON, RN R, MDS coordinator, Staffing Coordinator, DON, and Treatment Nurse 6/11/26 6p-6a: CNA N, CNA O, CNA P, CNA Q and LVN GDuring an interview with RN D on 6/26/26 at 11:29 a.m., he said RN R in-serviced him within the last week on abuse and neglect. During an interview with RN E on 6/26/26 at 11:43 a.m., she said she was in-serviced on abuse and neglect on 6/25/26. She could not recall who in-serviced her. During an interview with CNA L on 6/26/26 at 11:57 a.m., she said she could not remember who, what and when she was most recently in-serviced. During an interview with CNA H on 6/26/26 at 12:01 p.m., she said the Unit Manager in-serviced her on abuse and neglect within this week or last week. During an interview with CNA S on 6/26/26 at 12:04 p.m., she said the Unit Manager in-serviced her on abuse and neglect on 6/22/26 or 6/24/26. During an interview with RN D on 6/26/26 at 1:49 p.m., he said he could not recall how many in-services he signed and could not recall signing 3 in-services on 6/11/26. During an interview with CNA H on 6/26/26 at 1:59 p.m., she said she could not recall how many in-services she signed and could not recall signing 3 in-services on 6/11/26.During an interview CNA L on 6/26/26 at 2:00 p.m., she could not recall how many in-services she signed and could not recall signing 3 on 6/11/26. She also did not know if she worked on 6/11/26. During a telephone interview with the NP on 6/26/26 at 3:20 p.m., he said he expected all staff to be reeducated after an incident or accident. During an interview with the DON on 6/26/26 at 3:51 p.m., she said she asked the Unit Manager to [PH22.1][SB22.2]reeducate the staff in the memory care unit on resident rights, abuse and neglect, and incidents and accidents. She said she was there when the Unit Manager in-serviced the staff on 6/11/26. She said she was not aware the Unit Manager made photocopies of the in-service roster. She explained she asked the Unit Manager to split up the in-services on three separate sheets. During an interview with the ADM on 6/27/26 at 1:22 a.m., he said the Unit Manager initiated in-services on 6/11/26. He was not aware the Unit Manager made photocopies of the in-service roster. He knew the importance of in-servicing all staff and said, So in-services were fresh in staff's mind, they know the procedures and know how to act. Residents were not at risk as long as staff followed protocols.During an interview with LVN I on 6/29/26 at 11:17 a.m., she said the Unit Manager, ADON, DON, or ADM in-serviced staff whenever there was a concern or after an incident. She knew the importance of in-servicing all staff and said, Because we all make mistakes and to remind staff of protocols and new protocols. Residents could be at risk of staff not providing appropriate care and services.During a telephone interview with LVN A on 6/29/26 at 12:58 p.m., she said the Unit Manager, ADON, DON, and ADM in-serviced staff often. She knew the importance of in-servicing all staff and said, To make sure everyone was properly trained to take care of residents in a productive and safe manner. Residents could be at risk of incidents happening again and harm if staff were not in-serviced or properly trained. Review of the facility's Training Requirements policy, implemented 1/1/26, reflected, It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 3.Competencies and skill sets for all new and existing staff, and individuals providing services must be consistent with their expected roles.4.Facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program. 5.Training requirements should be met prior to staff independently providing services to residents, annually, and as necessary based on the facility assessment.6.Training content includes, at a minimum:b.Resident rights and facility responsibilities for caring of residents.h.Abuse, neglect, and exploitation prevention.7.It is the responsibility of each employee to complete required training.a.The facility offers a variety of training methods and times to accommodate individuals.b.An individual's failure to complete required training in a timely manner will result in removal from schedule until compliant or termination of employment.8.In-service training is provided by qualified personnel (in house or outside entities) in a variety of formats (e.g., facilitated training, computer-based training, self-directed learning, mentoring and/or coaching, etc.).

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials for 1 (R#1) of 7 residents reviewed for incidents. The facility failed to report R#1's hematoma to left eyebrow area on 6/11/26 to the SSA. This failure could place residents at risk of their injuries worsening without proper medical intervention or remain vulnerable to further harm, abuse or neglect. Findings include: Review of R#1's admission Record, dated 6/26/26, reflected she was admitted to the facility on [DATE]. She had medical diagnoses of traumatic subarachnoid hemorrhage (bleeding in the fluid-filled space between the brain and the skull), difficulty walking, lack of coordination, muscle weakness, and Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills). Review of R#1's Quarterly MDS Assessment, dated 5/29/26, reflected she had a BIMS of 3, which indicated she had severe cognitive impairment. Review of R#1's Care Plan, revised 6/26/26, reflected there were no notes related injuries of unknown origin. Review of R#1's Progress Notes reflected: LVN A created a note on 6/11/26 at 11:48 a.m., While returning from morning meeting. This nurse was made aware from CNA that resident has a hematoma (a collection of pooled, clotted blood that forms outside of a blood vessel) to eyebrow area. Complete assessment done. No other injuries noted. NP at facility at assessed resident. Received new order for facial x-ray stat, and Tylenol 650mg po tid. Resident RP notified and voiced understanding. Neuros initiated per protocol. Resident keep in common area for close observation. care ongoing. LVN A created a note on 6/11/26 at 4:00 p.m., Complete assessment done. Hematoma noted to Right side of forehead/eyebrow area. No other new injuries noted at this time. vss. Afebrile (normal body temperature). no s/s of distress or discomfort noted. [RP] notified. NP notified. Xray here to do Xray on face. neuros initiated per protocol. care ongoing.Review of R#1's Physician Progress Notes reflected: Visit note, dated 6/11/26, reflected, Patient is seen today for hematoma to the right forehead. Nurse reports hematoma was noted today. No reports of recent trauma. Patient is a poor historian due to dementia. Neurochecks unremarkable. Will obtain facial x-ray. Multimodal pain management. Discussed with nursing to closely monitor and notify for worsening. DON has been notified.Review of R#1's Change in Condition Evaluation, created by LVN A on 6/11/26 at 10:00 a.m., reflected R#1 was observed with a skin issue on the left eyebrow area. Review of R#1's Injury of Unknown Origin Investigation, created by the ADON on 6/11/26, reflected the injury was discovered on 6/11/26 at 9:30 a.m. The investigation initiated on 6/11/26 and the ADM was conducting it. CNA H last observed R#1 in the memory care unit activity room on 6/11/26 at 9:15 a.m. before the injury was discovered. CNA N observed the injury. The source of the injury was not observed by anyone and the source of the injury could not be explained by R#1. Review of R#1's Facial X-Ray, created by LVN A on 6/11/26 at 9:15 a.m., reflected R#1 was examined on 6/11/26 at 4:33 p.m. The results were reported on 6/11/26 at 6:10 p.m. The NP reviewed the X-ray results on 6/18/26 at 11:38 a.m. The results reflected, Findings: Evaluated limited due to motion. The osseous structures demonstrate no acute fracture or destructive bone lesion.Conclusion: .Consider CT scan to best evaluate. Review of the facility's Incident Log, from 5/1/26 through 6/26/26, reflected R#1 had a skin bruise incident on 6/11/26 at 10:00 a.m. LVN A prepared the report, which reflected, While returning to morning meeting. This nurse was made aware from CNA that resident has a hematoma to left eyebrow area. The hematoma occurred due to resident ambulating without assistance and bumping into activity area furniture. Resident unable to give description. Incident was not witnessed. During a telephone interview with R#1's RP on 6/26/26 at 10:09 a.m., RP said R#1 was admitted to the facility's memory care unit due to her severe dementia, severe cognitive impairment, and diminished capacity to make informed decisions. They said DON called and notified them on 6/11/26 that R#1 was walking fast without standby assistance, fell, hit her face and head on the floor, and sustained injuries to her head and face on 6/11/26 between 8:00 a.m. and 12:00 p.m. They did not know whether R#1's first fall was witnessed or not. They also said the DON also told them that a nurse assessed R#1, had an x-ray done, and the x-ray showed she did not sustain any fractures. During an observation and interview of R#1 on 6/26/26 at 11:25 a.m., R#1 was sitting in her wheelchair at the memory care unit nurse's station. She had a dark red laceration on the left side of her forehead that had stiches. The surveyor attempted to interview R#1, but she was unable to answer any questions.During an interview with the ADM on 6/26/26 at 12:31 p.m., he said there were no facility reported incidents he submitted to the SSA related to injuries of unknown origin within this and last week. During an interview with the ADM on 6/26/26 at 2:53 p.m., he said R#1's first incident on 6/11/26 was an unwitnessed fall. He said he initiated an investigation on 6/11/26 because R#1 had a hematoma observed on 6/11/26 around 9:45 a.m. During an interview with the NP on 6/26/26 at 3:20 p.m., he said he saw R#1 on 6/11/26, was not notified she fell at the time he observed her, he observed the hematoma to her forehead, asked the staff about the hematoma and they did not know what caused the hematoma on 6/11/26. He said staff did not tell him if R#1 had a fall prior to him seeing her on 6/11/26. He said he would have expected staff to notify him and said, So we can decide if additional treatment need to be ordered for the resident and if the resident needed to be sent out to the hospital.During an interview with the DON on 6/26/26 at 3:51 p.m., she said staff did not know if R#1's first incident on 6/11/26 was as a result of a fall. She explained staff observed a bruise on R#1, notified the NP, NP ordered a STAT x-ray, and they initiated neurological monitoring. She said the ADM was responsible for submitting injury of unknown origin reports to the SSA within 2 hours. She said she did not believe the ADM self-reported the first incident. She explained the ADM performed a soft investigation and found during staff interviews that staff suspected R#1 sustained the bruise as a result of hitting her head on furniture. She said she told the Unit Manager initiate in-services on abuse and neglect, resident rights, and accidents/incidents on 6/11/26 after R#1's first incident. During an interview with the ADM on 6/27/26 at 11:22 a.m., he said LVN A notified him on 6/11/26 around 9:30am-9:45am that R#1 had a bruise on her forehead. He said after the notification, he had the Unit Manager initiate in-services and he conducted a soft file investigation of the suspected injury of unknown origin. He said he was able to determine that R#1 hit her head on a piece of furniture and said, If there was an injury of unknown origin or if it was suspicion of abuse or neglect, I would have reported it. He said would report injury of unknown origin to the SSA within 2 hours. He said he did an internal report and he did not believe it warranted a report to the SSA.During an interview with the ADM on 6/26/26 at 3:10 p.m., he said the facility followed the Long-Term Care Regulation Provider Letter when determining Suspicious injuries of unknown source. During an interview with LVN I on 6/29/26 11:17 a.m., she said the ADM reported injuries of unknown origin to the SSA within 24 hours. During an interview with the ADON on 6/29/26 at 11:43 a.m., she said the ADM reported injuries of unknown origin to the SSA. She said the DON was the designee. She also said the report must be made within 2 hours of notification. She said she knew it was important to report injuries of unknown origin to the SSA and said, It's important because to inspect and determine if the incident occurred. Residents could be at risk of worsening change in condition. During a telephone interview with LVN A on 6/29/26 at 12:58 p.m., she said the ADM reported injuries of unknown origin to the SSA within an hour or 2 hours. Review of the facility's in-services from 6/1/26 through 6/26/26 reflected the Unit Manager trained staff on Abuse, Neglect and Exploitation. The Abuse, Neglect and Exploitation policy was attached. RN E, LVN F and LVN G were not listed on the roster. Review of the facility's Long Term Care Regulation Provider letter, issued 8/29/24, reflected, A nursing facility must report the following types of incidents, in accordance with applicable state and federal requirements: .Suspicious injuries of unknown source.Do report injuries of unknown source immediately, but not later than two hours after the incident occurs or is suspected.Injuries of unknown source:Note: an injury should be classified as an injury of unknown source whenALL of the following conditions are met: The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; and The injury is suspicious because of: the extent of the injury; or the location of the injury (e.g., the injury is located in an areanot generally vulnerable to trauma); or the number of injuries observed at one point in time; or the incidence of injuries over time.Review of the facility's Abuse, Neglect and Exploitation policy, revised 12/1/25, reflected, I. Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 5.Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following:a.Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences;b.Defining how care provision will be changed and/or improved to protect residents receiving services;c.Training of staff on changes made and demonstration of staff competency after training is implemented;d.Identification of staff responsible for implementation of corrective actions;e.The expected date for implementation; andf.Identification of staff responsible for monitoring the implementation of the plan.B.The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on observation, interview, and record review, the facility failed to review and revise residents' comprehensive care plans for 1 (R#1) of 7 residents reviewed for care plans. The facility failed to timely review and revise R#1's care plan after her two incidents on 6/11/26 and one incident on 6/23/26.This failure could place residents at risk of not receiving treatment and care to meet residents' needs. Findings include:Review of R#1's admission Record, dated 6/26/26, reflected she was admitted to the facility on [DATE]. She had medical diagnoses of traumatic subarachnoid hemorrhage (bleeding in the fluid-filled space between the brain and the skull), difficulty walking, lack of coordination, muscle weakness, and Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills). Review of R#1's Quarterly MDS Assessment, dated 5/29/26, reflected she had a BIMS of 3, which indicated she had severe cognitive impairment.Review of R#1's Care Plan, revised 6/26/26, reflected she was at risk for falls related to her unsteady gait and history of falling and getting herself back up. She had a witnessed fall on 6/11/26 and 6/23/26. Interventions initiated on 6/15/26 included ensure she wore non-skid, well-fitting shoes. Interventions initiated on 6/19/26 included move her closer to the nurse's station. Interventions initiated on 6/26/26 included conduct purposeful staff rounding. Review of R#1's Progress Notes reflected: LVN A created a note on 6/11/26 at 11:48 a.m., While returning from morning meeting. This nurse was made aware from CNA that resident has a hematoma to eyebrow area. Complete assessment done. No other injuries noted. NP at facility at assessed resident. Received new order for facial x-ray stat, and Tylenol 650mg po tid. Resident RP notified and voiced understanding. Neuros initiated per protocol. Resident keep in common area for close observation. care ongoing. LVN A created a note on 6/11/26 at 4:00 p.m., Complete assessment done. Hematoma (a collection of pooled, clotted blood that forms outside of a blood vessel) noted to Right side of forehead/eyebrow area. No other new injuries noted at this time. vss. Afebrile (normal body temperature). no s/s of distress or discomfort noted. [RP] notified. NP notified. Xray here to do Xray on face. neuros initiated per protocol. care ongoing. LVN B created a note on 6/12/26 at 5:09 a.m., Resident on a witnessed fall follow-up with neuro check & head injury. Large hematomas approximately golf ball-sized to bilateral forehead/eyebrow areas. Swelling and bruising noted around affected sites. No active bleeding observed. X-ray completed with negative results for fracture. Neurological status remains at baseline. Resident alert and responsive. Vital signs stable. No s/s of pain, headache, dizziness, nausea, vomiting, visual changes, or changes in mental status noted. Remains in bed this shift, bed at lowest position, call light within easy reach. Care ongoing. LVN B created a note on 6/13/26 at 4:45 a.m., F/u witnessed fall Day 3/3 with neuro check & head injury. Large hematomas approximately golf ball-sized to bilateral forehead/eyebrow areas healing well. Continues with swelling and bruising around affected sites. Neurological status remains at baseline. Resident alert and responsive. Vital signs stable. No s/s of pain, headache, dizziness, nausea, vomiting, visual changes, or changes in mental status noted. Remains in bed this shift, bed at lowest position, call light within easy reach. Care on going. LVN A created a note on 6/14/26 at 1:04 p.m., Aaox1- pleasantly confused. Wanders. Poor safety awareness. No s/s of distress or discomfort noted. Fall precautions in place. Kept at nurses station for close observation. VSS afebrile. Care ongoing. Cont. neuros WNL. F/u fall. Bruising noted to both sides of face with facial swelling noted to ous. Care ongoing. LVN C created a note on 6/14/26 at 5:45 a.m., Resident has increased orbital edema to right eye. Ice pack administered for comfort and to reduce edema (the abnormal accumulation of excess fluid within the interstitial spaces (the spaces between cells and tissues), which leads to swelling). LVN A created a note on 6/14/26 at 1:08 p.m., Aaox1- pleasantly confused. Wanders. Poor safety awareness. No s/s of distress or discomfort noted. Fall precautions in place. Kept at nurses station for close observation. VSS afebrile. Care ongoing. Cont. neuros WNL. F/u fall. Bruising noted to both sides of face with facial swelling noted to ous. Care ongoing. RN D created a note on 6/15/26 at 10:09 a.m., Resident arrived back to facility from appt. with orders. This writer notified NP of orders and received new orders to transfer to medical center for increased (R) eye orbital edema. RP aware. RN D created a note on 6/15/26 at 10:36 a.m., EMS just left facility to transport resident to medical center. RN D created a note on 6/18/26 at 11:28 a.m., Resident arrived at facility via medical transport on a gurney accompanied by two EMS personnel. Transferred from gurney to bed by two-person slide. She is alert and oriented x 1. She denies pain or discomfort. Hospital wrist bands removed. Resident has discoloration around both eyes as expected from previous bruising. No new skin issues observed. Vital signs. 122/66 P 77 R 18 T 97.8 O2 Sat. 97% room air FSBS 121mg/dl. No acute distress observed. Bed placed in lowest position, call light within reach. Care ongoing. RN E created a note on 6/20/26 at 5:15 p.m., Skilled for Traumatic subarachnoid hemorrhage. Noted bruises on both sides of the eyelids. Took all meds and tolerated well. Denies pain or discomfort. Even and unlabored breathing. Res stays on wheelchair. The DON created a note on 6/23/26 at 6:10 p.m., Resident was observed sitting on the couch in the common area watching television. Resident attempted to transfer from the couch to her wheelchair. While attempting to sit, resident realized the wheelchair was not properly positioned, with the seat not facing her. Resident attempted to correct her position and stand upright but lost her balance, stumbled several steps forward, and fell into the lower portion of an electric piano. During the fall, resident sustained a skin tear/abrasion to the left temple after making contact with the lower edge of the piano. RN D and Unit Manager, immediately responded to the scene and found resident on the floor. Pressure was applied to the left temple wound with gauze and an ABD pad to control bleeding. Resident remained awake, verbal, and responsive throughout the event. No loss of consciousness noted. PERRLA 2+ bilaterally. Vital signs obtained and within normal limits. Resident alert and oriented x1, consistent with baseline cognitive status. DON notified and responded to the scene. Resident's (RP), notified by DON. EMS activated for evaluation and transport. EMS arrived at 1625. Resident remained responsive and exhibited no signs of acute distress while awaiting EMS arrival. LVN F created a note on 6/23/26 at 9:00 p.m., Resident returned back to the facility transported by ambulance via stretcher post ER visit SPF with laceration to the LF side of the forehead, noted dry dressing to area of laceration, stable and situated in room, neuro checks cont., NP notified, RP notified, notified DON/Administrator.Review of R#1's Physician Progress Notes reflected: Visit note, dated 6/11/26, reflected, Patient is seen today for hematoma to the right forehead. Nurse reports hematoma was noted today. No reports of recent trauma. Patient is a poor historian due to dementia. Neurochecks unremarkable. Will obtain facial x-ray. Multimodal pain management. Discussed with nursing to closely monitor and notify for worsening. DON has been notified. Visit note, dated 6/23/26, reflected, R#1 was sent to ED on 6/15/26 due to worsening hematoma to the forehead. Hematoma to the forehead was initially detected on 6/11/26. I saw R#1 at that time and facial X-ray was ordered which resulted negative for fracture. Nurse called to report that patient had increased hematoma to the forehead and therefore patient was sent to ED for further evaluation on 6/15/26. ED workup included CT of the head which was remarkable for minimal SAH in the left sided high cerebral region. NSGY was consulted and no acute intervention was recommended. Brilinta was discontinued and patient discharged back to facility on 6/18/26 in stable condition. On exam, patient is seen in the memory care unit up in wheelchair watching TV. She is awake and alert. No acute distress or discomfort. She has bruising and hematoma to bilateral forehead right slight larger than left side. She is a poor historian due to dementia. Neuro exam are unremarkable. Fall precautions per facility protocol. PT/OT to eval and treat. Chart reviewed including nurses notes, recent labs and medications.During a telephone interview with R#1's RP on 6/26/26 at 10:09 a.m., RP said R#1 often fell at home before she was admitted to the facility's memory care unit due to her severe dementia, severe cognitive impairment, and diminished capacity to make informed decisions. They said DON called and notified them on 6/11/26 that R#1 was walking fast without standby assistance, fell, hit her face and head on the floor, and sustained injuries to her head and face on 6/11/26 between 8:00 a.m. and 12:00 p.m. They did not know whether R#1's first fall was witnessed or not. They also said the DON also told them that a nurse assessed R#1, had an x-ray done, and the x-ray showed she did not sustain any fractures. They said the DON also called and notified them on 6/11/26 that she witnessed R#1 walking fast without standby assistance, fell and hit her face again on 6/11/26 between 1:00 p.m. and 6:00 p.m. They said R#1 was not sent to the hospital after the first and second fall on 6/11/26. They said they did not know why R#1 was not sent to the hospital. They also said they observed R#1 sitting at the nurse's station with a swollen eye and blood noticeable in her eyes on 6/13/26. They said R#1 was sent to the hospital on 6/15/26, was x-rayed again, CT scanned, the CT scan reflected she sustained internal bleeding to her eyes and brain and was sent to the ICU. They said R#1 was discharged from the hospital and returned to the facility with discharge paperwork and instructions from the hospital doctor to make sure she rest and not fall again on 6/18/26. They said the ADM and DON told them on 6/19/26 that the staff could not monitor her at all times. They said the ADM and DON did not mention anything to them about what interventions they were going to put in place to prevent and intervene when she fell. They said the DON called and notified them on 6/23/26 that R#1 wandered away during an activity, fell, hit her face and head on the floor, sustained a head laceration, bled, staff could not control her bleeding, and sent her to the hospital on 6/23/26. They said R#1 received stiches at the hospital and returned to the facility on 6/23/26. During an observation and interview of R#1 on 6/26/26 at 11:25 a.m., R#1 was sitting in her wheelchair at the memory care unit nurse's station. She had a dark red laceration on the left side of her forehead that had stiches. The surveyor attempted to interview R#1, but she was unable to answer any questions.During an interview with the ADM on 6/27/26 at 11:22 a.m., he said he expected the IDT (MDS, ADONs, DON, ADM, Wound Care and Social Worker) to meet every morning within the first 72 hours of admission, during initial baseline care plan, after care plan review, after each incident, and quarterly to review incidents, discuss interventions, and implement interventions for staff to follow. He said he believed the MDS nurse updated the care plan for R#1. He also said he expected care plans to be revised as soon as possible.During an interview with LVN A on 6/29/26 at 12:58 p.m., she said the nurse manager reviewed and revised residents' care plans. She said the nurses on the floor had access to residents' care plans. She knew the importance of reviewing and revising residents' care plans in a timely manner and said, For any changes the physician made or wanted to do, to ensure continuity of care, and to ensure physician's orders were followed.

Based on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal care for 1 of 5 residents (Resident #1) reviewed for ADL care. The facility failed to provide nail care to Resident #1, leaving the toenails thick, dirty, long, and discolored.This failure could place residents at risk of social embarrassment, isolation, infection, injury, pain, deterioration of health and a diminished quality of life.Findings included:Record review of Resident #1's face sheet, dated 06/08/26, reflected Resident #1 was admitted [DATE]. He was an [AGE] year-old male diagnosed with dementia, hypertension, insomnia, lack of coordination, muscle weakness, and cognitive communication deficit.Record review of Resident #1's initial MDS assessment, dated 05/28/26, reflected that an assessment for BIMS could not be completed as the resident was rarely/never understood. Further review revealed that for self-care he was fully dependent.Record review of Resident #1's care plan, dated 04/10/26 reflected that he required assistance for performing ADLs due to muscle weakness. The relevant intervention was checking nail length and trimming and cleaning on bath day and as necessary.During an observation and interview with RN A on 06/08/26 at 10:50 a.m., it was noted that all of Resident #1's fingernails were appropriately trimmed. However, an assessment of his feet revealed that his toenails were approximately half an inch long on both feet. The toenails were thick, dirty, yellow in color, and exhibited a yellow substance underneath. There was no sign of any infection or pain on the toes. RN A stated that she occasionally worked on Resident #1's hall as the charge nurse but had not paid attention to his feet. She stated that the toenails needed to be trimmed as soon as possible but expressed concern about her ability to perform the task, citing that it appeared more complicated and required specialized expertise. RN A indicated she would request a podiatrist to address this issue today, as untrimmed nails pose a risk of infection and injury.An attempt to interview Resident #1 at 11:00 a.m. on 06/08/26 was unsuccessful due to his cognitive deficits.During an interview on 06/08/26 at 2:35 p.m., the ADON stated that no staff reported the condition of Resident #1's toenails to her. She explained that, according to facility protocol, staff were responsible for reporting overgrown nails to the nurse-in-charge. She said if the resident was diabetic or if the nails appeared complicated, staff were expected to report the issue to the ADON so that a referral to a podiatrist can be made. The ADON stated that overgrown toenails could lead to injuries and infections, which was especially critical for residents with medical conditions such as diabetes.During an interview on 06/08/26 at 1:10 p.m., the DON stated that nail care should be performed appropriately and timely. She said that Resident #1's toenails had become overgrown and required evaluation by a podiatrist. She stated that the yellow substance beneath the nails was most likely fungal growth and that attempting to trim the nails by an RN would be risky. The DON explained that the Social Worker handled podiatry appointments and follow-ups. She also stated that Resident #1's toenail issue was discussed during the IDT meeting a few weeks prior; however, no referral had been made until this day. The DON stated she thought since the podiatrist visits once a month, there was no need for an earlier referral. She stated overgrown toenails posed infection control concerns because the nail bed could harbor germs that caused infectious diseases. The DON said that long nails could cause scratches and injuries, which could have more serious consequences for residents with diabetes, peripheral vascular disease ( a condition thta narrows, blocks, or spasms blood vessels outside the heart and brain) , or those taking blood thinners.Record review of the document Request for service/Consultation it was revealed that the request for podiatry service for Resident#1 was made on 06/08/26 by the ADON. Record review of the facility policy titled, Nail Care, dated 10/01/2025, reflected : Purpose: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health.Policy Explanation and Compliance Guidelines:1. Policy Explanation and Compliance Guidelines: Principles of nail care:a. Nails should be kept smooth to avoid skin injury.b. Only licensed nurses shall trim or file fingernails of residents with diabetes. Toenails of residents with diabetes or circulation problems shall be filed only.c. If a resident has a toe infection, diabetes mellitus, neurologic disorders, or renal failure, toenail trimming should be performed by a physician or practitioner.d. Resident without complicating disease processes, may have their toenails clipped by staff who have received education and training to provide this service within professional standards of practice and as per facility policy.

Based on observation, interview and record review the facility failed to ensure each resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1 ) of one Resident reviewed for transfers RN A and CNA B failed to properly transfer Resident #1 with a gait belt on 5/19/2026, they used Resident #1's pants to transfer her from the wheelchair to the bed. This failure place resident at risk of fall, injury and hospitalization. Findings included:Review of Resident #1's face sheet dated 05/19/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills. It is the most common form of dementia, primarily affecting adults aged 65 and older), Generalized Anxiety (involves persistent, excessive, and uncontrollable worry about everyday issues like health, money, or work. It is characterized by feeling constantly on edge on more days than not for at least six months), Type 2 Diabetes Mellitus without complication (indicates the presence of high blood glucose without systemic organ damage, difficulty walking, and other abnormalities of gait and mobility. Review of Resident #1's care plan initiated 06/11/2025 reflected Resident #1 had an ADL self-careperformance deficit r/t Alzheimer's, has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's, risk for falls r/t muscle weakness & poor safety awareness. Initiated on 05/03/2026, Resident #1 had cellulitis and bruising to left hand. Resident #1's care plan did not address skin tears and interventions. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 99 indicating Resident #1 was unable to complete the interview and staff assessment of mental status was conducted. It was also reflected Resident #1 had both long and short-term memory problems. Section GG-Functional Abilities reflected Resident #1's mobility device was a wheelchair. Section GG also reflected, Resident #1, Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed and Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) were coded as 2 indicating Resident #1 required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. During an observation on 05/19/2026 at 10:53 am, Resident #1 was sitting in her wheelchair in the living area, no geri sleeves on, visible bruising and skin tear at left lateral lower extremity, no dressing present. Resident #1 was taken to her room by CNA B for skin assessment. It was observed while RN A and CNA B were transferring Resident #1 from the wheelchair to the bed, both staff held unto Resident #1's pants, using Resident #1's pants to transfer her from the wheelchair to the bed without the use of a gait belt. During an interview on 05/19/2026 at about 11:03 am, RN A stated Resident #1 used to ambulate, but she no longer ambulated but moved around in her wheelchair by moving her feet. RN A stated he was hoping Resident #1 would stand during the transfer from her wheelchair to her bed, he and CNA B were just giving Resident #1 a boost by grabbing her by the pants to stand. RN A stated that even if a gait belt was used, they would still use the resident's pants to stand them up. RN A later stated a gait belt probably would have helped. RN A stated using a resident's pants for transfer was a dignity issue. During an interview on 05/19/2026 at 11:13 am, CNA B stated she worked with Resident #1 on 05/15/2026 and there were no skin tears. CNA B stated they were supposed to use a gait belt while transferring Resident #1 from the wheelchair to the bed to prevent falls and injury. CNA B stated they were not supposed to transfer Resident #1 using her pants. During an interview on 05/19/2026 at 1:47 pm, the ADON stated Resident #1 relied on staff to provide care, move her feet while in the wheelchair but relied on staff to take her from one location to the other. The ADON stated staff shouldn't be grabbing residents by the clothes to aid in transfers, it could cause pain or skin tears. During another interview with the DON on 05/19/2026 at 3:12 pm, the DON stated she had not yet seen Resident #1's skin tears to BLE but the Wound Care Nurse told her she had done the wound care. The DON stated Resident #1 needed a gait belt for transfers, she would not lift Resident #1 by the pants. The DON stated, if the staff were transferring Resident #1, they needed a gait belt to help support the staff, using Resident #1's pants to transfer Resident #1 would cause injury, ruin her clothes and cause discomfort like a wedgie.Review of facility's policy titled Safe Handling/Transfer revised 12/01/2025 reflected: Policy:It is the policy of this facility to ensure that residents are handled and transferred safely to prevent orminimize risks for injury and provide and promote a safe, secure and comfortable experience for theresident while keeping the employees safe in accordance with current standards and guidelines.Policy Explanation:All residents require safe handling when transferred to prevent or minimize the risk for injury tothemselves and the employees that assist them.Compliance GuidelinesHandling aids may include gait belts, transfer boards, and other devicesStaff members are expected to maintain compliance with safe handling/transfer practices. Failure tomaintain compliance may lead to disciplinary action up to and including termination of employment. Resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on observation, interviews, record reviews and the comprehensive assessment of a resident, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for one (Resident #1) of four residents review for quality of care in that: The facility failed to ensure Resident #1 was wearing her Geri-sleeves as ordered to reduce the risk of injury. The facility failed to intervene appropriately when Resident #1 had a skin tear on her left lateral calf on 05/11/2026 which led to Resident #1 having another skin tear on her right posterior lower leg. The facility failed to ensure Resident #1's wound care was done as ordered when the dressing came off. These deficient practices placed Residents at risk for infection, injury and decreased quality of care. Findings included:Review of Resident #1's face sheet dated 05/19/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills. It is the most common form of dementia, primarily affecting adults aged 65 and older), Generalized Anxiety (involves persistent, excessive, and uncontrollable worry about everyday issues like health, money, or work. It is characterized by feeling constantly on edge on more days than not for at least six months), Type 2 Diabetes Mellitus without complication (indicates the presence of high blood glucose without systemic organ damage, difficulty walking, and other abnormalities of gait and mobility. Review of Resident #1's care plan initiated 06/11/2025 reflected Resident #1 had an ADL self-careperformance deficit r/t Alzheimer's, has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's, risk for falls r/t muscle weakness & poor safety awareness. Initiated on 05/03/2026, Resident #1 had cellulitis and bruising to left hand. Resident #1's care plan did not address skin tears and interventions. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 99 indicating Resident #1 was unable to complete the interview and staff assessment of mental status was conducted. It was also reflected Resident #1 had both long and short-term memory problems. Section GG-Functional Abilities reflected Resident #1's mobility device was a wheelchair. Section GG also reflected, Resident #1, Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed and Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) were coded as 2 indicating Resident #1 required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Review of Resident #1's wound assessment dated [DATE] reflected Resident #1 had non-pressure bruise on her left arm, non-pressure bruise on right arm and non-pressure-skin tear/abrasion/scratch on her right calf measuring 6.5 cm x 2.0 cm. Review of Resident #1's incident report dated 05/11/2026 at 8:00 pm written by LVN D reflected: This nurse observed a paper tower with dried blood in resident's trash. Inquired from CNA if she was aware of any injuries on resident and cna stated that she had noticed a skin tear on resident's Lt lateral leg while giving her a shower. Head to toe assessment done, Skin tear noted on Lt lateral leg. skin tear measures 3.8cm x 3cm with Skin flap still present. Area cleansed with wound cleanser, skin well approximated. Some bleeding noted at this time, border dressing applied. Incident report also reflected on 05/14/2026 the facility documented, Resident resides in facility's memory care unit LTC with diagnosis of Alzheimer's disease. Residents depend on staff to provide ADL care.Event - resident noted with skin tear to left shin.RCA - resident transferred by CNAs without removal of footrests causing her shin to bump against footrestIntervention - nurse educated staff on removing footrests prior to transfersANE ruled out based on RCA / event. Review of Resident #1's incident report dated 05/14/2026 at 08:30 am written by LVN C reflected: CNA was pushing resident in the w/c from dining area to living area and noted a skin tear to posterior right lower leg. complete assessment done. area cleansed, pat dry, non-adherent pad applied and wrapped with kerlex (a brand of medical gauze primarily used for bandaging, packing, and protecting wounds), resident tolerated well. NP at facility and notified. Rp notified. care ongoing. Resident Unable to give Description. Incident report also reflected on 05/19/2026 the facility documented, Resident resides in facility's memory care unit LTC with diagnosis of Alzheimer's disease. Residents depend on staff to provide ADL care.Event - resident noted with skin tear to left shin.RCA - resident transferred by CNAs without removal of footrests causing her shin to bump against footrestIntervention - nurse educated staff on removing footrests prior to transfersANE ruled out based on RCA / event. Review of Resident #1's physician orders reflected the following:Preventative Treatment - Geri Sleeves every shift Moisturize skin, then apply geri-sleeves to bilateral upper extremities to prevent skin breakdown. May take off occasionally for bathing and ADLs with start date of 06/03/2025 (Geri sleeves- specialized, non-compression tubular protectors designed to safeguard fragile, thin skin. They are commonly used by seniors, post-surgery patients, and those in wheelchairs to prevent skin tears, bruising, and abrasions caused by friction or minor impacts.) WOUND TREATMENT: Bruise to left arm, monitor for any changes and report to MD/NP. every day shift with start date of 05/07/2026 WOUND TREATMENT: Bruise to right arm, monitor for any changes and report to NP/MD. every day shift with start date of 05/07/2026WOUND TREATMENT: Skin tear to right shin. Clean with NS/WC, pat dry and apply xeroform and cover with dry dressing. every day shift every Mon, Wed, Fri for wound care with order date of 05/13/2026 and start date 05/15/2026WOUND TREATMENT: Skin tear to right posterior lower extremity. Clean with NS/WC, dap dry and apply xeroform and cover with dry dressing. every day shift every Mon, Wed, Fri for wound tx with order date of 05/14/2026 and start date of 05/15/2026 During an observation on 05/19/2026 at 10:53 am, Resident #1 was sitting in her wheelchair in the living area, no geri sleeves on, visible bruising and skin tear at left lateral lower extremity, no dressing present. Resident #1 was taken to her room by CNA B for skin assessment. While in Resident #1's room, it was observed that the skin tears at left lateral lower leg and right posterior lower leg skin tears were in line with the pointed metal piece on Resident #1's wheelchair from which Resident #1's footrest can be attached, footrest was not present while Resident #1 was in the wheelchair. Observation of Resident #1's skin revealed a partially opened skin tear to left lower extremity with serous (Clear, watery plasma. It is thin, slightly yellow, and normal during the initial inflammatory healing stage) drainage coming out, redness around skin tear on left lower extremity. Skin observation also revealed an open skin tear at right lower extremity, wetness within the wound, redness around the wound, 3 little skin tears with scab above major skin tear. Bruises noted on Resident #1's both arm. During an interview on 05/19/2026 at about 11:03 am, RN A stated Resident #1 used to ambulate, but she no longer ambulated but moved around in her wheelchair by moving her feet. RN A stated the bruises and skin tears on Resident #1 could be from her bumping herself into the wall or from her wheelchair. RN A stated the skin tears on Resident #1's lower extremities looked like they were from her wheelchair. RN A stated Resident #1 could have scratched her legs on the metal on her wheelchair. RN A stated the staff do not put the footrests on Resident #1's wheelchair. RN A stated the Wound Care Nurse handle wounds and dressing changes; he did not do wound care because he had lot going on as a nurse. RN A stated there were wound care orders and maybe the orders were stopped and he did not recall Resident #1 having wound dressing on her wounds. During an interview on 05/19/2026 at 11:13 am, CNA B stated she worked with Resident #1 on 05/15/2026 and there were no skin tears. CNA B stated Resident #1 would sometimes get agitated, try to get up from the wheelchair, turn in her wheelchair and the metal part of her wheelchair hurt her. CNA B stated sometimes Resident #1 would hit something and get bruised. CNA B stated Resident #1 was no longer able to get up from her wheelchair. During an interview on 05/19/2026 at 12:12 pm the Wound Care Nurse stated she worked from Monday through Friday from 8am to 5:00 pm. The Wound Care Nurse stated Resident #1 had some unknown bruises on her hands and skin tears on both legs. The Wound Care Nurse stated she did not know how Resident #1 got the skin tears but Resident #1 was supposed to have treatment done on her skin tears on her legs and the skin tears should be covered. The Wound Care Nurse stated Resident #1 was on the memory care unit and tends to remove wound dressings. The Wound Care Nurse stated she was not made aware by nursing staff that Resident #1's wound dressing was off. The Wound Care Nurse stated the charge nurse for the hall was supposed to perform wound care /treatment on Resident #1's wound when the previous dressing came off, the charges nurses were not supposed to wait for the Wound Care Nurse. The Wound Care Nurse stated Resident #1's wounds could get infected if left opened. During an interview on 05/19/2026 at 12:36 pm, the DON stated she was aware of Resident #1's skin tears but she had not seen the skin tears. The DON stated Resident #1 was prone to removing the bandage from her wound. The DON stated, if a resident removed their wound dressing, she expected the CNAs to notify the charge nurse so the charge nurse can re-dress the wound. The DON stated she expected the charge nurses to know if a resident's wound needed to be covered, the charge nurses do not have to wait for the Wound Care Nurse to come before wound care was done. The DON stated the Wound Care Nurse does staging of wounds, measurements and documentations and the charge nurses were expected to perform wound care in the absence of the Wound Care Nurse. The DON stated any wound that was left open, not covered or wrapped was at risk for infection. The DON stated Resident #1 got her wound from hitting her legs on the footrest and hit her foot on the footrest when trying to get up. The DON stated the facility would see if Resident #1's footrest was easy to remove when she was being transferred. The DON stated the facility would have the maintenance staff take a look at Resident #1's wheelchair footrest. The DON stated she would have to follow up with the Administrator on the intervention for the skin tear because he was the one that first assessed the situation. During a phone interview on 05/19/2026 at 1:03 pm, LVN C stated on 05/14/2026, right after breakfast, while Resident #1 was being pushed in her wheelchair from the dining area to the living area, she noticed a skin tear to Resident #1's right posterior lower leg and wound dressing on left lateral lower leg. LVN C stated she cleaned the skin tear at Resident #1's right posterior leg and applied non-adhesive pad due to the skin tear not being approximate (even edges). LVN C stated she notified the NP who was already in the facility making rounds and also the DON. LVN C stated she did not see how Resident #1 got the skin tears on her legs but there was a possibility that it came from Resident #1's wheelchair footrest. LVN C stated Resident #1's wound was supposed to be covered to prevent infection. LVN C stated if the Wound Care Nurse was not around, the charge nurse would initiate the wound orders, and the Wound Care Nurse could change the order at any time. LVN C stated she had seen Resident #1 pulling on her wound dressing but if a resident removed their wound dressing, the charges nurses were supposed to replace the dressing. LVN C stated she worked with Resident #1 on 05/17/2026 and there was dressing on Resident #1's wound. LVN C stated Resident #1 was supposed to wear Geri-sleeves to prevent bruises and skin tears on her hands. During an interview on 05/19/2026 at 1:23 pm, the Administrator stated Resident #1 was noted with bruises on her hands on 05/03/2026, head to toe assessment was completed and abuse and neglect were ruled out. The Administrator stated he was made aware of Resident #1's skin tears on 05/11/2026 and 05/14/2026. The Administrator stated for the incident on 05/11/2026 regarding Resident #1's skin tear to the left lateral leg, he went and looked at Resident #1's skin tear, the wheelchair, spoke with staff and tied the skin tear to Resident #1's wheelchair footrest because Resident #1 had the tendency to kick her feet off the leg rest. The Administrator stated Resident #1's legs were in line with Resident #1's leg rests. The Administrator stated they had the Wound Care Nurse evaluating Resident #1's skin tear and putting in orders for wound care. The Administrator stated the facility was monitoring Resident #1's wound and staff were educated on transfer policy. The Administrator stated he was not sure if they did a skill validation or the policy but staff were educated on removal of Resident #1's leg rest before transfers. The Administrator stated the facility was keeping Resident #1's leg rest on while about and remove for transfers. The Administrator stated they couldn't remove Resident #1's leg rest completely and they discussed modifying the leg rest areas with pads but ultimately, they did not pad it. The Administrator stated, 3 days later, Resident #1 got another skin tear, incident report was completed. The Administrator stated that the ADON and the Wound Care Nurse would know more about interventions that were put in place to prevent further skin tears, whether effective or reevaluated, and he knew that both skin tears were from the same cause and 3 days apart. The Administrator stated the intervention was to take off the leg rests before transfers and the team came up with that based on what Resident #1 was doing with her legs. The Administrator stated Resident #1 could have hit her legs against the wheelchair regardless of being transferred or not and he would have to speak with therapy. The Administrator stated he expected staff to follow wound care orders and dressings were ordered for wounds to prevent infection. The Administrator stated the charge nurses were responsible for ensuring wound dressings stay in place. The Administrator stated Resident #1 was on the memory care unit and it was hard because the residents ripped off their wound dressings. The Administrator stated if a resident was ripping off their wound dressings, he expected it to be documented. During an interview on 05/19/2026 at 1:47 pm, the ADON stated Resident #1 relied on staff to provide care, move her feet while in the wheelchair but relied on staff to take her from one location to the other. The ADON stated she was made of Resident #1's skin tear on 5/11/2026 and it was due to transfer from the wheelchair. The ADON stated staff were educated to remove Resident #1's footrest before she was transferred. The ADON stated 3 days later, Resident #1 had another skin tear on 05/14/2026 from the footrest again and Staff were again educated on removing the footrest before transfer. The ADON stated she was aware of the metal on Resident #1's wheelchair that was pointed once the footrest was removed and she guessed the problem of preventing skin tears from the wheelchair was not solved. The ADON stated the facility probably needed another wheelchair for Resident #1 or wrap the metal with tape or something because Resident #1 had fragile skin. The ADON stated wound care was another intervention in place for Resident #1. The ADON stated the expectation was for the skin tears to be clean and covered with dressing as ordered and when the dressing falls off, for the nurses to replace it. The ADON stated Resident #1's wound would potentially get infected if it was left open. The ADON stated the assigned nurse for Resident #1 should have replaced Resident #1's wound dressing. The ADON stated if there was an order for Resident #1 to wear Geri sleeves, Resident #1 should be wearing Geri sleeves due to fragile skin to prevent bruising and skin tears. The ADON stated the CNAs were responsible to put Resident #1's Geri sleeves on. On 05/19/2026 at 2:07 pm, attempts made to call LVN D, no response, left a voice message and there was no call back. During a phone interview on 05/19/2026 at 2:45 pm, the NP stated he was made aware of Resident #1's 2 skin tears to her legs, he saw Resident #1 skin tears sometime last week. The NP said the skin tears were superficial when he saw Resident #1 and the staff were applying dressings to the skin tears. The NP stated Resident #1 did not need antibiotic or procedure such as sutures or staples. The NP stated staff were supposed to continue to apply daily dressing changes until the wound was healed. The NP stated, if there was no scab over Resident #1's wound, there was risks for infection when left uncovered. The NP stated that the facility staff did not know how Resident #1 got the skin tears. The NP stated that the facility staff were supposed to assess and put interventions in place based on what they thought had happened to prevent further skin tears. The NP stated Resident #1 was not at risk for serious injury or hospitalization unless her wounds were infected. During another interview with the DON on 05/19/2026 at 3:12 pm, the DON stated she had not yet seen Resident #1's skin tears to BLE but the Wound Care Nurse told her she had done the wound care. The DON looked at a picture of Resident #1's skin tear on her right posterior leg and stated she had seen wounds like that left open to air. The DON described the wound on Resident #1's right posterior leg by saying the wound was red inside and around with bruising and the wound had wet tissues. The DON then looked at a picture of Resident #1's left lateral leg and described it as angry skin, opened wound with surrounding red tissues. The DON stated Resident #1's wounds needed to be covered but Resident #1 took off the dressing all the time. The DON stated there should be documentation if Resident #1 was removing her wound dressings. The DON stated that the wound needed to be covered to prevent infection. The DON stated Resident #1's skin tears were caused by her wheelchair, and the interventions were removing the footrest when transferring Resident #1. The DON stated the first skin tear on 05/11/2026 was from Resident #1 dropping her foot and hitting the footrest. The DON also stated she did not go to assess Resident #1 to know how the second skin tear happened, but she spoke with the Wound Care Nurse who stated it was from the footrest, and it was discussed to ensure the footrest was removed during transfers. The DON stated if Resident #1 had an order for Geri sleeves, Resident #1 should be wearing Geri sleeves. On 05/19/2026 at 3:35 pm, the DON stated the facility had a PIP on Pressure Ulcers, but she was not done with it yet. The DON stated she would complete the PIP, but it was never provided to the Surveyors upon request. Review of facility's policy titled Wound Treatment Management dated 11/01/2025 reflected: Policy:To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Policy Explanation and Compliance Guidelines:Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.Dressing changes may be provided outside the frequency parameters in certain situations:Feces has seeped underneath the dressing.The dressing has dislodged.The dressing is soiled otherwise, or is wet.

Based on observation, interview, and record review, the facility failed to ensure each resident's bedside, toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 8 residents (Resident #16, Resident #22, and Resident #81 ) reviewed for resident call system .The facility failed to provide a working communication system, which was easily at reach, which would allow Resident #16, Resident #22, and Resident #81 the ability to safely call for staff for assistance.This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.Findings included:Record review of Resident #16's Face Sheet dated 03.09.26, reflected a [AGE] year-old female admitted [DATE]. Resident #16 had diagnoses which included Chronic Respiratory Failure with hypoxia (do not have enough oxygen in the blood), Type 2 Diabetes Mellitus with Hyperglycemia (elevated blood sugar levels), Hypertensive Heart Disease with Heart failure (high blood pressure cause of heart failure), lack of coordination, and muscle weakness. Record review of Resident #16's Quarterly MDS, dated [DATE], reflected Resident #16 had a BIMS Score of 0, which indicated severe cognitive impairment problems with thinking and memory. The MDS further reflected Resident #16 needed the assistance of two or more helpers for his activities of daily living, bed mobility, and transfers, and she used a wheelchair for mobility.Record record review of Resident #16's Care Plan, dated 12/15/25, Be sure Resident #16's call light was within reach and encourage the resident to use it for assistance as needed. Resident #16 needed prompt response to all requests for assistance.Record review of Resident #22's Face Sheet, dated 03/09/26, revealed an [AGE] year-old malewas admitted [DATE]. Resident #22's diagnoses included senile degeneration of brain (progressive deterioration of brain tissue and function that occurs beyond normal aging, affecting memory, cognition, and behavior), vascular dementia(a type of cognitive decline caused by damage to the blood vessels in the brain), adjustment disorder (excessive emotional or behavioral responses to identifiable stressors) with anxiety ( feelings of fear or apprehension about what's to come and persistent and excessive worry).Record review of Resident #22's Quarterly MDS, dated [DATE], reflected Resident #22 had a BIMS Score of 02, which indicated severe cognitive impairment problems with thinking and memory. The MDS further reflected Resident #22 was dependent on staff for his activities of daily living, bed mobility, and transfers, and assistance of two or more helpers is required for the resident to complete the activity.Record review of Resident #22's Care Plan, dated 01/22/26, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.The resident needs prompt response to all requests for assistance. Record review of Resident #81's Face Sheet, dated 03/09/26, revealed a [AGE] year-old female who was admitted [DATE]. Resident #81's diagnoses included acute respiratory failure with hypoxia (do not have enough oxygen in the blood, gastrostomy status (surgically placed gastrostomy tube for direct access to the stomach for nutrition, hydration, or medication), furuncle of buttock (a painful, pus-filled bump caused by a bacterial infection of hair follicle).Record review of Resident #81's Quarterly MDS, dated [DATE], reflected Resident #81 had a BIMS Score of 0, which indicated severe cognitive impairment. The MDS further reflected Resident #81 was dependent on staff for all her activities of daily living, bed mobility, and transfers, and he used a wheelchair for mobility.Record review of Resident #81's Care Plan, dated 02/22/26, Be sure Resident #81's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.During an interview and observation of Resident #81'ss on 03/09/26 at 10:12 a.m., revealed that she could not verbally communicate her needs and her call light was not within reach of the resident. Observation revealed the call light was located to the left of Resident #81 and hanging off the bed. During an observation on 03/10/26 at 11:44 a.m., Resident #16's call light was wound around the upper right bedframe and it was not located within reach by resident. During an interview and observation on 03/09/26 at 11:03 a.m., it was revealed that Resident # 22 did not know his call light was twisted around the bed frame. During an observation on 3/09/26 at 11:03 a.m., the call light was not within reach of the resident. During an observation on 03/10/26 at 12:36 p.m., Resident #22's call light was observed tied to the upper bed frame and it was hanging off the left side of the bed, not within reach of Resident # 22. During an observation on 03/11/2026 9:22 a.m., Resident #22's call light was located to the left of resident hanging off the bed and not within reach of resident.During an observation of Resident #81's call light, 03/09/2026 10:38 a.m., revealed that her call light was tied to the right side of the bed frame and it was hanging 15 inches off the bed, and it was not within reach of resident.During an interview with CNA B on 03/11/2026 10:09 a.m., she stated she was trained on resident rights. She said the policy was the call light had to be always within the resident's reach. She said the call light should be within reach any time the resident was in bed or in their room. She said if the call light was not in the resident's reach the resident would not be able to get the help they need. She said that the CNAs were responsible for ensuring the call light was within reach. She said when the CNAs did their rounds, they were supposed to check the call light and make sure it was in the resident's reach. She said she did not know why the residents' call lights were not in reach.During an interview with LVN A on 03/11/2026 9:41 a.m., it was revealed that she had been trained on resident rights. She said that the call light was supposed to be where the resident could reach it. She also said that there are alternative types of call lights that can be used for residents with limited mobility or limited range of motion. She said all staff were responsible for ensuring the call light was within reach. She said if the call light was not within the resident's reach that the resident could fall or get hurt. She also said that the nurses and CNAs were responsible for ensuring the call lights were within the resident's reach. She said the CNAs and nurses monitor the call lights by doing rounds and will put the call light in the resident's reach if it was not in their reach. She said that she was not aware of any call lights that were not within residents' reach. She stated interventions can be used by leaving a resident's door open. During an interview with the RT on 03/11/2026 1:36 p.m., it was revealed that he had been trained on resident rights. He stated the policy was that each resident should have call light within reach and call light should remain within reach of the resident. He stated, care givers are all responsible for making sure the call light is within the residents' reach. He stated, Resident # 81 would not be able to request assistance if the call light is not within reach. He said call lights were monitored by doing rounds. He said he was not sure why the call light was not in reach of Resident # 81. He said he may have taken the call light off Resident # 16's bed prior to caring for her and he might not have repositioned it when he was done. During an interview with ADON on 03/11/26 at 2:15 p.m., it was revealed that she had been trained in resident rights. She said that the call light was supposed to be within the resident's reach. She also said that if anyone saw the call light not in reach the staff member was responsible for putting it within the residents' reach. He said if the call light were not within the resident's reach that the resident could not let staff know what they needed or communicate with the staff. She also said that all staff were responsible for ensuring the call lights were within the residents' reach. She said call lights were monitored by doing rounds. She said she did not know why the call light was not in reach of three residents.During an interview with the ADM on 03/11/2026 at 4:12 p.m., revealed that he and staff had been trained on resident rights. He said that the call light was supposed to be within the resident's reach. He also said that primarily the care giver was responsible for putting the call light within the resident's reach. He said if the call light were not within the resident's reach that the resident could not call for help when they needed it. He also said that care givers and management were responsible for ensuring the call lights were within the resident's reach. He said call lights were monitored by doing rounds. He said he did not know why the call light was not in reach. He stated, we can try to provide a touch pad for Resident # 16.Record Review of the facility policy titled, Call Lights: Accessibility and Timely Response, ,dated 10/01/25 and policy review date 12/01/25, revealed, Policy Explanation and Compliance GuidelinesEach resident will be evaluated for unique needs and preferences to determine any special accommodation that may be needed in order for the resident to utilize the call system.Special accommodations will be identified on the resident's person - centered plan of care and provided accordingly.The call light system will be accessible to the residents at each toilet and bath or shower facility. The call system will be accessible to residents while in their bed or other sleeping accommodations.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 10 residents (Resident# 43, Resident #80, and Resident #114) reviewed for ADL care. The facility failed to ensure Resident# 43, Resident #80, and Resident #114 was groomed and did not have unwanted facial hair. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.Findings included: 1. Record review of Resident #43's face sheet, dated 03/10/2026, reflected a [AGE] year-old female. s admitted [DATE]. Resident #43's diagnoses included dementia (memory, thinking, difficulty), type 2 diabetes mellitus with unspecified complications (high blood sugar), hyperlipidemia (high cholesterol), muscle weakness, lack of coordination and depression. Record review of Resident #43's Quarterly MDS Assessment, dated 01/14/2026, reflected Resident #43 had a BIMS score of 0 indicating severe cognitive impairment. Resident #43 required- supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently). Record review of Resident #43's Comprehensive Care Plan, dated 01/22/2026, reflected Resident #43 had an ADL self-care performance deficit related to dementia with interventions including observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. During an observation of Resident #43 on 03/09/2026 at 10:32 a.m., Resident #43 was walking down the hall. She had facial hair on her chin. During an interview with Resident #43 on 03/09/2026 at 10:34 a.m. she said she was fine and walked off. She did not answer any questions about the facial hair; she just kept walking. During an observation of Resident #43 on 03/10/2026 at 10:57 a.m., she had facial hair on her chin. During an interview on 03/10/2026 at 4:28 p.m., Resident #43's RP said Resident #43 would shave every day. She said Resident #43 would be embarrassed if she was cognitive enough to know she had hair on her chin. 2. Record review of Resident #80's face sheet, dated 03/10/2026, reflected an [AGE] year-old female. admitted [DATE]. Resident #80's diagnoses included dementia (memory, thinking, difficulty), major depressive disorder (mental health disorder characterized by persistent depressed mood), anxiety (feeling of uneasiness or worry), muscle weakness, anemia (not enough healthy red blood cells), and weakness. Record review of Resident #80's Quarterly MDS Assessment, dated 02/04/2026, reflected Resident #80 had a BIMS score of 2 indicating severe cognitive impairment. The MDS also revealed Resident #80 had substantial/maximal assistance indicating the helper does more than half the effort and lifts or holds trunk or limbs for personal hygiene. Record review of Resident #80's Comprehensive Care Plan, dated 09/16/2025, reflected the resident had an ADL self-care performance deficit related to dementia. Care planned interventions for PERSONAL HYGIENE/ORAL CARE indicated Resident #80 was able to set up and required prn assistance. During an observation on 03/09/2026 at 10:55 a.m., Resident #80 was lying in her bed. Resident #80 had hair on her chin. During an interview on 03/09/2026 at 10:56 a.m., Resident #80 said she was fine. When asked about the hair on her chin she said her kids were good. She could not answer the questions about the hair on her chin. During an observation on 03/10/2026 at 4:01 p.m., Resident #80 was sitting in the dining room. Resident #80 had facial hair on her chin. 3. Record review of Resident #114's face sheet, dated 03/10/2026, reflected a [AGE] year-old female, admitted [DATE]. Resident #114's diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental function), dementia (memory, thinking, difficulty), muscle weakness, lack of coordination and abnormalities of gait and mobility. Record review of Resident #114's Quarterly MDS Assessment, dated 02/04/2026, reflected Resident #114 had a BIMS score of 6 indicating severe cognitive impairment. The MDS also revealed Resident #114 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity and helper assists only prior to or following the activity) with personal care. Record review of Resident #114's Comprehensive Care Plan, dated 09/16/2025, reflected Resident #114 has an ADL self-care performance deficit related to decreased mobility. Interventions were Resident #114 required set up assistance, by one staff with personal hygiene and oral care. During an observation on 03/10/2026 at 4:07 p.m., Resident #114 was walking in the hall. She was looking for a nurse to help her. She had facial hair on her chin. During an interview with Resident #114 on 03/11/2026 at 4:16 p.m., she said she wanted to have her facial hair shaved or have the facial hair pulled. She said the facial hair drives her crazy. She said staff never offered her assistance with removal of the facial hair. She said she wished she had something to pull the facial hair. She said if she had something to pull the facial hair, she could pull it herself. She said she did not like having hair on her face. She said she did not want to look like a man. During an interview with LVN D on 03/11/2026 at 11:29 a.m., said she was trained on ADL care. She said staff were to follow the policy, so the residents received the care they needed. She said the ADL care was tailored to the resident. She said the ADL care should be done every day. She said the CNAs were responsible for ensuring residents were shaven and groomed. She said if a female resident had facial hair the resident may feel embarrassed or feel like they were not well groomed. She said the charge nurse was responsible for ensuring the CNAs groomed and shaved the residents who wanted to be shaven. She said the nurse monitored by doing observations. She said she did not know why Resident #43 and Resident #80 had facial hair. She said Resident #114's facial hair blended in with the resident's skin tone. During an interview with CNA F on 03/11/2026 at 11:43 a.m., she said she was trained on providing ADL care. She said the policy for providing ADL care to residents was to keep the residents clean and well groomed. She said the staff member who was caring for the resident was responsible for ensuring the resident was shaved and well groomed. She said if a female resident was not shaved the resident may feel bad and it would affect the resident's dignity. She said the nurse monitored to ensure the CNAs cleaned and groomed the residents. She said the nurse monitored by observations and checking the shower sheets the CNAs filled out. She said she did not know why Resident #43, Resident #80 and Resident #114 had facial hair that was not removed. During an interview with the MCD on 03/11/2026 at 11:53 a.m., she said she did not do resident care anymore. She said she did not know what the policy was for ADL care. She said she expected staff to keep the residents clean and well groomed. She said the CNAs were responsible for ensuring the residents were shaven and groomed. She said staff wanted the residents to appear nice because it showed respect towards the residents. The MCD said if a female resident had facial hair the resident may feel upset. She said the residents in the memory care were not aware of how they looked. She said there were a few male residents who wanted to be shaven and feel well-groomed and the CNAs stepped in to help those residents. She said the nurses and the MCD was responsible for monitoring to ensure the residents were well groomed. She said the nurses and the MCD monitored through charting on a resident and the shower sheets that were filled out when the resident was given a shower. She said she did not know Resident #43, Resident #80 and Resident #114 had facial hair. Record review of the facility's Activities of Daily Living (ADL) Policy, dated 12/01/2025, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.1. Bathing, dressing, grooming and oral care.2. Transfer and ambulation.3. Toileting.4. Eating to include meals and snacks; and5. Using speech, language, or other functional communication systems.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to establish a system of accurate reconciliation, determine that drug records were in order, an account of all controlled drugs was maintained and periodically reconciled for 1 of 4 medication carts (Medication Cart #1-700 Hall) in the facility effecting 1 of 20 residents (Resident #105) reviewed for pharmacy services and failed to provide pharmaceutical services including procedures that assure the accurate acquiring of all drugs and biologicals by monitoring for expiration dates in 1 of 2 medication rooms reviewed for pharmacy storage. The facility failed to ensure LVN D and the LVN E accurately reconciled Resident #105's narcotic medication log when LVN D administered but did not sign for Resident #105's Hydrocodone-Acetaminophen 5-325 MG 1 tablet on 03/10/2026 at a.m. (unknow exact time of administration) and at 2:00 p.m. during shift change the LVN E did not reconciled the correct medication count of Resident #105's Hydrocodone-Acetaminophen 5-325 MG. 2. The facility failed to ensure the removal of expired medications from the medication room [ROOM NUMBER]'s refrigerator: Heparin Sodium injections 5000/ML expired on 03/09/2026 and Bisacodyl 10mg expired 4/2025. These failures could place residents at risk of not receiving their prescribed and emergency medications, risk of drug diversion and at risk of receiving expired medications which could result in delayed healing. Findings included: 1.During an observation of Medication Cart #1's reconciliation with LVN E on 03/10/2026 at 3:57 p.m., LVN E opened med cart #1. The reconciliation of controlled medications on med cart #1 revealed the blister pack with Hydrocodone-Acetaminophen tablets 5-325 MG for Resident #105 contained 34 tablets with count of 35 tablets on the controlled medication log. During an interview on 03/10/2026 at 3:59 p.m., LVN E stated she did not administer Hydrocodone-Acetaminophen 5-325 MG to Resident #105, but LVN D, who was working on this cart 6:00 a.m. - 2:00 p.m. shift, administered it to Resident #105 this morning. LVN E stated that not documenting the narcotic medication when administered could cause a discrepancy since someone would not know residents had already received narcotic medication. LVN E stated she missed this discrepancy during the shift change count as tablets were not pushed in order on the blister pack. During an interview on 03/10/2026 at 4:02 p.m., LVN D stated he administered Hydrocodone-Acetaminophen 5-325 MG one tablet PRN dose today around noon to Resident #105 but forgot to sign the controlled log as a lot was going on at that time. He stated he counted controlled medications at the end of his shift at 2:00 p.m. with LVN E and they both did not notice a discrepancy in the count. During an interview on 03/11/2026 at 3:33 p.m., LVN E stated she changed her previous statement on 03/10/2026 and stated that she knew about the discrepancy during the count with LVN D and before the med cart #1's reconciliation with state surveyor. She stated LVN D forgot to sign during their count as he did not have a pen with him. She stated that the nurse who worked on the cart was responsible for that med cart and she was responsible when she accepted the key for med cart #1. Record review of Resident #105's face sheet, dated 03/10/2026, indicated a [AGE] year-old male, admitted [DATE] with diagnoses which included hemiplegia affecting left nondominant side (a severe or total loss of motor function on one side of the body caused by brain damage), pain, and type 2 Diabetes mellitus (a chronic metabolic disorder where cells resist insulin, causing high blood sugar). Record review of Resident #105's Annual MDS assessment, dated 11/30/2025, indicated a BIMS score of 13 which indicated intact cognition. The MDS assessment indicated Resident #105 received PRN opioid pain medication to treat his pain. Record review of Resident #105's comprehensive care plan, dated 12/15/2025, indicated Resident #105 had pain medications PRN ordered with interventions screen for pain on admission and daily. Assess to determine if experiencing pain. If pain is present, conduct and document pain assessment. Discuss with resident and family/caregivers any adverse effects of unrelieved pain or side effects of pain medications. Record review of Resident #105's order summary report, dated 03/11/2026, indicated an order, starting date on 06/03/2025, for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give one tablet by mouth every six hours as needed for chronic back pain and right hip pain. Record review of Resident #105's MAR for 03/10/2026 indicated Resident #105 received Hydrocodone-Acetaminophen Oral one tablet 5-325 MG on 03/10/26 (unspecified time) a.m. when medication was not documented in the controlled medication administration log. 2.During an observation of Med room [ROOM NUMBER]'s refrigerator for Halls 500, 600, 700 and 800 on 3/10/2026 at 4:15 p.m., eight Heparin Sodium injections vials 5000/ML each (to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels) labeled with sent for regular Ekit replacement expired on 03/09/2026 and two boxes of Bisacodyl with 24 capsules 10 MG each capsule (stimulant laxative suppository) expired 4/2025. During an interview on 03/11/2026 at 3:36 p.m., the ADON stated she had Medication Administration, controlled medication, and medication storage in-services monthly and skilled check-off was completed at the end of February of 2026. She stated all nursing staff in the facility were trained annually and on as needed basis. She stated she provided in-services to nursing staff on these topics monthly and as needed. She stated ADONs were responsible for auditing med rooms on each side and med cart audit. She stated each charge nurse or medication aide was responsible for their medication carts and counting controlled medication at shift change. The ADON stated that signing for controlled medication should be immediate after administration She stated that it could cause medication errors. She stated the facility's-controlled medication administration policy was to count controlled meds with upcoming shift and signing administered medications right away. She stated not signing after administration of medication could cause overdosing and medication error. During an interview on 03/11/2026 at 3:41 p.m., the DON stated she had medication administration, controlled medication, and medication storage in-services in the last 6 months. She stated that all nursing staff in the facility had this training annually and on as needed basis. She stated that ADONs and herself were doing the random med rooms and med cart audits. She stated that each charge nurse or med aide was responsible for their medication carts and counting controlled medication at shift change. The DON stated that signing for controlled medication should be immediate after administration and if not signed, the next nurse or medication aide would not know if residents received the medication. She stated that it could cause medication errors. She stated that expired medications if not removed from med rooms and administered to residents, could have reduced intended therapeutic benefits for residents. During an interview on 03/11/2026 at 4:22 p.m., the ADM stated he was trained in medication administration and storage today on 03/11/2026. He stated he was not sure when controlled medication had to be signed for, but he thought it should be immediately after administration. He stated that DON, ADONs, charge nurses, and medication aides were responsible for counting controlled medications at shift change and monitoring for medication discrepancies especially with controlled medication to prevent drug diversion. He stated the DON and ADONs randomly audited med carts and med rooms for expired medications. He stated if discrepancies were noted, nurses or med aides were responsible to notify the ADON and DON. He stated that if not monitored and properly counted, it would potentially harmful affect residents. He stated that nursing staff received medication administration in-services on 3/11/2026, quarterly, and annually. Record review of facility's Medication Administration policy, dated revised 11/01/2025, indicated that .19. Sign MAR after administering medication. 20. If medication is a controlled substance, sign narcotic book. Record review of facility's Medication Storage policy, dated revised 12/01/2025, indicated that 8. all medication rooms are routinely inspected by consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our destruction of unused drugs policy. Record review of facility's In-Services for last 12 months did not reveal any record of completed nursing staff training on medication storage and labeling. Record review of facility's In-Services for last 12 months reveal the Medication Administration in-service, dated 03/02/2026, completed and signed by seven members of nursing staff including LVN D but not LVN E.

Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 of 23 residents (Resident #2 and Resident #42) reviewed for infection control. The facility failed to ensure LVN C followed proper infection control procedures after completing the wound care for Resident #2, removing biohazardous trash from Resident #2's room and did not sanitize her hands after removing gloves and before touching clean supplies on her treatment cart. The facility failed to ensure LVN D followed proper infection control procedures after completing blood sugar check for Resident #42, exiting Resident #42's room, using the same gloves to open nursing cart, removed the insulin storage box for multiple residents on 700 Hall, and withdrew insulin from vial for Resident #42, and walked back to Resident #42's room to administer his insulin without changing gloves and sanitizing hands. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization.Findings included: 1. During an observation on 03/11/2026 at 9:48 a.m. of wound care for Resident #2, LVN C did not take her gloves off after completing the wound care for Resident #2, removed biohazardous trash (dirty wound care supplies she removed during wound care) from Resident #2's room, and did not sanitize her hands after removing gloves and before touching clean supplies on her treatment cart. During an interview on 03/11/2026 at 10:06 a.m. LVN C stated she received hand hygiene and infection control in-services at the beginning of March 2026, and the training covered the proper infection control steps and when the nursing staff should wash hands/sanitized hands. LVN C stated she was supposed to wash hands before starting residents' care/wound care procedure, between changing gloves, and before exiting the room and touching her treatment court. She stated that she did not wash her hands before exiting Resident #2's room as she forgot to do it. She stated potential risk for residents if not following proper infection control measures could be the spread of infection. During observation and interview of Resident #42 on 3/11/2026 at 10:06 a.m., he did not appear in distress and did not voice any complaints. Record review of Resident #2's face sheet, dated 3/11/2026, revealed a [AGE] year-old female admitted [DATE]. Her diagnoses included Alzheimer's disease (a progressive, irreversible brain disorder that causes dementia, it slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks), Type 2 Diabetes Mellitus (a chronic metabolic disorder where cells resist insulin, causing high blood sugar), and pressure ulcer of right heel, stage 4 (painful damage to skin and underlying tissue caused by prolonged pressure, friction, or shear, often over bony areas like the hips or heels). Record review of Resident #2's Quarterly MDS assessment, dated 01/22/2026, revealed Resident #2's BIMS score of 3 indicating severe cognitive impairment. Record review of Resident #2's Care Plan, dated 1/07/2026, reflected: Resident #2 had a risk of developing pressure ulcer/injuries with current stage 4 pressure ulcers which was present upon admission with a goal of MDRO (germs, primarily bacteria, resistant to many commonly used antibiotics, making infections difficult to treat. They usually spread via direct contact, often in healthcare settings, and are managed through strict infection control, hand hygiene, and antimicrobial stewardship) reduction over next 90 days with implementation of Enhanced Barrier Precautions and monitoring for signs and symptoms of infection and wound care with application of dressing to right foot. Record review of current orders for Resident #2 revealed the wound care order, dated 03/11/2026, right heel pressure injury: clean with Dakins 1/2 strength solution, pat dry. Pack with calcium alginate and cover wound bed, apply honey fiber to slough. Apply no-sting preparation to peri (around) wound, cover with ABD pad (highly absorbent, sterile, multilayered dressings designed for heavily draining wounds, post-surgical incisions, and trauma injuries) and secure with rolled gauze. 2. During an observation of blood sugar check and insulin administration for Resident #42 on 3/11/2026 at 11:59 a.m., revealed LVN D did not take his gloves off after completing blood sugar check for Resident #42, exiting Resident #42's room, used the same gloves to open nursing cart and removed the insulin storage box for multiple residents on 700 Hall and supplies for insulin administration for Resident #42, and walked back to Resident #42's room to administer his insulin without changing gloves and sanitizing hands. During observation and interview of Resident #42 on 3/11/2026 at 11:59 a.m., he did not appear in distress and did not voice any complaints. Record review of Resident #42's face sheet, dated 3/11/2026, revealed a [AGE] year-old male admitted [DATE] and readmitted on [DATE]. His diagnoses included type 2 Diabetes Mellitus (a chronic metabolic disorder where cells resist insulin, causing high blood sugar), legal blindness (a government-defined, non-medical status indicating severe visual impairment that qualifies individuals for benefits and services), chronic kidney disease, stage 4 (severe). Record review of Resident #42's admission MDS assessment, dated 12/16/2026, revealed Resident #42's BIMS score of 15 indicating intact cognition. Record review of Resident #42's Care Plan, dated 12/21/2025, reflected Resident #42 had the diagnosis of type 2 Diabetes Mellitus with interventions in place: Diabetes medication as ordered by doctor. During an interview on 03/11/2026 at 12:05 p.m., LVN D stated he had an in-service on hand hygiene not too long ago. He stated that according to the facility's policy he was supposed to sanitize his hands between each resident's tray during meal tray pass. He stated that not sanitizing his hands properly could lead to potential cross contamination. During an interview on 3/11/2026 at 3:36 p.m., the ADON stated charge nurses should monitor how staff were conducting hand hygiene and following infection control measures, and the ADONs and the DON conducted oversight. The ADON further stated the facility policy on hand hygiene during residents' perineal care (cleaning the genital and anal areas to prevent infection, odors, and skin breakdown, particularly for patients with incontinence or catheters), wound care, and urinary catheter care was to conduct handwashing before nursing staff come out of resident rooms. The ADON stated she was trained on infection control and hand hygiene monthly and the potential negative outcome for the residents when not practicing good hand hygiene was cross-contamination. During an interview on 03/11/26 at 3:41 p.m., the DON stated the DON and ADONs were responsible for ensuring all staff was conducting proper hand hygiene/following infection control measures when providing care including wound care for the residents. She stated she and ADONs conducted periodic audits and provided hand hygiene in-services to staff. She stated the policy on hand hygiene, providing peri-care, wound care, and urinary catheter care was to conduct hand hygiene before going in the room, between dirty and clean area, between changing gloves and before coming out of the room. The DON stated training on infection control and hand hygiene was taught during annual skills training. The DON stated a potential negative outcome for the residents could be cross contamination. During an interview on 3/11/2026 at 4:22 p.m., the ADM stated he had hand hygiene training sometimes today, quarterly, and annually which covered the policy for conducting the proper handwashing/hand hygiene before/after conducting the care for residents including the wound care and passing meal trays. He stated a negative outcome to the residents could be the risk of cross contamination. Record review of Hand Hygiene Policy, dated 12/01/2025, revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a change in residents health status for 1 of 1 resident (Resident #1) reviewed for notification of changes. LVN B failed to immediately notify Resident #1's physician and Resident # 1's RP when CNA A reported to him that resident had skin tears to right hand and right elbow. This failure could place residents at risk of injury, hospitalization, and/or decreased quality of life. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included Parkinsonism (A set of movement symptoms associated with Parkinson's disease (PD) and other disorders, Unspecified Dementia (Condition which involves memory loss, affecting thinking, and social abilities which interfere with their daily lives.), Atherosclerosis (is a hardening of your arteries from plaque building up) and Heart Disease (is a broad term for conditions that affect the structure and function of the heart). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #1's care plan dated 01/31/2026, revealed the resident was at risk for falls related to unsteady gait. Interventions were to include low bed as ordered on 07/02/2025 and assist rails required as enabler to promote as much independence as possible as ordered on 6/22/2025 and the resident's call light is within reach and encourage the resident to use it for assistance as needed as ordered on 05/19/2025. Record review of Resident #1's Wound assessment dated [DATE] at 3:30 PM. Wound Care Treatment Nurse. Assessment of 2 new wounds with onset date of 02/10/2026. Description of wounds as Non-pressure- Skin Tear/ Abrasion/ Scratch. Wound # 1 location is on Right hand (back) length 7.5 CM, width 5 CM. Wound # 2 location is on Right elbow length 6 CM, width 2.5 CM. Notification for change in condition related to wounds was reported to Resident #1, RP and Physician on 02/10/2026 upon completion of the Wound Assessment at 3:30 p.m. Record Review of Resident # 1's Radiology report located in Progress notes dated 02/10/2026 at 7:04 p.m. Bilateral Hand X-ray results were Electronically signed and finding included no evidence of fracture or dislocation, typical soft tissue senescent changes, no aggressive osseous lesions. Conclusion: mild degenerative changes without acute findings. In an interview on 02/12/2026 at 6:46 p.m., CNA A said on 02/10/2026 at about 5:00 a.m. he was walking the hallway on rounds, and he found Resident #1's forearms tangled in the left side assist bars. CNA stated, I lifted his arms out of the assist rails, and I noticed skin tears on both of Resident #1's elbows and bruising on his hands and forearms. CNA A stated Resident # 1 had bruises on his forearms prior to this incident and now the bruises look worse than before. CNA A stated he immediately reported this incident to the Male Charge Nurse who looked at Resident # 1's arms and he cleaned them up. In an observation and interview on 02/12/2026 at 6:49 p.m., Resident #1, could not verbalize answers to the question of how he got bruises and cuts to his arms. Observed resident sitting in his wheelchair using his left hand to point at his spilled coffee cup on the floor. Resident appeared well groomed. In an interview on 02/12/2026 at 7:27 p.m., LVN B said at around 5:30 a.m. CNA A came to the nurse's station, and he told me he noticed bruises on Resident # 1's arms. LVN B stated, {CNA A} just asked me to come and see, he didn't tell me that the resident fell or got tangled. LVN B stated, I looked at Resident #1 and I asked him what happened? Resident # 1 didn't answer. LVN B stated he found just bruises, no cuts and he put moisturizer cream on Resident #1's arms. He stated, I called the NP, and he said to just monitor, he didn't order x-rays because there was no fall. I was off for 2 days and when I came back to work, I noticed that x-rays had been ordered on 02/10/2026. LVN B stated on 02/10/2026 his shift was over at 6:00 a.m. and he left the facility at the end of his shift. LVN B said he returned to the facility approximately 8 hours after he was notified of Resident # 1's incident and on that date at 1:24 p.m. he made a late entry in the progress notes for Resident # 1. Per witness statement on 02/12/2026, LVN B wrote on 02/2026, {CNA A} on the hall called me into resident room, noted discoloration to bilateral arms, resident could not state how it happened. Incident report was completed RP/ NP notified. Signed and dated 02/12/2026. In an interview on 2/13/2026 at 11:56 a.m., TN revealed that the 24-hour report indicated that Resident # 1 needed to be assessed. Per statement on 02/12/2026, CNA A wrote: when I was doing my last walk thru on Tuesday morning 2/10/26 I found Resident # 1 between bed rail and mattress not on floor. I put him back in bed and reported it to nurse. Per record review of progress notes on 02/10/2026 at 1:24 p.m., LVN B noted Resident presented with decolorated area to bilateral arm, resident could not state how it happened. Notified RP/NP. Per Record review of Telehealth Visit dated 02/10/2026 at 11:29 a.m. and Telehealth Facilitator was DON. The date and time of visit with NP was 02/10/2026 9:43 a.m. In an interview on 02/13/2026 at 10:07 a.m., DON said CNA A reported the incident to the Charge Nurse (LVN B). DON stated, his expectation was that staff were to report immediately to the NP of any incidents or changes occurred to a resident. DON stated, LVN B did not enter progress notes in a timely manner and that notes were entered 8 hours after LVN B was notified of the incident. DON stated he had facilitated the call with the NP at 9:43 a.m. and that this was approximately 4 hours after the incident with Resident # 1. In an Interview on 02/13/2026 at 11:29 a.m., UD revealed that around 7:30 - 8:00 a.m. on 02/10/2026 Charge Nurse, (LVN C) asked if I knew anything about the bruises on Resident # 1's hands. UD placed call to CNA A to inquire about the bruises on Resident #1's hands. CNA A explained he found resident hands tangled in the assist bed rail during the early hours of the morning on 02/10/2026 and he had reported it to LVN B. UD stated she went to the dining room, and she observed Resident #1's sitting in the dining room eating breakfast, he was wearing a long sleeve shirt so she couldn't see his forearms or elbows, but his hands were visible, and she saw he had bruising on them. UD said occasionally, Resident # 1 will get a little discoloration but, the hand bruising she saw on 02/10/2026 was unusual for Resident # 1. In an interview on 02/13/2026 at 12:11 p.m., LVN C stated, on 02/10/2026 I arrived for work for my shift 6 a.m. to 6 p.m. I looked in PCC to see if there was a note about {Resident # 1's} bruising from the night shift. There were no notes entered by the night charge nurse. LVN C stated, the bruises were worse than what I usually saw so I reported it immediately to the ADM. In an interview on 02/17/2026 at 3:51 p.m., RD stated it was her expectation that if a Nurse has been notified of an injury or incident or fall, they are to immediately perform an assessment of the resident. RD stated LVN B should have assessed Resident # 1, documented the assessment, notified the NP, family, Administrator and the DON and that was not done. RD stated, LVN B should not have left the assessment to the Treatment Nurse. Policy Incident and Accidents. Dated 10/01/2025 reviewed / revised 12/1/2025 It is the policy of this facility for staff to utilize the risk management - incident report in the electronic health record to report, investigate, and review any accident of incident that occurred allegedly occurred, on facility property and may involve or allegedly involve a resident.Policy Explanation:The purpose of incident reporting can include:assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrence and improve the management of resident care.Conducting roof cause analysis to ascertain causative/ contributing to avoid further occurrences. Alert risk management and/ or administration of occurrences that could result in claims or further reporting requirements.Meeting regulatory requirements for analysis and reporting of incident and accidentCompliance Guidelines4. Any injuries will be assessed by the licensed nurse or practitioner, and the effect individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions.5- the supervisor or other designee will be notified of the incident/ accident. If necessary, law enforcement may be contacted for specific events.6. The Nure will contact the residents' practitioner to inform them of the incident/ accident, report any injury so other findings, and obtain orders if indicated which may include transportation to the hospital dependent upon the nature of the injury.8. The residents' family or representatives will be notified. (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)S483.10(g)(14) Notification of Changes.(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention.

Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #1 & #2) of 16 residents reviewed for quality of care. The facility failed to ensure that the residents were cared for in a kind manner for Residents #1 and Residents #2 by walking away from the residents and not returning. The noncompliance was identified as PNC. The noncompliance began on 09/10/25 and ended on 09/17/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving necessary care. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old woman who admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of cerebral infarction (a condition where blood flow to the brain was interrupted, leading to brain cell damage or death) with additional diagnoses of insomnia (sleep disorder where you have difficulty falling asleep) and unspecified generalized anxiety disorder (when a person experiences significant anxiety symptoms that do not fully meet the criteria for other specific anxiety disorders, such as panic disorder or social anxiety disorder).Review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS score of 15 which indicated Resident #1 was cognitively intact. Resident #1's Quarterly MDS also reflected she was frequently incontinent which means (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Review of Resident #1's care plan, dated 06/11/2025, reflected Resident #1 was care planned for required assistance x1 staff to move between surfaces during toileting needs. This care plan indicated this may fluctuate with weakness, fatigue, or weight bearing status.During an interview with Resident #1 on 09/25/2025 at 4:00PM, Resident #1 stated she felt a staff member had treated her unkindly. Resident #1 stated CNA A entered her room a while back, after Resident #1 pushed her call light for assistance to the bathroom. Resident #1 stated CNA A responded to the call light and stated, why didn't you get up and go to the bathroom? then proceeded to leave Resident #1's bedroom without helping her to the bathroom. Resident #1 stated CNA A came back approximately 30 minutes later and did not speak during the encounter. Resident #1 stated she had not experienced this type of behavior from a staff member again. Resident #1 stated that made her feel bad about asking for help.Review of Resident #2's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction (complete paralysis on one side of the body, Weakness on one side of the body), type II diabetes mellitus with diabetic nephropathy (serious kidney complication caused by prolonged, poorly controlled high blood sugar and high blood pressure, leading to damage in the kidney's filtering blood vessels), and end stage renal disease (condition where the kidneys have deteriorated to the point where they can no longer function effectively). Review of Resident #2's Quarterly MDS, dated [DATE], reflected a BIMS score of 14 which indicated resident was cognitively intact. Resident #2's Quarterly MDS also reflected he required partial/moderate assistance for toileting needs which meant the helper less than half lifts, holds, or supports trunk or limbs, but provides less than half the effort.Review of Resident #2's care plan, dated 08/06/2025, reflected Resident #2 was care planned for an ADL self-care performance deficit r/t generalized weakness, amputation.During an interview with Resident #2 on 09/25/2025 at 4:30PM, Resident #2 stated he felt CNA A treated him unkindly. Resident #2 stated CNA A, during the night shift, had turned around and walked away from him when he needed to be clean him up. Resident #2 stated sometimes he could feel dizzy and would need help with going to the restroom. CNA A stated he reported the incident to the administrator. Resident #2 stated his care improved after the incident. Resident #2 stated it made him feel like he was not getting the care he needed. During an Interview with LVN A on 09/25/2025 at 4:30PM, LVN A stated they had been employed at the facility for 3 months. LVN A stated she had received training on both Resident Rights and Abuse/Neglect/Exploitation. LVN A stated that she had heard gossip about CNA A not treating residents fairly. LVN A confirmed that that CNA A had been placed on suspension during the investigation. During an interview with ADM on 09/25/2025 at 5:15PM, ADM stated they had been employed at the facility for 7 months. ADM stated he had received training on both Resident Rights and Abuse/Neglect/Exploitation. ADM stated the training included the residents have the right to be treated with dignity. ADM stated he had been made aware of the incident regarding Resident #1 and CNA A. He stated that Resident #1 had written a letter stating that CNA A had treated her unkindly during the night shift. Additionally in the written letter, she addresses CNA A by name and stated that the behaviors that CNA A made her feel upset. ADM stated that he had suspended CNA A during the investigation (starting 9/10/2025) and had relocated CNA A to work a different hallway (9/17/2025) and completed in services for the staff members including CNA A (9/17/2025). On 09/25/2025 at 5:30PM, an attempted phone call for CNA A was performed, in which they did not answer the phone. Record Review of an undated policy titled Dignity that was provided by the facility, revealed the following information:1. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 2. When assisting with care, residents are supported in exercising their rights. For example, residents are:a. groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).b. encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities.c. encouraged to dress in clothing that they prefer.d. allowed to choose when to sleep, eat and conduct activities of daily living; ande. provided with a dignified dining experience. The noncompliance was identified as PNC. The noncompliance began on 09/10/25 and ended on 09/17/25. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to ensure the residents were free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for one of six residents (Resident #1) reviewed for abuse.The facility failed to ensure Resident #1 was free from abuse when Resident #2 physically assaulted her on 09/27/25.The noncompliance was identified as PNC. The noncompliance began on 09/27/25 and ended on 09/30/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse.Findings included:Record review of Resident #1's face sheet dated 10/15/25 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes, lack of coordination, muscle weakness, hypertension, heart failure, difficulty in walking, depression, anxiety disorder and chronic pain. Record review of Resident #1's quarterly MDS dated [DATE] revealed her BIMS score was 11 indicating her cognition was moderately impaired. Record review of Resident #1's care plan dated 07/26/25 revealed Resident #1 was at the risk for falls r/t decreased mobility. The relevant intervention was educating the resident/family/caregivers about safety reminders and what to do if a fall occurs. Record review of Resident #2's face sheet dated 10/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included parkinsonism, chronic obstructive pulmonary disease (difficulty in breathing), type 2 diabetes, chronic kidney disease, hypertension, schizoaffective disorder (a mental disorder), anxiety disorder and muscle weakness. Record review of Resident #2's quarterly MDS dated [DATE] revealed her BIMS score was 14 indicating her cognition was intact. She was not coded for any physical, verbal or other behavioral symptoms directed towards others. Record review of Resident #2's care plan dated 07/26/25 revealed Resident #2 had potential to be physically aggressive r/t schizoaffective disorder, anxiety, and depression. The relevant interventions were, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior and encourage seeking out of staff member when agitated. Record review of the Provider investigation report dated 09/30/25 reflected, on 09/27/25 charge nurse, LVN A responded to a scream from the room of Resident #2. Upon entering, she observed Resident #1 on the floor and Resident #1 alleged that Resident #2 pushed her and she lost her balance and fell. Resident #1 had a skin tear to the left elbow from the fall and that was cleansed and treated with triple antibiotic ointment. During an observation and interview on 10/15/25 at 10:50am Resident #2 was emerging out from her room and sat in the living room. She stated she had changed her room two days ago and the current roommate was okay. She stated her previous roommates were not good as she had arguments with them. Resident #2 stated her previous roommate called her names and litter the room with various things. Resident #2 said the SW was trying to find the most suitable placement in another facility with the right kind of people and she stated she was okay with it. She stated she had issues with depression and anxiety and the medications that she had were not fully effective. When the investigator asked about the incident that occurred on 09/27/25 with Resident #1 , she stated Resident #1 was a frequent visitor in her room to meet her roommate and she did not like any other residents entering her room. Resident #2 stated she was angry at that time, shouted at her and tried to push her out of the room. She stated she felt sorry later about the incident and, she apologized to Resident #1. She stated she did not have any intention of hurting anyone. During an interview on 10/15/25 at 3:20pm Resident #1 stated she was visiting her friend who shared the room with Resident #2. She added, without any provocation, Resident #2 approached her screaming and shouting and pulled her hair and pushed her down to the ground. She stated it was a very traumatizing experience mentally and physically and had a skin tear on her elbow area from the fall. She stated she did not retaliate and shouted for help instead as she believed in nonviolence . Resident #1 stated she asked the staff to call the police as Resident # 2 assaulted her. Resident #1 said, next day Resident #2 approached her and apologized, though she was not sure how genuine she was. During a phone interview on 10/15/25 at 2:30pm LVN A stated, on 09/27/25 at about 9:50am she heard a scream from Resident #2's room and upon entering the room she saw Resident #2 was sitting on her bed. LVN A said she was furious and yelled Get the hell out of my room and stop bothering me. I don't want her in my room. LVN A said at that time Resident #1 was lying on the floor. She said Resident #1 reported to her that Resident #2 pushed her, lost her balance and fell. She said the residents were separated and Resident #2 was escorted from the scene and allowed to calm down. LVN A said she conducted a head-to-toe assessment on Resident #1, and it was revealed there was no head injury or contusion, no changes in her vision, no pain or any other complications however she sustained a skin tear on her left elbow, which was cleansed and dressed. She stated she reported the incident to the on-call physician and RP. She said she initiated vital signs observations and frequent neuro checks, and Resident #1 was on frequent observation as part of it. On 10/15/25 at 1:40pm the investigator tried to interview Resident #2's previous room mate who was in the room when the incident occurred on 09/27/25. She was busy with activities (bingo) in the dining hall and stated she was not interested in being interviewed.During an interview on 10/15/25 at 12:55pm MA B stated she was the med aide administering medications in the hall where Resident #2 resides. She stated Resident #2 told her that she pushed Resident #1 to the ground because Resident #1 went into her room and was verbally abusive. MA B stated she did not believe that as she had never seen Resident #1 ever became aggressive and abusive. She stated Resident #1 had a very calm demeanor and had lots of friends at the facility as she was very helpful with the residents physically and emotionally. She said, sometimes Resident #1 went out of the way and helped others more than she could do. MA B said Resident #2 was a loner who kept to herself mostly, however, could be impulsive and became abusive and aggressive when triggered. During an interview on 10/15/25 at 1:17pm the SW stated she was aware of the incident between Resident #1 and Resident #2 that occurred on 09/27/25. The SW said Resident #2 was a difficult resident as she would not get along with everyone. She said Resident #2 had changed her room two times after the incident because she was not compatible with the roommates. The last change was two days ago since she had not liked the roommate. The SW said the facility was in the process of finding an appropriate placement for Resident #2 due to her unsafe behavioral issues. During an interview on 10/15/25 at 1:45pm, the DON stated the facility was doing all levels of care to make sure the residents at the facility were safe. She said the facility had taken necessary measures to make sure Resident #1 was safe. They were immediately separated and redirected. She stated the incident was reported to the weekend NP , RP and the abuse coordinator immediately after the incident. The DON stated Resident #2 was moved to another hallway away from Resident #1. She stated both the residents were under observation until they were settled down after the incident. The DON said Resident #2 expressed her remorsefulness about the incident.The DON stated , the social worker completed psychosocial assessments with no issues noted . She said Resident #2 received new orders for lab tests and on 09/30/25 the psychiatrist met with her and increased her Depakote to 125mg BID for the diagnosis of schizoaffective disorder. During an interview on 10/15/25 at 10:35 am the ADM stated, on 09/27/25 at about 9:30pm Resident #1 went into Resident #2's roommate who was Resident #1's friend. He added, since Resident #2 did not like it, she pushed Resident #1 to the ground. He said he began an internal investigation and reported the incident to the state. The ADM stated both the residents had undergone psychiatric evaluation and Resident #2 received a modification in her psychotropic medication . The ADM stated he reported the incident to the police, conducted safety surveys and in-service on 'resident-to-resident abuse and neglect' for the staff as protocol. He stated the situation got better further when Resident #2 went and apologized to Resident #1. The ADM stated a care plan meeting for Resident #2 was held on 9/30/25. The ADM said Resident #2 stated that she received psychiatric counselling for anger management, how to control anger in the future, and that she had since apologized to Resident #1 for the incident. Record review of the in-service record revealed an ongoing in service on Abuse and Neglect started on 09/27/25. The review of the sign-in sheet revealed 47 staff members attended this in-service. Record review of the facility policy Abuse Protocol reflected: The patient [Resident] has the right to be free from abuse, neglect , mistreatment of resident property and exploitation.Our facility will not condone patient abuse, neglect mistreatment or misappropriation of patient property and exploitation (collectively patient Abuse) by anyone including staff members, other patients, consultants, volunteers, staff or other agencies serving the patient, family members, legal guardians, sponsors, friends or other individuals. The facility implemented the following prior to the surveyor's entrance to the facility on [DATE]. Resident #2 was removed from the room immediately after the incident and deescalated.Labs were ordered and psychiatrist conducted a medication review.A care plan meeting conducted on 09/30/25 for Resident #2, met with the RP and ombudsman to discuss behaviors.The SW completed psychosocial assessment on Resident #2 and updated BIMS with a score of 14.Resident#1 was assisted off the floor, physical, neurological and vitals assessment performed.Resident #2 was relocated to another hallway away from Resident #1.The staff were in- serviced on ANE. The noncompliance was identified as PNC. The noncompliance began on 09/27/25 and ended on 09/30/25. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to develop and implement a comprehensives person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of four residents reviewed for care plans. The facility failed to ensure Resident #1's care plan intervention for needing assistance with eating was implemented on 08/06/25. This failure could place residents at risk of not receiving the appropriate care to meet their needs. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility from 08/05/25 - 08/06/25 with a diagnosis including fractures of nasal bone and his vertebra (spine). Review of Resident #1's EMR, on 08/09/25, reflected an admission MDS assessment had not been completed. Review of Resident #1's initial care plan, dated 08/05/25, reflected he had an ADL self-care performance deficit with an intervention of requiring one staff member's assistance to eat. During a telephone interview on 08/08/25 at 7:54 PM, Resident #1's RP stated he needed assistance with feeding and was not able to feed himself. She stated when she went to visit him around 6:38 PM on 08/06/25, his dinner tray was on his bedside table untouched. During a telephone interview on 08/09/25 at 12:55 PM, CNA A stated he worked the 6:00 PM - 6:00 AM shift on 08/06/25 and worked the hall that Resident #1 was on. He stated he remembered delivering him his dinner tray. He stated he did not assist him with dinner because he was able to feed himself. He stated he knew how to look up how much assistance residents needed with care in Kardex (documentation system), but he did not believe he did for Resident #1 that night. During an interview on 08/09/25 at 2:46 PM, the DON stated the admitting nurses were responsible for the initial comprehensive care plan. She stated they would review hospital paperwork or obtain information from the family to enter the assistance the resident needed required for care. She stated the care plan was the plan of care for each resident. She stated the care plans were always changing based on the residents' needs and it was like a guide. A potential outcome of not following the residents' care plan could be harm. She stated if a resident needed assistance with feeding, her expectations were that the aides followed that requirement. She stated a resident could get sick, health could decline, or they could become malnourished. Review of the facility's undated Comprehensive Care Plans Policy reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 5 of 7 residents (Resident's #2, #3, #4, #5, and #6) reviewed for care plans. 1. The facility failed to ensure that Resident #2's care plan was revised, updated, and individualized to address Resident #2's risk for dehydration. 2. The facility failed to ensure care plan interventions (1:1 and/or in room activities) were implemented and documented for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. These failures placed residents at risk of not receiving the appropriate care to meet their current needs. Findings included: 1. Review of Resident #2's face sheet, printed on 06/04/25, reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included unspecified dementia (decline impacting memory, thinking and social abilities), cognitive communication deficit (difficulty with communication), anxiety, depression, and generalized muscle weakness. Review of Resident #2's annual MDS assessment, dated 03/03/25, reflected a BIMS score of 3 which indicated severe cognitive impairment. Review of Resident #2's undated care plan reflected Resident #2 was at risk for dehydration related to (blank). The goal reflected the resident would not exhibit any signs and symptoms of dehydration but did not specify a time frame. Interventions included offer additional fluids with meals and consults as needed. An observation and attempted interview on 06/03/25 at 12:07 PM, revealed Resident #2 sitting at a table in the common area as she prepared to feed herself lunch. Resident #2 smiled and nodded but did not engage in conversation. 2. Review of Resident #2's undated care plan reflected Resident #2 had risk for diversional activity deficit with a goal to participate in group and/or individual activities 2-3 times per week as tolerated. Interventions included to provide 1 on 1 visits to meet activity goal and provide room visits 2-3 times per week. Review of Resident #3's face sheet, printed on 06/04/25, reflected an [AGE] year-old female admitted on [DATE]. Her diagnoses included unspecified dementia, anxiety, depression, and other abnormalities of gait and mobility. Review of Resident #3's significant change in status MDS assessment, dated 05/22/25, reflected a BIMS score of 4 which indicated severe cognitive impairment. Review of Resident #3's undated care plan reflected Resident #3 was at risk for diversional activity deficits with a goal to participate in group and/or individual activities 2-3 times per week as tolerated. Interventions included to provide 1 on 1 visits to meet activity goal. During an observation and interview on 06/03/25 at 12:04 PM, Resident #3 was sitting in the common area at a table getting ready for lunch. Resident #3 stated the lunch looked good. Review of face sheet for Resident #4 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (progressive neurodegenerative disorder that affects the brain's ability to function), unspecified dementia (decline impacting memory, thinking and social abilities), cognitive communication deficit (difficulty with communication), difficulty walking, and major depressive disorder (serious mental illness characterized by persistent sadness, loss of interested and other symptoms affecting mood or thoughts). Review of Resident #4's quarterly MDS dated [DATE] reflected a BIMS score of 2 which indicated severe cognitive impairment. Review of Resident #4's undated care plan reflected Resident #4 was at risk for diversional activity deficits with a goal to participate in group and/or individual activities 2-3 times per week as tolerated. Interventions included to provide 1 on 1 visits to meet activity goal and provide room visits 2-3 times per week. Observation of Resident #4 on 06/03/2025 at 9:26 AM revealed Resident #4 sat in common area and was group with other residents. Review of Resident #5's face sheet reflected an [AGE] year-old female admitted on [DATE] with diagnosis of unspecified dementia decline impacting memory, thinking and social abilities), other lack of coordination (difficulties with movement, balance and coordination), depression (persistent feeling of sadness or loss of interest in activities), and chronic systolic (congestive) heart failure (long-term condition where the heart's ability to contract and pump blood is impaired). Review of Resident #5's quarterly MDS dated [DATE]/2025 reflected Resident #5 was unable to complete BIMS and is rarely or never understood. Further review reflected Resident #5 had a memory problem unable to recall after 5 minutes and appeared to recall long past. Review of Resident #5's undated care plan reflected Resident #5 had a risk for diversional activity deficit with a goal to participate in group and or individual activities 2-3 times per week. Interventions included provide 1 on 1 visits to meet activity goal and provide room visits 2-3 times per week. During an attempted interview on 06/03/2025 at 1:53 PM with Resident #5 revealed Resident #5 was confused and did not respond to simple questions. Review of Resident #6's face sheet reflected a [AGE] year-old-female admitted on [DATE] with diagnoses of Alzheimer's disease (progressive neurodegenerative disorder that affects the brain's ability to function), depression (persistent feeling of sadness or loss of interest in activities), anxiety disorder (group of mental health conditions characterized by excessive fear or worry), dementia (persistent feeling of sadness or loss of interest in activities) , and cognitive communication deficit (difficulty with communication). Review of Resident #6's quarterly MDS dated [DATE] reflected a BIMS score of 3 which reflected a severe cognitive impairment. Review of Resident #6's undated care plan reflected Resident #6 had a risk for diversional activity deficit with a goal to participate in group and or individual activities 2-3 times per week. Interventions included provide 1 on 1 visits to meet activity goal and provide room visits 2-3 times per week. During an interview on 06/03/2025 at 9:24 AM revealed Resident #6 was confused and not oriented to time or place. Review of activity logs dated 04/01/2025 and 04/02/2025 reflected Resident #2, Resident #3, Resident #4, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/03/2025 reflected Resident #2, Resident #3, and Resident #4 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/04/2025 reflected Resident #4 and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/14/2025 reflected Resident #2, Resident #4, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/21/2025 reflected Resident #3, Resident #4, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/22/2025 reflected Resident #2, Resident #3, Resident #4, and Resident #6 were not provided in-room visits or 1 to 1 activities Review of activity logs dated 04/23/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/24/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/25/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/29/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 04/30/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/01/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/02/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/05/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/06/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/07/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/16/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/19/2025 reflected Resident #2, Resident #3, Resident #4, and Resident #6 were not provided in-room visits or 1 to 1 activities. Review of activity logs dated 05/20/2025 reflected Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were not provided in-room visits or 1 to 1 activities. During an interview on 06/04/2025 at 12:54 PM, the AD stated that she had an assistant (AA) that worked in memory care and provided activities. The AD stated that she visited memory care to ensure the activities were implemented and checked in with the AA daily. The AD stated that the AA was responsible to provide 1:1 activities. The AD did not list Resident #4, Resident #5 or Resident #6 as residents who were provided 1:1 activities. The AD stated that residents in memory care will usually do group activities and if they do not participate for the day then the AA will do 1:1 activities. The AD said 1:1 activities were documented in a binder. The AD stated she was responsible to update the activity part of the care plan. The AD stated a resident who did not come out of their room is what determined that they got a 1:1 activity. During an interview on 06/04/2025 at 1:20 PM, AA stated that she was responsible for activities in memory care Monday through Friday. The AA stated she tried to keep a routine for the residents in memory care. She stated that in room visits or 1:1 activities occurred daily, Monday to Friday, from 1:30 - 2:00 PM. The AA did not include Resident #4, Resident #5 or Resident #6 as residents who received 1:1 activities. The AA stated she reviewed residents' care activity care plans and if the care plan specified the residents to have a 1:1 activity then they should have been having a 1:1 activity. The AA stated that activities were documented in a binder and stated not all of May 2025 activities had been documented. During an interview on 06/04/25 at 2:27 PM, the ADM stated that he expected the plans were completed timely. He stated he expected the care plans to be resident-centered and accurate . He stated the IDT was responsible for the care plans. During an interview on 06/04/25 at 2:40 PM, the DON stated each individual resident required different elements of care which were reflected on the care plan. She stated she expected interventions to be implemented and then monitored and revised if needed. She stated everyone was responsible for assisting with care plans and they were monitored in the morning meeting with the IDT. During an interview on 06/04/2025 at 2:55 PM, SW stated that interventions were added to the care plan by the MDS nurse or nursing. SW stated she provided her input at care plan meetings or to the IDT for interventions. During an interview on 06/04/2025 at 4:29 PM, the DON stated that the charge nurse and unit manager were responsible to ensure activities were being conducted and implemented in memory care. The DON stated that the AD or a CNA could provide 1:1 activities. The DON stated that the unit manager role was created to help alleviate or decrease resident to resident behaviors the unit manager was responsible to round frequently and ensure activities were implemented frequently as non-pharmacological interventions. During an interview on 06/04/2025 at 4:41 PM, the ADM stated that 1:1 activities should be documented in the activities binder and he expected them to be documented and implemented. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered revised March 2022, reflected in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; e. reflects currently recognized standards of practice for problem areas and conditions . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Intake #557738 Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 7 of 29 residents (Resident #1, Resident #17, Resident #68, Resident #39, Resident #80, Resident #159, Resident #21) reviewed for infection control. 1.The facility failed to test all residents who had flu like symptoms. 2. The facility failed to put place residents on quarantine or droplet precautions when indicated. An IJ was identified on 01/15/25 at 4:45 pm. The IJ template was provided to the facility on [DATE] at 7:15 pm. The plan of removal was accepted on 01/17/25 4:52 pm. While the IJ was removed on 01/17/25 at 5:30 pm the facility remained out of compliance at a scope of pattern and a severity of no actual harm identified as patterned due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 4. LVN E did not follow Enhanced Barrier Precautions by not putting on a gown when conducting medication administration via gastrostomy tube for Resident #17. 5. The SC did not follow Enhanced Barrier Precautions by not putting on a gown before providing peri-care and assistance during wound care for Resident #1. These failures placed the residents at risk of infection transmission, respiratory distress, hospitalization , and even death. Findings included: Resident #68 Record review of Resident #68's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included an acute upper respiratory infection, chronic pain syndrome, heart failure, hyperlipidemia, depression, seasonal allergic rhinitis, arthritis, shortness of breath, dementia, Vitamin D deficiency, and Vitamin B deficiency. Record review of Resident #68's Quarterly MDS assessment, dated 01/09/25 reflected a BIMS score of 15, indicating her cognition was mildly affected. Further review of the MDS revealed Resident #68 required set-up or clean up assistance for meals and oral hygiene, and partial/moderate assistance for her activities of daily living. Further review of the MDS reflected Resident #68 used a manual wheelchair for mobility. Record review of Resident #68's Care Plan dated 01/17/25 reflected she has episodes of shortness of breath and was at risk for respiratory distress. The goal indicated decreased episodes of shortness of breath, and no signs or symptoms of respiratory distress/failure over the next 90 days. Interventions included use of oxygen and take slow deep breaths, nursing to monitor for signs of relief from shortness of breath and provide respiratory treatments per orders, administer medications as ordered, and assess respiratory status by checking breath sounds, respiratory rate, skin color and notify physician of abnormal findings. Record review of Resident #68's Clinical Notes reflected: o 01/13/25 at 02:01 PM - Resident #68 refused to take geri-tussin 10 mL. o 01/13/25 at 04:25 PM - X-ray result came back and notified Nurse Practitioner, who ordered Tamiflu 75mg PO BID x 5 days. Carried out order and faxed to pharmacy. Called her RP and left a message. o 01/13/25 at 05:53 PRM - Nurse Practitioner ordered Influenza testing. Scheduled with [Company Name] to come onsite to get the test, in-house Influenza testing kit is out. Scheduled 01/14/25. No Test Results were available. Observation of resident's room on 01/14/25 at 4:50 pm revealed no airborne precautions or PPE signage outside the door. Observation on 01/14/25 at 12:45 pm revealed CNA N passing out trays to resident #68 room without donning proper PPE. Resident #39 Record review of Resident #39's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic pain due to trauma, a contusion of head, wedge compression fracture 3rd lumbar vertebrae, rheumatoid arthritis, fracture of left femur and nasal bones, repeated falls, severe protein-calorie malnutrition, hypotension, nausea, Record review of Resident #39's Quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating her cognition was intact. Further review of the MDS revealed Resident #39 required moderate to substantial assistance for her activities of daily living, and she used a wheelchair. Record review of Resident #39's Care Plan dated 12/10/24 reflected she was at risk for allergic reaction related to allergies to codeine and gluten. The goal was for Resident #39 to not have an allergic reaction for the next 90 days. Interventions included a review of listed allergies prior to giving new medications, review of diet for food allergies, notify physician if Resident #39 has an allergic reaction to new medications or foods, and document signs and symptoms of allergic reaction. Record review of a Clinical Note for Resident #39 dated 01/12/25 at 12:54 AM reflected Resident #39 felt as if she was getting sick or it may be allergies. Resident #39 denied any pain after the nurse offered her pain meds. Resident #39 stated she was going to continue without any medication and if it becomes worse she would ask for something. Record review of a Clinical Note for Resident #39 dated 01/16/25 at 03:13 PM reflected a Rapid Flu Test Procedure Card showed a negative test result and NP would be notified about negative test . Observation of resident #39's door on 01/14/25 revealed no PPE or airborne precaution signage Observation on 01/14/25 at 12:45 pm revealed CNA N passing out trays to resident #39 without donning proper PPE. Resident #80 Record review of Resident #80's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included syncope and collapse, urinary tract infection, diabetes mellitus type 2, seizures, encephalopathy, altered mental status, legal blindness, hyperlipidemia, hypertensive heart disease, cerebrovascular disease, and personal history of malignant neoplasm of organs and systems. Record review of Resident #80's 5-day MDS assessment, dated 12/22/24 reflected a BIMS score of 10, indicating her cognition mildly to moderately affected. Further review of the MDS revealed Resident #80 required partial/moderate assistance for her activities of daily living, and she used a walker and a wheelchair. Record review of Resident #80's Care Plan dated 01/16/25 reflected Resident #80 required extensive assistance with bed mobility, bathing, hygiene, dressing and grooming. The goals were for Resident #80 to be odor free, dressed and out of bed daily over the next 90 days, and Resident #80 would assist with her activities of daily living to the highest degree possible. The interventions included transfer status with gait belt with one staff assist and set up assist with her meals . Record review of resident's progress notes revealed no notification between the staff and doctor. Observation of Resident #80's room revealed no signage of PPE outside the room. Observation in resident #80's room on 01/14/25 at 07:25 am revealed RN U entering room to provide a head to toe assessment for resident 80. Observation on 01/14/25 at 12:45 pm revealed CNA N passing out trays to resident #80 room without donning proper PPE. Observation in resident #80's room on 01/15/25 at 12:15 pm revealed CNA N entered room with only a surgical mask on. Interview with Resident #80 on 01/15/25 at 12:15 revealed the resident had been feeling ill over the weekend. She reported symptoms of diarrhea, cough and congestion and body aches. She was not offered a flu shot or flu test. Resident #159 - Record review of Resident #159's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included a fracture of right femur and orthopedic aftercare, hypertension, congestive heart failure, mild intermittent asthma, vascular dementia, repeated falls, presence of an implantable cardiac defibrillator, non-Hodgkin lymphoma, coronary atherosclerosis due to calcified coronary lesion, pneumonia, urinary tract infection, depression, and anxiety. Record review of Resident #159's MDS revealed a BIMS of 0 indicating severe cognitive impairment. Record review of Resident #159's Care Plan dated 12/10/24 reflected: o A diagnosis of asthma and she was at risk for shortness of breath and respiratory failure. The goal was for asthma to be relieved by medication within 30 minutes of administration over the next 90 days, and interventions included monitoring for shortness of breath, notify physician of shortness of breath that is not relieved by medication, and administer oxygen for unrelieved shortness of breath. o A potential for fluid volume overload related to Congestive heart failure, with a goal stating she would be free from signs and symptoms of fluid volume overload. Interventions included administering diuretics and monitor for side effects, assess for breath sounds and observe for labored breathing, encourage adequate fluid intake within restrictions as ordered, keep head of bed elevated, monitor for signs and symptoms of fluid overload such as edema, shortness of breath, and report to physician. and turn and reposition every 2 hours and as needed. Record review of Resident #159's Physician Orders reflected: o 12/10/24 - Take vital signs by shift, o 01/14/25 - Regular Ground Continuous diet, o 01/15/25 - Pulse Oximetry every shift, and o 01/17/25 - Droplet Isolation Precautions every shift for 6 days, and a Proactive Health Check (Covid/RTA Prevention) every shift. Observation on 01/14/25 at 12:45 pm revealed CNA N passing out trays to resident #159 room without donning proper PPE. Observation on 01/15/25 at 11:30 am revealed no signage on the door for PPE Precautions. Observation on 01/16/25 at 3:30 pm revealed airborne precaution signage on the resident's door. Interview with Resident #159 on 01/14/25 at 7:30 am stated that they felt very poorly. Resident was moaning in between words and could not answer any further questions. Interview with RN U on 01/17/25 at 4:00 pm revealed that he notified the doctor that day. Resident #159 had been tested for the flu and was positive . Resident #21 Review of Residents admission sheet showed an [AGE] year-old female admitted to the facility on [DATE]. Pertinent diagnoses included coronary artery disease (heart disease), Type 2 diabetes, Dementia, and Heart Failure. Record review of Resident #21's MDS revealed resident had a BIMS score of 06 which indicated severe cognitive impairment and partial to moderate assistance with ADL's Record review on 01/15/24 nursing notes revealed that family had called into the facility and reported that the resident was experiencing flu like symptoms and went to the ER. Observation on 01/15/24 at 12:30 pm of Resident#21 revealed no signage of PPE outside the door . Observation on 01/14/25 at 12:45 pm revealed CNA N passing out trays to all residents on the 700 and 800 halls without donning proper PPE for residents suspected of having the flu. Interview with CNA N on 01/16/25 at 4:45 pm stated that she noticed Sunday evening the residents were not feeling good. She stated that she had talked to the nurse about it and the nurse had given the residents fever and pain reducing medications. Interview with RN U on 01/14/24 at 8:35 am, he stated that when he arrived at work on 01/13/25 he saw multiple people with a decline in condition. He notified the DON and called the NP to get orders for the residents. He began administering PRN fever reducers, cough, and congestion medicine. He did not focus on putting proper PPE signage on the door because he assumed that was the job of the DON or ADON. He stated he retrieved masks and began to wear a mask while providing care to the residents. He stated that if he did not wear proper PPE the residents could get more sick. Record review of the facility's Performance Improvement Plan dated 1/13/25 reflected the problem area was Resident #21 had tested positive for the flu at the hospital, which initiated an outbreak. Changes implemented to reach baseline: 1. Monitor all residents for signs and symptoms of flu initially and daily. 2. tested symptomatic patients. 3. Notified Medical Director- plan to treat patients prophylactically and standing orders giving based on lab results. 4. Inservice staff on hand hygiene and flu 5. Deep clean all resident rooms to include side rails and overbed tables. 6. Place all positive patients on droplet precautions 7. Encourage all staff to wear mask, mandatory for unvaccinated staff during flu season. 8. Monitor all positive patients for serious complications - notify Medical Director and /or providers if found. Interview with the DON Interview on 01/15/25 at 09:55 AM with IP/ADON who revealed she had worked a double shift on the east unit, which included the 600 and 700 halls. The IP/ADON stated the first case of Influenza in the facility was on Sunday, 01/13/25. She stated around 10:00 AM many of the residents on the 700/800 halls were sleeping in, and during breakfast she started hearing some of the residents coughing and having congestion. Around noon, the diarrhea and vomiting started. She stated very few residents ate dinner on Sunday. Many had very low appetites. She stated she knew something was going on with the residents, but it was hard to tell because it was a variety of symptoms. Guidance from the DON was to write down resident symptoms as the day went on. She stated she did not contact the doctor and they only tested people who were very sick for the flu because the facility ran out of flu shots . Interview with NP on 12/15/25 at 1:42 pm revealed that he or his doctor had not been contacted by the facility on Sunday, 01/12/2025, when the symptoms had begun. They contacted him Monday morning 01/13/2025 with the symptoms and I directed them to do testing and start treatment. If they were running a fever with cough and congestion, he started them on Tamiflu. Without a fever he wanted to look at them and see what's going on. He expected them to report the symptoms immediately. He reported that they sent two to the hospital with respiratory distress but couldn't recall directly which residents . Interview on 01/15/25 at 04:24 PM with ADM revealed Resident #21 had been out on pass with her family, and they took her to the hospital for flu-like symptoms. The ADM stated Resident #43 had developed upper respiratory symptoms and went to the hospital. He further stated on Monday 01/14/25 the committee had a quick QA meeting and consulted with the physician for parameters for monitoring residents for flu-like symptoms. The ADM stated that he was notified of an Influenza outbreak on Sunday night, 01/13/25. The ADM stated his expectations were for all residents testing positive for influenza and flu-like symptoms to be placed on isolation precautions or cohorted with other residents with similar flu-like symptoms . Interview with LVN V on 01/17/25 at 4:40 pm revealed that she had been in-serviced on outbreak standards, PPE usage, and reportable incidences on 01/16/25. Interview with CNA R 01/17/25 at 4:45 pm revealed that she had been in-serviced on outbreak standards, PPE, and reportable incidences on 01/16/25. Record review of Infection Control Policy of Type and Duration of Precautions recommended for Selected Infections Appendix A stated Human Seasonal Influenza stated single patient room when available cohort mask patient when transported out of the room and give vaccine to control outbreaks. Use gown and gloves according to standard precautions. Duration of precautions for immunocompromised patients cannot be defined. Isolation duration of five days. Review of facility policy titled quick reference for isolation precautions states, in addition to Standard Precautions, use Droplet Precautions for Patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include: o Adenovirus o Influenza o Mumps o Parvovirus B 19 o Rubella Record review of an in-service report dated 1/13/25 covered the topics of the flu with droplet and contact precautions washing hands with soap and water and wearing masks. Record review of an in service on 01/06/25 with the topic of cross contamination prevention that covered: -Hand hygiene as a part of standard and transmission-based precautions. -Sanitize or wash hands with soap and water before and after resident care serving meals applied gloves restroom renews eating etcetera . Plan of Removal This is to confirm the submission of our Plan of Removal provided by this facility. For F880 IJ. The submission of this POR does not constitute an admission on the part of the facility as to accuracy of the surveyor's findings, the conclusion drawn from there, nor is the scope and or severity regarding any deficiency cited applied correctly. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. The Director of Nursing and Administrator will be inserviced on 1/16/25 by the Regional Director of Clinical Services on Influenza Outbreak Management in Long Term Care. On 1/16/25 at 1238 PM the Medical Director and patients assigned providers were updated on all patients with flu symptoms and on all patients that were positive by the DON. All licensed staff to be inserviced on notifying providers of changes in condition to include a pre/post test by the Regional Director of Clinical Services and/or Director of Nursing Services beginning 1/16/25 with a completion date of 1/17/2025. All staff to be educated on Influenza and Outbreak Management in long term care to include a pre/posttest by the Regional Director of Clinical Services and/or Director of Nursing beginning 1/16/25 with a completion date of 1/17/2025. Inservice will include signs and symptoms, precautions to take, prevention measures, isolation and outbreak management. All licensed staff will be inserviced on Proactive Healthcheck orders by the Regional Director of Clinical Services and/or Director of Nursing beginning 1/16/25 with a completion date of 1/17/2025 . The licensed nurse will enter this order for all patients to capture any flu signs and symptoms. The Proactive Healthcheck will be utilized through the remaining of the flu season. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 1/16/25-The Regional Director of Clinical Services completed a 100% chart audit, identifying all residents with flu symptoms to ensure the providers were notified. This was completed on 1/16/2025. All providers were notified by the Director of Nursing Services of all patients with symptoms. On 1/16/25-An audit was conducted by the Regional Director of Clinical Services identifying all patients with active flu and flu symptoms to ensure they were isolated according to the CDC guidelines. Completed 1/16/2025- all patients verified to have the correct precautions in place. Measures to be put into place or systemic changes made to ensure that the deficient practice will not recur; On 1/16/2025-Facility is utilizing the PHC Proactive Health Check daily -EHR tool which monitors for abnormal symptoms that may indicate a condition change and other possible illnesses in the residents. The symptoms monitored include-abdominal pain, chills or repeated shaking with chills, diarrhea or other GI upset, headache, loss of smell, loss of taste, muscle pain, nausea, Oxygen saturation, red shadowed eyes or pink eyes, shortness of breath, sore throat, and tingling sensation in face or hands. The PHC dashboard will be reviewed daily during stand up by the DON and/or ED. DON and ED were in serviced on 1/16/2025. This will monitoring will be on going. How the facility plans to monitor its performance to make sure that solutions are sustained. Beginning 1/16/2025. The Director of Nursing Services and/or designee (ADON, UM, ED) will review the 24 hour report (nursing documentation) daily during the clinical stand up meeting with staff monitoring for patient change of conditions and ensuring notification to providers was done. This process will be ongoing. The Sr. Regional Director of Clinical Services will review the 24 hour report (nursing documentation) weekly for four weeks beginning 1/20/2025 to monitor for patient change of conditions and ensure notification to providers was done. The DON and/or designee (ADON and/or IP) will perform a minimum audit of 3 random audits on different hallways daily for 1 week, the bi - weekly for 4 weeks beginning 1/17/2025 to monitor for PPE compliance. Compliance concerns to be addressed immediately by the DON and/or designee. Results of audits and reviews will be reported to and reviewed by QAPI committee monthly for three months. The state surveyor monitored the POR on 01/18/2025 as followed: Observation of exterior of the 11 resident's rooms' who tested positive for influenza reveal donning/doffing PPE outside the doors with signs that instruct how to properly don and doff PPE as well as signs that read, STOP droplet Precautions, everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit-CDC. During an observation and interview on 01/18/2025 at 1:45pm revealed CNA A and CNA B donning PPE before entering a resident's room. CNA A said she was in-serviced on how to properly don/doff PPE, and how to notice a change in condition and report it to their charge nurse. Interview with the ADM on 1/18/2025 at 12:15pm revealed that any staff not completing the in-servicing by 1/18/2024 will not be permitted to work until they are in-serviced over the topics related to the IJ. For new hires, nurses would get the change in condition, PHC trainings, and aides would receive the mechanical lift, and flu trainings. During interviews on 01/18/2025 from 12:55pm-3:00pm, the DON, two RN's and four CNA's from both shifts stated they were in-serviced on infection control, the order of donning: sanitize hands, apply gown, apply mask, apply shield, then gloves and once done with their task they must do everything in reverse order, dispose of the PPE, sanitize their hands and put on new mask. They were in-serviced on reporting of ANE, including the ANE coordinator being the Administrator. They also revealed knowledge of using Proactive Health check in the residents' EMR . Interview with the DON on 1/18/2025 at 3:45pm revealed that she received training from the DCS regarding influenza and infection control, what signs and symptoms need to be reported, change in condition must be reported to the MD, RP, and clinical staff working with the resident. How to properly don/doff PPE, and that the ADM is the abuse coordinator. The DON, ADM, and DCS had been taking turns providing proactive health check, proper PPE application and removal, and outbreak in-services to direct care staff. The DON revealed she will be responsible for providing in-servicing for new hires and any PRN staff must complete the training before working the floor. Review of in-service titled Abuse/Neglect & Resident Rights reflected it was presented by DCS dated 1/17/2025 was provided to the ADM and the DON Review of in-service titled PHC checks should be done once a shift during outbreak. Notify MD/NP of any abnormal findings. Ensure all new admissions have orders for PHC checks once daily while in outbreak. Presented by the DCS dated 1/16/2025 reflected it was provided to nursing staff. Review of in-service titled Donning/doffing. Influenza symptoms, management, preventing spread of. Droplet precautions. When you exit a room with droplet precautions, you must sanitize your hands, dispose of old mask, sanitize hands, put on clean mask. reflected it was presented by the DCS dated 1/16/2025- ongoing. Review of PHC dashboard dated 1/16/2025 and 1/17/2025 reflected audits conducted by the ADM. Review of in-service titled, Proactive Health Check Monitoring, Clinical notes review, auditing PPE compliance reflected it was presented by the DCS to the ADM and the DON dated 1/16/2025. Review of PPE Observation Audit log dated 1/17/2025 reflected no issues. The ADMIN and the DON were informed the Immediate Jeopardy (IJ) was removed on 01/17/24 at 5:30 pm. The facility remained out of compliance at a severity of no actual harm that was not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Resident #1 Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain), vascular dementia (a type of dementia cause by brain damage from impaired blood flow), hemiplegia affecting right dominant side (occurs when parts of the brain that control movement become damaged, affecting muscles on right side of the body), aphasia (a communication disorder caused by brain damage that affects verbal and written language), dysarthria (a motor speech disorder that makes it difficult to form and pronounce words due to nervous system damage), anemia, diabetes mellitus type 2, reduced mobility, and expressive language disorder( a communication disorder in which there are difficulties with verbal and written expression). Record review of Resident #1's Quarterly MDS assessment, dated 12/12/24 reflected a BIMS Score of 9, indicating her cognition was moderately impaired. Further review of the MDS revealed Resident #1 required substantial/maximal assistance for her activities of daily living, and she used a wheelchair. Record review of Resident #1's Care Plan dated 01/16/25 reflected Resident #1 was transferred to and from her bed, chair and wheelchair and was totally dependent on staff. Her goal was to be out of bed daily as tolerated, and interventions included transfer with mechanical lift, and quarter rails as enabler to assist with bed mobility and transfer. Observation on 01/16/25 at 12:40 PM revealed the SC did not follow Enhanced Barrier Precautions by not putting on a gown before providing peri-care and assistance during wound care for Resident #1 . There was no signage on the resident's door for PPE. An interview on 01/16/25 at 1:05 PM revealed the SC had forgotten to put on a gown before providing care to Resident #1. The SC stated the importance of following Enhanced Barrier Precautions was to reduce the spread of infection to the residents. Resident #17 Record review of Resident #17's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included spastic quadriplegic cerebral palsy (neurological disorder characterized by the permanent stiffness of all four limbs, which can lead to a loss of motor function and mobility), microcephaly (neurological condition where a child has a smaller head and brain than normal), anemia, muscle weakness, dysphagia (difficulty swallowing), epilepsy (seizure disorder), aphasia (a communication disorder caused by brain damage that affects verbal and written language), gastroparesis (a condition that affects the normal muscle movements of the stomach), and gastrostomy status (creation of an artificial external opening into the stomach for nutritional support or gastric decompression). Record review of Resident #17's Annual MDS assessment, dated 11/15/24 did not have a BIMS Score, indicating her cognition was moderately impaired. The MDS indicated Resident #17 had a diagnosis of cerebral palsy and received nutrition and medication via a gastrostomy tube. Further review of the MDS revealed Resident #17 required substantial/maximal assistance for her activities of daily living, and she used a modified wheelchair. Record review of Resident #17's Care Plan dated 01/17/25 reflected Resident #17 was transferred to and from her bed, chair and wheelchair, and was totally dependent on staff. Her care plan further stated she was at risk for impaired nutritional status due to being dependent for enteral feeding, with goal that Resident #17 will not exhibit signs and symptoms of formula intolerance over the next 90 days. Intervention included implementation of Enhance Barrier Precautions. Record review of Resident #17's Physician Orders dated 01/14/25 reflected infection or colonization with an MDRO and requirements included: 1. Gowns and gloves are recommended when performing high-contact resident care activities. 2. Residents are not restricted to their rooms and do not require placement in a private room. 3. Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be a longer-term approach. Observation on 01/16/25 at 12:59 PM with LVN E revealed he did not put on a gown prior to administering medication via gastrostomy tube for Resident #17. Observation on 01/16/25 at 12:59 pm revealed no PPE signage on the door to the resident' room. Interview on 01/16/25 at 01:16 PM with LVN E revealed he should have put on a gown before administering medication to Resident #17. LVN E further stated it was important to follow Enhanced Barrier Precautions when providing care, and following Infection Control protocols was to help stop the spread of infection to the residents.

Based on observation, interview, and record review the facility failed to ensure residents environment remained free of accident and hazards to prevent avoidable accidents for 1 (Resident #28) of 1 resident reviewed for safe transfers. The facility failed to ensure mechanical lift #1 was removed from the floor after it was deemed out of order on 01/03/2025. The facility failed to ensure mechanical lift #2 was in working order prior to Resident #28's transfer. The mechanical lift fell on top of Resident #28 and Resident #28 fell to the floor from the lift which resulted in Resident #28 being transferred to the ER to be treated for a lumbar fracture and hemorrhage on 01/03/2025. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 01/15/2025 at 6:15 PM. While the IJ was removed on 01/18/2025 at 6:15 PM, the facility remained at a level of no actual harm at a scope of isolated that is was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents who require a mechanical lift for transfers at risk for falls and/or serious injury or death. Findings included: Review of Resident #28 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of wedge compression fracture of second lumbar vertebra (break in the front of the vertebra that causes it to collapse into a wedge shape), memory deficit following cerebral infarction (common cognitive impairment that can affect memory, attention, concentration, and language), Traumatic subarachnoid hemorrhage without loss of consciousness (type of brain injury that occurs when there's bleeding between the brain and skull) and multiple sclerosis (a chronic disease that damages the central nervous system). Review of Resident #28 significant change MDS dated [DATE] revealed, Resident #28 had a fracture and major injury. Further review revealed Resident #28 was dependent on staff for chair to bed and bed to chair transfers. Review of Resident #28 undated care plan revealed Resident #28 was dependent on staff for transfers and required a mechanical lift. Further review revealed Resident #28 fell from mechanical lift on 01/03/2025 with interventions to keep area free of obstructions to reduce the risk of falls or injury. Review of Resident #28 nursing progress note dated 01/03/2025 revealed LVN D was called to Resident #28's room and Resident #28 was on the floor. Progress note revealed CNA N and CNA O tried to transfer Resident #28 from bed to her wheelchair and stated that she fell from lift and laid on the floor. Resident #28 stated she bit her tongue and small amount of blood was noted. Resident #28 stated she hit her head. NP was notified and provided order to send to ER. Review of Resident #28 nursing progress note dated 01/04/2025 revealed Resident arrived back to facility with diagnosis of lumbar spine fracture and subarachnoid hemorrhage. During an interview on 1/15/2024 at 12:02PM Resident # 28 started she remembered falling to the floor after staff tried to get her to her bed with the lift. Resident #28 stated she was scared, screamed and bit her tongue. She stated when she hit the floor, she thought she had broken her back. Resident #28 stated she did not remember going to the hospital or if she had any injuries. During an interview on 1/15/2024 at 1:40pm LVN D she stated she was working on 1/03/2025 and was called to the Resident #28's room. LVN D stated upon arrival Resident #28 was on the floor and he two aides (CNA N and CNA O) told her they tried to transfer Resident #28 from bed to her wheelchair and that Resident #28 fell from the mechanical lift and laid on the floor. She stated Resident #28 was alert and the resident told LVN D that she bit her tongue. LVN D stated she did notice a small amount of blood that stopped bleeding by itself, and that Resident #28 told LVN D she hit her head. LVN D stated she completed vitals and called the NP, which gave the order to send out Resident #28 to the ER for further evaluation. LVN D stated she also called and informed Resident #28's son. During an interview 1/15/2024 at 1:54PM CNA N stated, she worked 6:00 am to 2:00 pm on 01/03/2024 and at 10:00 am she and CNA N went to Resident #28's room to get her out of bed for activities. CNA N stated they had already used the mechanical lift at 6:00 am on Resident #28 and with two other residents without problems and did not have any knowledge of the mechanical lift being out of order. CNA N stated when they moved the mechanical lift from the bed, the top of the mechanical lift fell on top of Resident #28. CNA N stated, Resident #28 screamed out loud when she fell to the floor and fell on her back. CNA N stated that Resident #28 stated she bit her tongue and saw it was bleeding. CNA N stated she ran to contact the charge nurse LVN N and stated LVN N came to the room and completed vitals and Resident #28 was sent to the ER because she hit her head. During an interview on 1/15/2025 at 2:05PM CNA O she stated as they pulled the mechanical lift away from the bed the top of the lift fell on top of Resident #28, and she fell on her back to the floor. CNA O stated Resident #28 screamed out due to the impact. CNA O stated she stayed with the resident while CNA O when to get the nurse. She stated LVN D came immediately. During an interview on 01/15/2025 at 3:05 PM MD stated that the company who serviced mechanical lifts came out earlier in the day on 1/03/2025. He stated that the technician stated he left an out of order sign on a mechanical lift. MD stated he did not confirm there was a sign on the mechanical lift and that later he heard a resident fell . MD stated that the service provider does not inspect the mechanical lift he only calibrates the scale. MD stated that upon his inspection after the fall he saw that a washer separated from the bolt which caused it to come out and what caused the mechanical lift to fall onto the resident. MD stated that he removed the mechanical lift from the floor after the incident. MD stated that he inspected each mechanical lift weekly and the service provide calibrates mechanical lifts monthly. MD stated he does not document his weekly inspections. MD stated that there used to be an app the staff could report issues, but it did not work out and there are maintenance binders that staff write down issues in. During an interview on 01/15/2025 at 3:20 PM DON stated she was not working when the fall happened with Resident #28. DON stated she returned to work on 1/06/2025. DON stated mechanical lift training was completed on 12/24/2024 with staff, but not again after the incident with Resident #28. DON stated no additional training was done regarding safe transfers and it was her intention to do it, but it did not happen. During an interview on 01/15/2025 at 3:57 PM ADM stated that staff said they were transferring Resident #28 and the central arm came loose and she fell off the bed and onto the floor and was between the legs of the lift. ADM stated Resident #28 was sent to the hospital. ADM stated that when the service provider come to service the mechanical lift, they calibrate the lift and do not inspect it. He stated there was not routine maintenance done unless something is was wrong with the lift. He stated that the MD inspected lifts routinely but not in a formalized process. He stated that the service provider was out earlier in the day on 1/03/2025. He stated he had not heard that they marked a mechanical lift out of order. ADM stated they used it for Resident #28's shower earlier in the day and two other residents before her fall. ADM stated that the only thing that was not working was the battery in the scale but that was for weighing purposes. ADM stated if someone stated that there was something wrong with mechanical lift, he would have expected it to be taken it off the floor. ADM stated if the mechanical lift was out of order and used it would risk of someone getting hurt and stated that someone did get hurt, but depended on if something was truly wrong with it. ADM stated he was not sure if he had a policy on servicing mechanical lift. ADM stated he expected service providers to notify management of any issues with equipment so it could be pulled off the floor. In a subsequent interview on 01/15/2025, ADM stated that the service report for the mechanical lift serviced on 01/03/2025 was different than the lift that fell on Resident #28. During an interview on 01/15/2025 at 05:30 PM DON stated all staff should report mechanical lift issues to MD and if it was after his working hours, the staff should inform the immediate nurse and they should contact MD. DON stated all staff were responsible for removing a non-working mechanical lifts from resident care areas. During an interview on 01/15/2025 at 5:30 pm CNA P stated that if the equipment was not working, he would have been able to tell when he felt it not working like it used to. CNA P stated he did not know what the policy was for reporting broken equipment, but stated he would report it to his chain of command. CNA stated he would not know a mechanical lift was broken from the look of it. CNA P stated if it was broken someone could get hurt. Observation and interview on 01/15/2025 at 5:35 PM revealed a second mechanical lift with an orange sign on it wheeled into MD's office that had do not use on it. MD stated that this lift was on the floor and that ADM would have to be asked about if it was being used. MD stated it apparently already had the sign on it not to use but he was unsure where it was and to ask ADM. During an interview 01/15/25 at 5:35 PM, MA Q stated she would not know if equipment were broken unless they put a sign on it. She would not be able to identify something was broken until it was not working properly. MA Q stated if she needed to report it, she would have reported it to her charge nurse. MA Q stated if they used broken equipment, they could hurt themselves or others. During an interview on 01/15/2025 at 5:43 PM, CNA R stated if equipment was not working properly, she would let the nurse know and would write a sign and remove it. CNA R stated she would move the equipment outside the area. CNA R stated if she used a piece of equipment that was broken, it could hurt herself or another resident. During an interview on 01/15/2025 at 5:44 PM, service provider supervisor stated that the company only calibrates the scales on the mechanical lifts. He stated that if there was an issue with the lift, they would notify management. He stated that they would normally not tag the lift that it was out of order and if it was not functioning, they would notify management. During an interview on 01/15/2025 at 5:50 PM, LVN S stated she was a charge nurse. LVN S stated if a piece of equipment was broken a CNA would let her know. LVN S stated she normally worked 10:00 PM - 6:00 AM and they did not use a lot of equipment. She stated they would scan the QR Code that was implemented in May 2024 to notify the MD. LVN S stated CNAs would let us know and then they would go through the steps of reporting. LVN S stated they would remove the equipment, put a sign on it and push it to the back on in a closet if it was not working. During an interview on 01/23/2025 at 11:54 AM, representative from mechanical lift manufacturer stated that it was advised to do at least a monthly inspection of the mechanical lifts to look around for normal wear and tear. Representative recommended that a day be set aside once a month to inspect the lift. Review of service report dated 01/03/2025 revealed mechanical lift #1's serial number matched the service report, and it was serviced on 01/03/2025. Further review revealed service reported noted motor that spreads wheels does not work but scale is accurate left out of tag order on lift. Further review revealed service provider emailed MD a copy of the service report on 01/06/2025. Review of technician kiosk sign in and out information revealed service provider technical checked in at 01/03/2025 at 9:05 am and check out of the facility at 9:58 AM. Resident #28 was reported to have incident at 10:00 AM. Review of undated facility investigation pictures of mechanical lift #2 revealed differing serial number than serial number of mechanical lift #1. Observation on 01/16/2025 at 3:30 PM revealed mechanical lift #2 revealed differing serial number than lift that was serviced on 01/03/2025. Review of facility accident/incident report dated 01/03/2025 revealed equipment as fall contributing factors. Review of manufacture owner's manual titled Battery Operated Patient Lift dated 03/01/2022 revealed the operator of the lift is to inspect the mechanical before each use and included to check all bolts and nuts are tight. Further review revealed at least once a month, the lift should be thoroughly inspected to recognize any signs of wear, and/or looseness of bolts or parts and to replace any worn parts immediately. Review of facility policy dated July 2017 titled Lifting Machine, using a Mechanical revealed make sure that all necessary equipment (slings, hooks, chains, straps, and supports) is on hand and in good condition. Further review revealed to test control and ensure emergency release feature works. ADM and DON were notified on 01/15/2025 at 7:17 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/17/2025 at 4:52 PM: F689 This is to confirm the submission of our Plan of Removal provided by this facility. For F689 IJ. The submission of this POR does not constitute an admission on the part of the facility as to accuracy of the surveyor's findings, the conclusion drawn from there, nor is the scope and or severity regarding any deficiency cited applied correctly. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. The resident went sent to the ER for further evaluation and treatment on 1/3/2025. The resident was treated for L2 transverse fracture and monitored for brain bleed and resolved. On 1/4/2025 Resident returned to the facility at her previous level of care with no changes and remains a two-person mechanical lift assist for transfers. How the facility will identify other residents having the potential to be affected by the same deficient practice; Residents who require a two person assistance with mechanical lifts have the potential to be affected. On 1/16/2025 Administrator reviewed last twelve months of incident reports with no instances mechanical lift malfunction with residents. There have been no other incidents with mechanical lift malfunctions. The mechanical lift used in the incident with this resident (serial number ending 50) was removed from service on 1/3/2025, secured and made inoperable for further use. The mechanical lift noted by the service technician as motor that spreads the wheels does not work (serial number ending 26) has been removed from service and secured from use on 1/15/25. As of 1/16/24 Administrator validated there are three Mechanical lifts in use; lift with serial number ending 35, lift with number ending 79, lift with number ending 500. On 1/16/25 Area Lead Maintenance Director completed a re-inspection of all mechanical lifts on site, all lifts in use are functioning properly. 1/16/25 Administrator and Area Lead Maintenance Director confirmed Director confirmed the two other lifts remain removed from service and secured. On 1/15/24 Maintenance director has been relieved of duty by Administrator pending investigation, retraining, and demonstrated skills competency by VP of Plant Operations. Measures to be put into place or systemic changes made to ensure that the deficient practice will not recur; On and beginning 1/15/25 the Director of Nursing and Administrator will conduct re-education including post test with direct care staff on safe transfer and lift operation, and reporting any operational concerns to management. On 01/15/2025 the Director of Regulatory Compliance in-serviced the Administrator and Director of Nursing on Abuse, Neglect, and Resident Rights. Administrator or designees initiated in-servicing all staff on Abuse, Neglect, and Resident Rights on 1/16/2025. Any staff who are not present to complete the in-servicing by 1/18/25 or new staff after that date will be required to complete the in-servicing at the start of their next shift before beginning work. Revised Lift Maintenance and Inspection policies and practices including documentation, and revised lock-out tag-out procedures will be implemented on 1/16/2025 to ensure continued safe operation of lift equipment. Any staff -including maintenance director who are not present to complete the in-servicing by 1/18/25 or new staff after that date will be required to complete the in-servicing at the start of their next shift before beginning work. Administrator and DON in-serviced by Lead Area Maintenance Director 1/17/25. Service provider will be notified of new requirement to personally review all lift inspections with the Administrator or Director of Nursing while on-site completion date 1/17/25. How the facility plans to monitor its performance to make sure that solutions are sustained. Administrator will directly review all mechanical lift inspections weekly for four weeks. Then bi-weekly for two months. Beginning 1/16/25 and ongoing. Beginning 1/16/25 and ongoing Area Lead Maintenance Director will conduct maintenance and safety inspections on all mechanical lifts monthly for three months then monthly thereafter by facility maintenance director . These inspections will be reviewed with Administrator while on-site. Beginning 1/17/25 Nurse Managers will observe five direct care staff a week for four weeks, during care, of residents who require mechanical lifts, to ensure that staff demonstrate competencies with re-education as needed. Then bi-weekly for two months. The Maintenance and Inspection logs, and results of observations will be reviewed at the monthly QAPI meetings for 3 months beginning with 1/17/25 and ongoing. The Administrator is was responsible for implementing the acceptable plan of correction. The POR was monitored from 01/16/2025 to 01/18/2025 as follows: During an interview on 01/16/2025 at 3:32 PM, ADM stated that the lift serviced on 01/03/2025 was identified as mechanical lift #1 and the serial number on the service report was different that mechanical lift #2 which is the lift that was used during the transfer with Resident #28. ADM stated that the lift in the service report was supposedly marked out of order but he was unsure who the technician check out with and notified of this. ADM stated that the lift in the report (mechanical lift #1) was pulled off the floor on 01/15/2025 and marked out of order. ADM stated he had not been made aware that there was an issue with mechanical lift #1 until then. ADM stated that the lift involved in Resident #28's fall was a different lift and had last been serviced on 11/05/2024. ADM stated that normally the MD would be responsible for repairing and ordering parts to service the lift outside of scale calibration. Observation on 01/16/2025 revealed mechanical lift #1 and mechanical lift #2 marks identified as out of order and zip tie through battery compartment to prevent use. Observation on 01/18/2025 of a locked maintenance closet revealed mechanical lift #1 and mechanical lift #2 were stored and tagged as inoperable with a zip tie through the battery compartment and no batteries attached. During an interview with the ADM on 1/18/2025 at 12:15pm he stated that any staff not completing the in-servicing by 1/18/2024 would not be permitted to work until they are in-serviced over the topics related to the IJ. He stated for new hires, nurses would get the change in condition, PHC trainings, and aides would receive the mechanical lift, and flu trainings. During interviews on 01/18/2025 from 12:55pm-3:00pm, the DON, two RN's and four CNA's from both shifts stated they were in-serviced on infection control, the order of donning: sanitize hands, apply gown, apply mask, apply shield, then gloves and once done with their task they must do everything in reverse order, dispose of the PPE, sanitize their hands and put on new mask. They were in-serviced on reporting of ANE, including the ANE coordinator being the Administrator. They were taught that all mechanical lifts are to be used by 2 people at a time, how to identify a resident needing mechanical lift transfers by the electronic record, and how to properly ensure working order and then use of the mechanical lift. They also revealed knowledge of using Proactive Health check in the residents' EMR. During an interview with the DON on 1/18/2025 at 3:45pm she stated she received training from the DCS regarding influenza and infection control, what signs and symptoms need to be reported, change in condition must be reported to the MD, RP, and clinical staff working with the resident. Mechanical lift in-servicing, how to properly don/doff PPE, and that the ADM is the abuse coordinator. The DON, ADM, and DCS had been taking turns providing the mechanical lift, proactive health check, proper PPE application and removal, and outbreak in-services to direct care staff. The DON revealed she will be responsible for providing in-servicing for new hires and any PRN staff must complete the training before working the floor. Review of a inspection log labeled [Mechanical] Lift Preventative Maintenance Inspection Log, reflected 5 lifts were documented as inspected on 1/16/2025. Review of a policy titled Mechanical Lift Maintenance and Inspection Policies dated revised 1/16/2025 reflected maintenance director will complete a visual and function inspection of all lifts weekly. If any area does not pass inspection, the lift with be removed from the service area, and a lock out/tag-out indicator affixed so as to prevent unauthorized use. Review of an email from the ADM to a scale inspector dated 1/17/2025 revealed that the inspector must notify the ADM and be accompanied by the ADM throughout a service technician's inspection of lifts at the facility. Review of document title Mechanical Lift Audit by Nurse Manager 5 per week for 4 weeks revealed an audit conducted on 1/17/2025 by the DCS. Review of in-service titled Abuse/Neglect & Resident Rights reflected it was presented by DCS dated 1/17/2025 was provided to the ADM and the DON. While the IJ was removed on 01/18/2025 at 6:16 PM, the facility remained at a level of no actual harm with the potential for more than minimal harm that is was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to ensure LVN A documented Resident #1's unwitnessed fall, conducted neuros, and informed the oncoming nurse on 11/28/24. The aides continued to notify the nurses of Resident #1's pain and was not sent to the ER until the late evening on 11/29/24, where she was diagnosed with a hip fracture. The noncompliance was identified as PNC. The IJ began on 11/28/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of not receiving necessary medical care, increased pain, injury, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, pain, muscle weakness, and generalized anxiety disorder. Review of Resident #1's quarterly MDS assessment, dated 10/09/24, reflected a BIMS could not be conducted due to rarely/never being understood. Section E (Behavior) reflected she wandered daily. Section J (Health Conditions) reflected she had falls since the prior MDS assessment with one resulting in injury. Review of Resident #1's quarterly care plan, dated 11/28/24, reflected she was at risk of falls related to dementia, fatigue related to constant pacing, and quick movement with an intervention of supervising her ambulation to prevent falls or other injuries when she was unsteady. It further reflected She had the potential risk for injury due to quick pacing with an intervention of educating patient/responsible party on the risks. Review of Resident #1's incident report, dated 11/28/24 at 5:20 PM (completed on 12/05/24 at 1:16 PM) and documented by LVN A, reflected the following: Fall - Unwitnessed [Resident #1] was noted sitting on the floor in the hallway playing with a box . [Resident #1] was assessed on suspicion of fall. [Resident #1] displayed no signs of pain/discomforts. No changes to skin. Review of Resident #1's progress note, dated 11/28/24 at 5:30 PM (documented on 12/05/24 at 12:23 PM) and documented by LVN A, reflected the following: [Resident #1] noted sitting on the floor. [Resident #1] taken to room for evaluation. Active nosebleed noted. Nostril cleaned and skin is intact with no discoloration. Nose care provided and bleeding subsided. Review of Resident #1's progress note, dated 11/29/24 at 11:25 PM and documented by LVN B, reflected the following: AM an PM CNAs reported that [Resident #1] has been in bed all day and is unable to stand up or walk. I assessed [Resident #1] and she has no bruising, swelling, no abrasions, or other visual signs of fall or injury. I attempted to sit [Resident #1] up to assist with standing. [Resident #1] grabbed her right hip area and yelled. She is shaking and appears to be in discomfort when I assessed her and when I checked her v/s. Her b/p is 160/90, pulse 100. Resp 22 . [Resident #1] left to (hospital ER) at 10:18 PM. Review of Resident #1's hospital paperwork, dated 11/29/24, reflected the following: .presents to ED for right hip pain from nursing home. Unsure if she fell but has been unwilling to stand today and has an abrasion to her cheek and dried blood in bilateral nares. Work up showed: right intertrochanteric femur fracture. .[Resident #1]'s RP stated she was not sure if she would want [Resident #1] to have hip surgery. Review of witness statements obtained by the ADM, on 12/10/24, reflected the following: [CNA D] Worked Thursday (11/28/24) & Friday (11/29/24) with [Resident #1]. Thursday [Resident #1] was up as usual ambulating on the unit. Mid morning she saw [Resident #1] sit on the floor near the windows at the end of the 300 hallway, she spoke to [Resident #1] and [Resident #1] got up on her own and walked back to the common area. Later in the day she also noted that [Resident #1] was sitting on the floor apparently in the living room area by the large armchair and sofa. [CNA D] assisted [Resident #1] to get up without incident. Did not report these instances of [Resident #1] on the floor. Thursday approaching 6:00 PM [CNA D] states she went to assist charge nurse [LVN A] with [Resident #1] who was on the floor just outside the door to her room. [CNA D] says that she and [LVN A] helped [Resident #1] get off the floor and brought her into her room and bed. [CNA D] states it appeared [Resident #1] had difficulty bearing weight on her right side. They noticed blood on her pants so they checked [Resident #1] while changing her brief and noted no source of blood on her body. However [Resident #1] had dried blood on her nostrils from an apparent nose bleed. She noticed a healing abrasion on [Resident #1]'s right cheek. [CNA D] states she finished changing [Resident #1] then stayed in the room and continued to make [Resident #1] 's bed and clean up and that [Resident #1] left the room walking on her own when [LVN A] did. On Friday, [CNA D] again worked with [Resident #1] and that [Resident #1] stayed in bed for breakfast but that was not unusual for [Resident #1]. She fed [Resident #1] and she ate well. She got [Resident #1] dressed but [Resident #1] did not want to get up and leave the room. [CNA D] reported to ADON that [Resident #1] was not getting out of bed. When nearing lunch time [CNA D] again tried to get [Resident #1] up for lunch but she refused and did not want to be repositioned in bed. [CNA D] brought [Resident #1] her lunch which she ate well. On Friday around dinner time [CNA D] again went to check and change [Resident #1] who still did not want to get out of bed and appeared tired. [CNA D] reported to oncoming [CNA E] that [Resident #1] had not been up that day and was sleeping at dinner time and did not yet eat dinner. [LVN A] On Thursday she noted [Resident #1] was up and active and ate well through the day. In the afternoon [Resident #1] was sitting on the floor near her room and had a cardboard box left by another resident's family, it appeared to [LVN A] this was purposefully sitting on the floor. [LVN A] reports that [Resident #1] didn't want to get up off the floor and let the box be taken to be discarded and verbally objected in her native language. [LVN A] noted that [Resident #1] enjoyed playing with the box and considered it safe and let her continue. Around 5:30 PM [LVN A] came to assist [CNA D] who was walking with [Resident #1] to her room. [Resident #1] was agitated and [LVN A] assisted her to bring [Resident #1] to get her cleaned and changed. At this time she noticed dried blood in her nostrils, and what appeared to be blood spots on her pants. She did a head to toe body check and noted no blood, scratches, bruising or discoloration. [LVN A] saw the healing abrasion on cheek. [LVN A] states that [CNA D] cleaned, changed and got [Resident #1] dressed at this time. [LVN A] then left [Resident #1]'s room. Subsequently [LVN A] and on-coming nurse [RN F] went to [Resident #1]'s room. [LVN A] informed [RN F] that [Resident #1] had a nosebleed earlier in the day but had resolved . [CNA E] Worked Thursday evening with [Resident #1]. [Resident #1] was already in bed when she started her shift. She noted [Resident #1] was laying in bed diagonally, provided peri-care to [Resident #1] around 1:30 AM and [Resident #1] indicated pain to her right hip. She informed charge nurse [LVN C]. In the morning around 4:30 AM [CNA E] says she checked and provided peri-care to [Resident #1] who indicated pain to her hip and reported that to oncoming charge nurse [ADON]. Friday evening [CNA E] noted [Resident #1] in bed and changed her brief with charge nurse [LVN B]. [Resident #1] indicated pain to her right hip to [CNA E] and [LVN B]. [LVN B] [LVN B] states that she came in to work around 6:10 PM on Thursday. She says [CNA E] reported to her that [Resident #1] had not been out of bed overnight Thursday into Friday, and [CNA D] told her that she not gotten out of bed on Friday. [LVN B] assessed [Resident #1] and though she had no bruising or swelling to indicate a fall, that [Resident #1] complained of pain to right hip, and was unwilling/ unable to stand . [ADON] On Friday November 29th this nurse worked as a charge nurse on hall 100/200, taking care of [Resident #1]. At 6am I received report from 10-6am nurse coming off shift with no reports of change in report of said patient. I did my own rounds checking on patients starting around 6:10 am and when I went into patient [Resident #1]'s room she was sitting on the side of her bed, AOx1-2 at baseline, talking in her language with no apparent distress noted at that time. I then returned to [Resident #1]'s room to give her medication between 7am-8am and taking her vitals, which were WNL. [CNA D] came up to me around about 8-9am telling me that the pt was not walking around as her usual baseline, and that it had been going on. I stated to her that I noticed pt wasn't walking around as well and that I had assessed her and noted no bruising of any sort and that the pt was sitting up for me and no c/o pain, so I then monitored her throughout my shift. I also checked her chart and noticed there was no documentation regarding any falls or change in her condition. At 10:18 am the DON called my phone and being that she usually covers the MC I asked her about any changes to said patient, and I let her know that since no one else made any documented notes, that I would. My note is in the patient's chart for 11/29/2024. [LVN C] [LVN C] states that [Resident #1] was in bed during her shift and that [CNA E] reported to her that [Resident #1] had difficulty standing when she cleaned and changed her brief. [LVN C] states she went to check on [Resident #1] after that and that she was sleeping, and she decided not to wake her as [Resident #1] usually sleeps through the time. She says she had no other interaction with [Resident #1] during the remainder of her shift. During an interview on 12/10/24 at 10:12 AM, the ADON stated she worked the floor on the MCU (where Resident #1 resided) on 11/29/24. She stated she relieved the night nurse at 6:00 AM (LVN C) and she did not relay any changes regarding Resident #1. She stated she did her initial rounds and Resident #1 did not appear to be in pain. She stated she ate breakfast in bed that morning and she typically walked around throughout the day, but thought she just needed the rest. She stated because her vitals were stable and she noted no abnormal changes, she had no reason to think anything was wrong with her wanting to rest. She stated around 9:00 AM, CNA D came to her and told her Resident #1 still did not want to get out of bed. She stated there were no notes in her chart that anything had happened the day before so she figured she would continue to monitor her since nothing was out-of-whack. She stated around 10:18 AM, she called the DON because she knew she had worked the day prior (11/28/24) and asked her if she knew if anything had happened with Resident #1 because she was not walking around that day. The DON told her she had not been aware of anything. She stated Resident #1 had a history of sitting down on the floor. She stated if an aide found her sitting on the floor, they should get a nurse so an assessment could be done as it should be seen as an unwitnessed fall. She stated if LVN C was notified by the aide during the night of 11/28/24 that Resident #1 was in pain, she should have assessed her no matter what, even if she was sleeping. She stated LVN C should have also documented that. She stated she did notice some dry blood to Resident #1's nose as if she had a nosebleed. She stated because nothing from the day before had been documented, she did not know anything about it (the fall). She stated it would have been important for this to have been documented so that she could have followed up. During an interview on 12/10/24 at 10:40 AM, LVN B stated she came in on 11/29/24 just to assist with medication pass from 6:00 PM - 10:00 PM. She stated CNAs D and E approached her and asked her to go check on Resident #1 as something was very wrong. She stated CNA D told her she had been in bed all day, had not been out of bed since the day before, did not think she could walk, and insinuated she could not get out of bed due to pain. She stated CNA D told her she had told the nurse about her pain and felt like something needed to be done. She stated she immediately went and assessed Resident #1 and she was shaking in excruciating pain while her vitals were elevated. She stated she gave her Tylenol until she could get ahold of the doctor, but it did not seem to alleviate her pain. She stated she still could not get ahold of the doctor, so she called the DON and notified her she was sending her out to the ER because she had been in bed since the day before and that was not normal for her. She stated Resident #1 did not have a history of sitting on the ground but did have a history of squatting to poop on the floor. She stated an aide should never pick her up if she was found on the ground before getting a nurse for an assessment. She stated she had recently been in-serviced on change in condition, reporting incidents, abuse and neglect, and unwitnessed falls by the DON. She stated everything regarding the resident (incidents, falls, changes in condition) should always be documented in residents' progress notes to ensure all staff knew what was going on with the resident. During a telephone interview on 12/10/24 at 11:01 AM, CNA D stated Resident #1 was found three times on the ground on 11/28/24. She stated she helped her up each time because she was her resident. She stated she normally walked around the unit really fast, almost like she was running. She stated she was slow on 11/28/24 and she thought something had happened. She stated the first time she was on the floor she picked her up and Resident #1 ran away. She stated the second time she found her on the floor in the living room around 2:00 PM. She stated the third time she was in the activity room on the ground, so she picked her up and put her in a chair. She stated after her break, she heard Resident #1 screaming in pain. She stated she went to her room where LVN A was and told the nurse she was not normal. She stated between the both of them, they tried to help her stand, but she could not because of weakness and pain to her right side . She stated the next day, 11/29/24, she ate breakfast in bed, which was not abnormal for her. She stated she did not want to get up after breakfast or for lunch. She stated that was when she told the ADON she normally got up for lunch, but she refused. She stated she told her Resident #1 was shaking and had pain to her right side. She stated she left her in bed the whole day because she was in pain, and she felt bad. She stated she told the ADON several times throughout the day. She stated when the night CNA (CNA E) arrived that evening, they talked about how something was wrong with Resident #1 as she was shaking and in pain. She stated they notified LVN B who assessed her. She stated she had recently been in-serviced by the DON on notifying a nurse when a resident was on the ground, falls, pain management, and abuse and neglect . She stated she should never pick up a resident off the floor without notifying a nurse first to ensure they were not injured. During an interview on 12/10/24 at 12:10 PM, the DON stated she went to the MCU on 11/28/24 between 3:00 - 3:15 PM and physically saw Resident #1 sit herself down on the floor. She stated if an aide ever found a resident on the ground, they needed to treat it as an unwitnessed fall. She stated the nurses would need to complete an assessment and start neuro checks prior to getting the resident off the floor. She stated after interviewing staff, she was informed of two other instances where she was found sitting on the ground that day. She stated LVN A told her she found her sitting on the ground, she assessed her, and cleaned her bloody nose from having dry nostril membranes. She stated the reason LVN A documented in Resident #1's EMR seven days later was because she asked her to. She stated LVN A verbally told her she assessed the resident but did not document it, so she verbally asked her to put it in later. She stated that did not meet her expectations as it needed to be documented the same day . She stated she did not hear about anything abnormal with Resident #1 until 11/29/24 at 10:30 AM when the ADON called to ask her if anything had happened. She stated nobody informed her of any falls, being in pain, or not being able to be repositioned. She stated she did not find out about the pain she was in or her not being able to stand until later that night (11/29/24) by LVN B. She stated her expectations were that she be notified of any change of condition . She stated neuro checks should have been completed by LVN A. She stated the nursing team really dropped the ball. She stated she immediately began in-servicing all nursing staff and they did not work their next shift until they were in-serviced. She stated they were just notified that morning (12/10/24) that Resident #1 was discharged to another facility and would not be returning. During an interview on 12/10/24 at 12:51 PM, CNA G stated she had recently been in-serviced on abuse and neglect, change of condition, notifying a nurse when a resident was on the ground, and pain management. During a telephone interview on 12/10/24 at 12:57 PM, LVN A stated on 11/28/24 Resident #1 was very active throughout the day. She stated closer to the evening time she saw her sitting on the floor playing with a box. She stated a little bit later, she saw a CNA walking her to her room and she was fighting her. She stated she noticed blood coming out of her nose, so she went and did a full skin assessment and took her vitals. She stated she had just forgotten to document anything from that shift. She stated she could not remember if she told the on-coming nurse about her sitting on the floor as she did not think it was a big deal. She stated she saw Resident #1 at the end of her shift (around 10:00 PM) and she was sleeping peacefully. During a telephone interview on 12/10/24 at 1:10 PM, LVN C stated she worked overnight on 11/28/24. She told her CNA E did not tell her Resident #1 was in pain, but that she had trouble standing up. She said she went to assess her, but she was sleeping. She stated in the morning she told LVN A she was not able to walk. She stated when she came back that evening (11/29/24), LVN B told her she was still not getting out of bed. She stated she told LVN B she told LVN A that morning that something was wrong, and it had to have been from a fall or something. She stated if she would have known Resident #1 had a fall when CNA E told her she was having trouble standing, she would have notified the NP immediately, tried to get her up, and sent her to the hospital. She stated she had recently been in-serviced by the DON on change in condition, pain management, abuse and neglect and documentation. She stated it was important to document all incidents and resident change of condition to ensure all staff were aware of what was going on with the resident. She stated neuros were important after an unwitnessed fall to ensure the resident did not have a change in their mental status. During a telephone interview on 12/10/24 at 1:20 PM, CNA F stated during the night shift on 11/28/24, Resident #1 was in a lot of pain. She stated when she tried to change her brief and turned her on her right side she started moaning in pain. She stated she immediately notified LVN C and asked her if anything had happened to her. She stated when she changed her before the end of her shift (at 6:00 AM on 11/29/24), she reacted the same way. She stated she told LVN C and the ADON of the pain she was experiencing. She stated she had recently been in-serviced by the DON on pain management, change in condition, and abuse and neglect . She stated she should never get a resident off the floor before notifying a nurse so they could assess for injury. Review of a PIP created by the DON, dated 12/05/24, reflected the following: Problem Area Identified: Inconsistency documenting and following the Accident/Incident process Changes Implemented to reach baseline: 1. Identify all patients with accident/incident reports 2. After morning report, ensure accident/incident process is opened and if not have, have nurse open before returning to the floor. 3. Accidents and incidents discussed daily at stand up and stand down - ongoing. 4. Ensure accident/incident process is opened, reports are completed, treatments are documented, process for unwitnessed falls have neuro checks initiated, and investigations are completed accordingly - ongoing 5. Audit accident/incident reports for completion daily. - ongoing 6. In-services: Accidents/Incidents, Change of Condition, Pain, and MD notification - 12/2/24 7. Education: Pre/Post test on Accidents/Incidents, Pain, and Change of Condition. 12/5/24. Review of an In-service entitled Change in Condition, Pain Management, and MD Notification, dated 12/02/24 and ongoing and conducted by the DON, reflected nursing staff were educated on patient care model systems, pain, change of condition, and physician notification. Review of an In-service entitled Charting and Documentation, dated 12/02/24 and ongoing and conducted by the DON, reflected nursing staff were educated on the importance of documentation and their Charting and Documentation Policy. Review of an In-service entitled Accidents/Incidents, dated 12/02/24 and ongoing and conducted by the DON, reflected nursing staff were educated on their Accident/Incident Report Policy. Review of an In-service entitled Abuse Protocol, dated 12/02/24 and ongoing and conducted by the DON, reflected nursing staff were educated on their Abuse and Neglect Policy. Review of the facility's undated Pain Management Policy, reflected the following: 1. A pain Assessment must be completed for a patient upon admission, including re-admission, the onset or an increase in pain, quarterly, and with any significant change in the patient's condition. Review of the facility's Change in Condition Policy, revised January of 2024, reflected the following: A significant change in Resident's status is any sign or symptom that is: - Acute or sudden onset - A marked change (i.e., more severe) in relation to usual signs and symptoms - New or worsening symptoms Review of the facility's Physician Notification Policy, revised January of 2024, reflected the following: The nurse will: - Recognize the condition change. - Monitor the patient and continue to assess the condition and changes. - Notify the physician, patient and representative of any changes in condition. Review of the facility's Charting and Documentation Policy, revised July of 2017, reflected the following: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Review of the facility's Accidents/Incidents Policy, dated May of 2016, reflected the following: 1. An Accident/Incident Report must be completed immediately upon facility staff becoming aware of the occurrence an accident/incident . Review of the facility's Abuse and Neglect Policy, dated April of 2019, reflected the following: 1. The patient has the right to be free from abuse, neglect, mistreatment of resident property, and exploitation . The noncompliance was identified as PNC. The IJ began on 11/28/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents reviewed (Resident #1) for pain management. The facility failed to ensure Resident #1 received a new [MEDICATION(S)] (narcotic pain relief) patch or [MEDICATION(S)] (medication for nerve pain) according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents who receive pain management at risk of worsening pain and injury to other residents. Findings included: Review of face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital records for Resident #1 dated 4/21/2022 reflected the following: Chronic pain -hx of 2/2 cancer, cancer treatments -[MEDICATION(S)] increased per PM&R -cw [MEDICATION(S)] patch and [MEDICATION(S)] -defer to PM&R Review of MDS assessments for Resident #1 reflected that he had no completed assessments. Review of care plan for Resident #1 dated 4/26/2022 reflected the following: Pain Management Acute/Chronic. (Resident #1) and family/caregiver will actively participate in assessment of pain, establishing pain management goals, and plan over the next 90 days. Assess (Resident #1) ability to use pain reporting scale and document scale preferred, verbal descriptor scale, routine intervals and before/after specific activities: Assess (Resident #1) for change in bowel habits, appetite, and ability to rest/sleep. Monitor (Resident #1) for signs of depression with respect to pain management. Engage (Resident #1) and family/caregivers to identify a pain management goal of acceptable pain level that will allow (Resident #1) to perform ADLs and other activities. Document this as the acceptable level of pain control. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 5 mg one tablet by mouth every four hours as needed starting 4/24/2022 for pain -[MEDICATION(S)] 25 mcg/hr transdermal patch. Every three days starting 4/24/2022 for pain -[MEDICATION(S)] 12 mcg/hr transdermal patch. Every three days starting 4/24/2022 for pain -[MEDICATION(S)] 50 mg capsule two tablets three times daily starting 4/23/2022 for hereditary and idiopathic [CONDITION(S)] Review of April 2022 MAR for Resident #1 reflected the following: [MEDICATION(S)] patch 25 mcg and 12 mcg were due to be give on 4/24/2022 at 9:00 a.m., and the note reflected Not Administered (Other). [MEDICATION(S)] 50 mg was due to be given 4/23/2022 at 9:00 p.m., 4/24/2022 at 9:00 a.m., 1:00 p.m., and 9:00 p.m., and 4/25/2022 at 9:00 a.m. and were not administered. Review of telephone orders for Resident # dated 4/23/2022 reflected an interim telephone order for Tylenol #3 with [MEDICATION(S)] every four hours as needed for pain. Review of nursing notes written by LVN B for Resident #1 reflected the following: -4/23/2022 at 9:00 p.m. - At (8:00 p.m.) patient was given PRN [NAME] #3 for neck and throat discomfort. He says I was about to call 911 and say I was having a [CONDITION(S)] so I could go to the hospital and get some pain meds. Patient denies pain at this time, states the [NAME]#3 has helped him get relief from discomfort. Says he's going to try to sleep at this time. -4/24/2022 at 9:53 a.m. - Patient was resting with eyes closed at 0800[8AM] when I entered his room. He woke and stated he slept well all night. He requested [NAME]. #3 for 5/10. neck pain. Stated I hope I will continue to feel okay until tomorrow. Patient is up in his w/c self mobile in facility. Came to nurses station looking for vending machines. Self mobile in w/c, denies pain at this time. Patient smiling, talkative and friendly. -4/24/2022 at 5:00 p.m.-Patient is self mobile and self transfers as needed. Comes to nurses station frequently to speak with nurses. He has received most of his medications taken from the E-Kit. Some medications arrived from pharmacy today. He denies SOB. HHN tx done per orders. Cleaned inner [CONDITION(S)] x2 at his request. No suction needed. Alert and oriented. Given PRN [NAME] #3 every 4 hours for 5/10 neck and throat pain. Refuses Ibuprofen prn as ordered. Patient denies he's having withdrawal symptoms today. States his [MEDICATION(S)] patch with [NAME]#3 is effective for pain relief. Except for the [MEDICATION(S)] and [MEDICATION(S)] patches, all medications were taken from our e-kits and administered to patient. -4/25/2022 at 2:11 a.m. by - Continues to request [NAME] #3 every 4 hours for 5/10 neck pain. Last dose was given at 1200 midnight. Patient just came to nurses station in w/c requesting more [NAME] #3. Reminded patient that both nurses came in at 1200 am and he took it at that time. Patient states he had forgotten and states he has 5/10 neck pain. He was offered PRN Ibuprofen but refused. Assisted him back to his room. Resting now with eyes closed. No SOB. Audible wheezing is noted. O2 sats 95% on room air. Pulse 80. Review of nursing notes written by the DON for Resident #1 reflected the following: -4/23/2022 at 2:00 p.m. - I was at the facility 4/23/22, so i stopped in to check on the resident. Still w/o complaints. Medications haven't been delivered yet; however, our pharmacy cut off time is 1800[6PM] (around the time he came to us). I anticipate pain medications to be delivered tonight. Resident w/o complaints. L [CONDITION(S)], up w/ SBA. Call light within reach. -4/23/2022 at 6:00 p.m. - Nursing staff called to let me know that the resident was c/o some pain, but mostly withdrawals from pain medications administered at previous facility. Resident told the nurse that he used to be a heroin addict and needs something to take the edge off. Withdrawal s/s reported so far are loose stool and sweating. Nursing instructed inform the NP/MD on-call and request alternative pain medications. -4/24/2022 at 1:00 pm - I received a call from (admissions) inquiring if the resident had all of his medications. Per (admissions) the CM from (previous facility) contacted him after speaking to the resident's (family member)/RP. Nursing hadn't contacted me, so i told him that I would look into it. I contacted (LVN) and she confirmed the controlled medications weren't at (current facility). [MEDICATION(S)] and [MEDICATION(S)] were reportedly delivered by (pharmacy) this AM and the rest of his medications, excluding controlled prescription were delivered by (pharmacy delivery company) last night. Nursing instructed to contact NP/MD for guidance. Per nursing, Tylenol #3 controls pain. Per nursing resident has been happy and sleeps w/o issues. -4/24/2022 at 9:00 p.m. - I checked on the resident again. Nursing confirms pain is controlled. I called the resident's (family member)//RP and discussed the situation and current pain management interventions. On-call NPs won't prescribe anything stronger than [MEDICATION(S)] or Tylenol #3. Resident's pain is controlled by Tylenol #3. Primary NP or MD will see resident in AM and can order something stronger if need be. I did page primary NP today to see if we could discuss the resident's medications, text wasn't responded to. RP seemed satisfied with plan. Nursing to call MD/NP for uncontrolled pain. During an interview on 4/26/2022 at 8:58 a.m., the ADM stated she and the DON could not determine how to make the results of pain assessments available for review. They were able to pull up pain assessments that was affiliated with administration of Tylenol #3 to Resident #1 as needed, and the Surveyor was able to view it on the ADM's computer. Review of PRN medication (Tylenol #3) administration pain assessments as presented by the ADM on 4/26/2022 for Resident #1 reflected the following: -4/23/2022 Night Shift 5/10 (4/24/2022 3:14 a.m.) -4/24/2022 Evening Shift 5/10 (4/25/2022 4:39 a.m.) -4/24/2022 Night Shift 7/10 (4/25/2022 3:04 a.m.) -4/24/2022 Day Shift 5/10 (4/25/2022 4:39 a.m.) No pain assessment was available in the A.M. for Resident #1. Review of follow-up pain assessments provided by the ADM in an emailed document on 4/26/2022 for administration of PRN medication for Resident #1 reflected the following: -4/23/2022 at 8:00 p.m. Follow-Up after Administration of Tylenol #3 pain level 0/10 -4/24/2022 at 8:04 a.m. Follow-Up after Administration of Tylenol #3 pain level 0/10 -4/24/2022 at 12:16 p.m. Follow-Up after Administration of Tylenol #3 pain level 0/10 -4/25/2022 12:09 a.m. 0/10 after resident medication arrived and was administered During observation and interview on 4/25/2022 at 9:40 a.m., Resident #1 was laying in his bed and sat up when addressed with controlled but forceful, jerking movements as if he was very angry. He had a [CONDITION(S)] and was only able to speak in a whisper. Resident #1 stated he had arrived on Friday 4/22/2022 from another rehab facility and had terminal cancer. He stated he had been on [MEDICATION(S)] for the last seven months and he had not received any pain medication since he had arrived at the facility. He stated he was in excruciating pain from his neck down to his left arm and his legs. He stated he was furious but if they took care of him and got him his medication right away, they might be able to salvage the situation. During an interview on 4/25/2022 at 9:57 a.m., LVN A stated it was her first day back at the facility after her regular days off, and Resident #1's medications had just arrived that day and still needed to be counted in . She stated she had just been in the room and was trying to convince Resident #1 to allow her to apply his breathing treatment, but he was too angry about his pain medications and was refusing . She stated she had given him pain medication at 9:00 a.m., and at that time, he stated he was at a 9 or 10 of 10 on the pain scale. She stated she did not know why his medications had not arrived until that day, but she was assuming that the nurse who admitted had gone over the orders with the doctors. She stated that she did not know whether he was on [MEDICATION(S)] or what orders he had from the hospital, but she had been gone when he admitted . She stated she had just given him Tylenol #3 with [MEDICATION(S)] from the eKit, and she believed he had received it all weekend whenever he was in pain . Observation on 4/25/2022 at 9:54 a.m., LVN A revealed that the eKit on the medication cart serving Resident #1's hall (hall 800) contained APAP w/[MEDICATION(S)] #3 300 mg/30 mg with 12 tablets remaining . Review of a document on the medication cart for hall 800 titled Controlled Substance Emergency Kit Usage Log reflected the following administrations for Resident #1: 4/23/2022 7:30 p.m., 4/24/2022 12:00 a.m., 4/24/2022 8;00 a.m., 4/24/2022 12:00 p.m., 4/24/2022 4:00 p.m., 4/24/2022 8:00 p.m., 4/25/2022 12:00 a.m., 4/25/2022 8:54 a.m. During an interview on 4/25/2022 at 10:25 a.m., Resident #1 stated that he had been receiving pain medication with [MEDICATION(S)], but it was not as strong as the medications he had been receiving. He stated it was not enough to keep him out of pain and the facility should have given him his real medications. During an interview on 4/25/2022 at 10:40 a.m., the DON stated Resident #1 also had [MEDICATION(S)] patches, and that with 37 mcg of [MEDICATION(S)], his pain should have been largely controlled even if he had been taking [MEDICATION(S)] and was only given Tylenol #3 with [MEDICATION(S)] for the past few days. She stated that the [MEDICATION(S)] was not at the facility over the weekend, and they obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that, if the hospital did not send the prescriptions to the pharmacy with the triplicate signed by the hospital physician, they were not able to receive the medications until their physician returned after the weekend. Observation on 4/25/2022 at 1:33 p.m. revealed all of Resident #1's medications were present on the medication cart for hall 800 and consistent with physician orders, with the exception of [MEDICATION(S)] 50 mg, [MEDICATION(S)] 10 mg, or either [MEDICATION(S)] patch (12 mcg/hr or 25 mcg/hr). Observation on 4/25/2022 at 1:50 p.m. revealed Resident #1 was in a position that made his [MEDICATION(S)] patches impossible to observe and was not able or willing to move to make them observable to the Surveyor. During an interview on 4/25/2022 at 1:50 p.m., LVN A stated that the [MEDICATION(S)] patches on Resident #1's shoulder were dated 4/23/2022. During an interview on 4/25/2022 at 2:35 p.m., LVN A stated that the [MEDICATION(S)] patches were dated 4/21/2022. When asked why she previously stated the patches had been dated 4/23/2022, she denied that she had done so. When asked when the patches should have been replaced, she stated she had just come back that day (4/25/2022) and only knew they were not on her schedule to administer. When asked if he might be experiencing pain after wearing [MEDICATION(S)] patches that should have been changed on 4/24/2022 according to physician orders, she did not answer . During an interview on 4/26/2022 at 8:28 a.m., the NP said she did not see Resident #1 because he admitted late Friday 4/22/2022, and she did not work weekends. She stated she had reviewed his chart on 4/25/2022 and had concerns about why he took so much pain medication. She stated she was somewhat aware his controlled medications had not arrived at the facility until 4/25/2022. She stated that was the hospital's responsibility, as there was no way they could obtain those kinds of prescriptions over the weekend when there was no doctor available to sign the triplicates. She stated the hospital had the ability to ensure the medications were sent to the pharmacy, and someone at the hospital failed to do so. She stated the on call nurse practitioner was contacted frequently during the weekend to ensure Resident #1's pain was addressed, and she returned Monday 4/25/2022 to an entire weekend of notes related to the facility's attempts to control the resident's pain. She stated when she looked over her notes, there was no report the resident's pain was uncontrolled over the weekend. She stated the on call nurse practitioner cannot start new medications; they can only prescribe one time administrations and confirm the orders that the resident already had. She stated what the facility failed to do was to contact the transferring facility (the hospital) to ensure the orders had been sent to the pharmacy or contacted the pharmacy to ensure they had the orders. She stated she knew Resident #1 admitted late, and it was unlikely that the hospital would have cooperated at that hour, but the pharmacy would have responded. However, the pharmacy would not have been able to do anything until it received the triplicates. She stated she knew it was the hospital's responsibility, but the resident still needed to have his medications and have his pain controlled. She stated she understood there should have been a process that ensures nothing like this fell through the cracks, and this process should have been overseen by the person who approved the resident's admission. She stated she was not entirely sure who this should have been, as she did not have very much contribution to the facility's processes. She stated she did not believe Resident #1 had been in uncontrolled pain all weekend, as the facility worked very hard from the time of his admission to the time that the medications arrived to ensure his pain was controlled . During an interview on 4/26/2022 at 8:55 a.m., the ADM stated that the hospital was supposed to send all medication orders to their pharmacy at the same time as they sent the resident to the facility, but the case manager at the hospital was new and did not complete the task. She stated she had only been at the facility for one week and was not aware of any backup plan but would be creating one. She stated she was still getting to know residents and staff and had not had time to review or create any new systems. She stated they had been interviewing the staff who worked with Resident #1 over the weekend, and he was not in uncontrolled pain at any point. She stated he was afraid of going through withdrawals due to his long history of opiate use, but he was not hurting significantly. She stated he said himself that the hospital should have ensured the controlled medications would be delivered to the facility, but he expected they would all arrive first thing Monday morning, 4/25/2022. When they were not there Monday morning, he was infuriated. She stated the procedure the facility staff should have taken when medications were not available was to call the on call NP and get orders for what was not on hand. She stated they did that all weekend and charted the situation and were very attentive to Resident #1 and his comfort, and the on call NP stated to administer Tylenol #3 until the other medications arrived. The ADM stated she was at the facility over the weekend, as well, and had visited with Resident #1. She stated when she saw him, he was happy and pain free. She stated she was not aware all three of his pain medications had not arrived. She stated that it was her mission to ensure that new residents have good admissions. She stated no one should have to be in uncontrolled pain. She stated that it was possible that the resident started to be in a lot more pain when it was a full 24-hours after his [MEDICATION(S)] patches should have been replaced. She stated since the beginning of the admission, before Resident #1was admitted , the communication could have been better. The poor communication with all players involved set them up for failure and may have resulted in Resident #1 experiencing pain on the morning of 4/25/2022. During an interview on 4/26/2022 at 9:15 a.m., LVN B stated she had been the charge nurse who had admitted Resident #1. She stated her process and procedure for new admission was to enter the resident into the EMR and enter the orders and then make sure the medications had arrived from the facility. She stated she called the pharmacy and sent them the orders but was told they required triplicates, and the pharmacist stated they would not be able to send the medications until the doctor signed, which she knew would not happen over the weekend. She stated there was not much she could do, so she contacted the on call NP and got orders to administer pain medication out of the eKit. She stated she notified the ADM who was physically in the building at that time. She stated she does not approve resident admissions , but if it had been up to her, she would have known that with a new admission on a Friday night and all those controlled medications, there was no way that was going to turn out well. She stated her DON, and her ADM were aware, and her DON knew none of her controlled medications were there. She stated they had conversations over the weekend (4/23/2022-4/24/2022) about all three of the medications not being at the facility . She stated she initially called the on call NP to tell them what was going on. She stated Resident #1 was not in pain at that point but was very afraid of opiate withdrawal. She stated she had the resident on speaker phone with the on call NP, because he was so nervous. She stated the NP asked for a list of what his discharge orders were, and she said she would call back. LVN B stated she called back within fifteen minutes and said to give Resident #1 Tylenol #3 every 4-6 hours, and that's what she did. She stated she took Tylenol #3 out of the eKit. She stated that he told her she was lucky she had brought the pills, because he had been planning to call 911 and fake a [CONDITION(S)] to get his medication from the hospital. She stated she told him he would not have to ask, and she would come to him and ask him every four hours when it was time for him to have another round of the medication. She stated she kept it going every four hours and passed on to the next shift that they needed to make sure they did not wait on the medication . She stated she never saw him in pain. She stated his pain scale was 5 of 10 in his neck every time she asked and 0/10. He declined ibuprofen when offered because the Tylenol #3 was effective. During an interview on 4/26/2022 at 11:36 a.m., the DON stated she was aware that Resident #1's [MEDICATION(S)], [MEDICATION(S)] patches, and [MEDICATION(S)] had not arrived at the facility until Monday 4/25/2022 . She stated she was made aware of that on Saturday 4/23/2022 and Sunday 4/24/2022. She stated she had claimed in an earlier interview that the [MEDICATION(S)] would keep him out of pain because she did not know the exact administration schedule and did not realize he should have received it on the morning of 4/24/2022. When asked if it would be consistent with facility procedure for her to have started an investigation into whether Resident #1's pain was controlled as soon as she learned his pain medications had not been delivered, she said Absolutely and then explained that all the reports she was getting were that he was comfortable and not in pain. She stated the process to ensure a resident who was newly admitted had everything was that their hospital liaison, who was an employee of the facility, started seeing what all they needed. She stated then she (DON) reviewed the resident's clinicals and what all they needed medically, such as DME or pain management. She stated the hospital should have sent the prescriptions to the pharmacy, and that should have been verified by the hospital liaison. She stated when the resident arrived, the charge nurse verified the medications and orders. She stated that, ideally, what they needed to do was call the pharmacy and speak to the pharmacist. She stated once the resident was out of the hospital, the hospital would no longer help them. She stated she did look at the clinicals for Resident #1 briefly before approving the admission. She stated she knew from the clinicals that the medications would not arrive Friday night, but she stated they usually arrived by the next night. She stated she did not put any intervention in place Friday night to ensure the resident was not in pain, because he still had new [MEDICATION(S)] patches, and the staff knew to call the on call nurse practitioner if the resident was in pain. She stated she did not hear anything from the facility about it on Saturday 4/23/2022 night and assumed the medications had arrived. She came up to the facility on Sunday 4/24/2022 for another reason and discovered they had still not arrived. She stated she spent a lot of time with LVN B on Sunday speaking to the NP and making sure Resident #1 was covered for pain. If his numbers are high or uncontrolled. She stated she was very big on pain management and was very involved in Resident #1's situation over the weekend. She stated there were not any real issues until Monday morning 4/25/2022, and she was so busy working with the Surveyors that she stopped tracking. She stated that LVN A was caring for the resident, and LVN A was a very experienced and competent nurse who she has known for a very long time, so she knew the resident was in good hands. She stated that it was possible that Resident #1 might have experienced pain when his [MEDICATION(S)] patch wore off. Review of facility's policy Pain Management dated March 2016 reflected the following: 1. A Pain Assessment must be completed for a Patient upon admission, including re-admission, the onset or an increase in Pain, quarterly and with any significant change in the Patient's condition. 2. Every Patient must be assessed for pain utilizing the Pain Intensity Scale (Faces/0-10) and or PAINAD for the non-verbal, cognitively impaired patient. 3. If a Patient's Pain intensity score is greater than or equal to 1 or has been assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. If a Patient is assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. If a Patient is assessed for unrelieved Pain, the nurse must notify the attending physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan must be completed and/or updated for any changes to Pain Management interventions. 7. The Monthly Quality Assurance & Performance Improvement Meeting (PCMS 19) must include a review of appropriate and timely usage of the Pain Assessment, the intensity score, and the use of appropriate Pain relieving measures. Review of facility's policy Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . GUIDELINES: Obtain order from physician authorized/designee. Read order back (TORB) to physician/designee to verify and/or clarify. Fill out telephone order form completely. Orders to be carried out as stated by physician .

Based on interview, and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare, the safety of individuals in the facility, and the resident's needs cannot be met in the facility for one (Resident #1) of one resident reviewed for discharge rights. The facility failed to have evidence Resident #1 was appropriately discharged when he left the facility while OOP. Resident #1 spent the night outside of the facility after his discharge, he did not have a place to go access to food, water, a restroom, or his medications. These failures resulted in an Immediate Jeopardy situation on 9/15/2021 at 5:48 p.m. While the IJ was removed on 9/21/2021, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions. The facility's actions included a potential for harm to Resident #1 because he was discharged without his prescribed psychiatric medication and shelter. Resident #1 was left outside the facility for 15 hours, from 09/07/2021, at 3:30 p.m., until 09/08/2021, at 8:00 a.m. Resident #1 missed his evening and morning [MEDICATION(S)] and [MEDICATION(S)] dosage, as well as his evening and morning meal. This deficient practice could affect residents being discharged unsafely and could result in placing them at risk for serious physical harm, pain, mental anguish, or emotional distress, and having their discharge rights violated. The facility's actions included a potential for harm to Resident #1 because he was discharged without his prescribed psychiatric medication. Resident #1 was left outside the facility for 15 hours, from 09/07/2021, at 3:30 p.m., until 09/08/2021, at 8:00 a.m. Resident #1 missed his evening [MEDICATION(S)] dosage, and his evening meal. Findings included: Review of Resident #1's Face Sheet printed 9/8/2021, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's MDS, dated [DATE], reflected he was cognitively intact as indicated by his BIMS score of 14. Resident #1 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 received antipsychotic, antianxiety, antidepressant, and hypnotic medication for six of the last seven days. Resident #1 exhibited no wandering behavior. Review of Resident #1's Care Plan dated 5/20/2021, reflected he was taking [MEDICATION(S)] to treat [CONDITION(S)] and [CONDITION(S)] disorder, [MEDICATION(S)] to treat anxiety, and [MEDICATION(S)] to treat mood disorders. Resident #1 needed supervision with his ADL's, transfers, and repositioning. Resident #1 was a fall risk as result of his medication. A review of Resident #1's Progress Notes reflected on 9/7/2021, at 3:30 p.m., CN signed him OOP. A further review of Resident #1's Progress Notes reflected an entry on 9/7/2021 at 3:30 p.m., signed by CN which stated [Resident #1] called a cab and left facility out of side door without informing staff where he was going. [Resident #1] left alert and oriented X4. A review of a document titled Release of Responsibility for Discharge AMA, and dated 9/7/2021, reflected the ED and the CN signed the form. A further review reflected Resident #1 did not sign the form. In an interview on 9/9/2021 at 9:33 a.m., the ED stated she had been at the facility for about five months. She stated on 9/7/2021, during a meeting with the SW, she was told Resident #1 patted [Resident #2] on the head and told her 'she was a good resident. The ED stated Resident #2 said she felt uncomfortable but was not afraid of Resident #1. The ED stated she was aware Resident #1 had two manic episodes in the last five months. The ED stated the CN informed her Resident #1 left the facility through the side door around 3:00 p.m., on 9/7/2021. The ED stated staff attempted to redirect Resident #1, but they failed, and he left the premises via taxi. The ED stated the SW notified the police at 3:30 p.m., and they were rerouted to a nearby McDonald's where Resident #1 was located. The ED stated she went to the McDonald's and conversed with the police; she stated the police told her they let Resident #1 leave because he answered their questions appropriately. The ED stated she made the decision to discharge the Resident #1 AMA later that day because he did not go out on a therapeutic pass. The ED stated she consulted with RCN that Resident #1 left AMA because they don't know where he is. The ED stated she let the CN know Resident #1 left the facility and the CN completed his discharge paperwork. The ED stated at 5:30 p.m., that same day, the SC notified her Resident #1 was banging on the side door. The ED stated she went out to speak with Resident #1, at which time he became verbally aggressive and physically intimidating, she stated she informed Resident #1 he was discharged AMA because he left the facility without saying where he was going. The ED stated she called the police later that evening because Resident #1 was causing spitting on the windows and rubbing his bare torso on the glass. The ED stated the police told Resident #1 he could go to the local psychiatric hospital, the ER, or leave the premises at which time the resident walked to the curb across the street. The ED stated the NN called the police around 11:00 p.m. because Resident #1 was attempting to break a window with an object, she stated the police asked her if they wanted to press charges, the ED said no, and the police left. The ED stated she arrived at the facility on 9/8/2021 at 7:00 a.m., and staff told her Resident #1 had been wandering the grounds the previous night and that morning. The ED stated she did not know if he had been outside all night, she stated the police arrived at 8:00 a.m. The ED stated the police tried to place the resident in a local Psychiatric Hospital, and the resident agreed to go. The ED stated she filed criminal trespassing charges against the resident. In an interview on 9/16/2021 at 9:00 a.m., the ED stated she had never discharged a resident AMA before she discharged Resident #1. She stated she was aware of one other resident who had been discharged AMA from the facility, she stated the SW handles resident discharges. The ED stated the nursing team tried to redirect him when he attempted to exit out the side door, she stated staff had no idea where he was going when he left the facility. The ED stated she conferred with Resident #1's PNP, his physician, and his NP, on 9/7/2021, and stated they supported her decision to discharge Resident #1 AMA . The ED stated she spoke to Resident #1 about discharging him AMA, and he became aggressive. The ED stated she did not know the CN signed Resident #1 OOP on 9/7/2021 at 3:30 p.m., the ED stated she did not know where Resident #1 spent the night of 9/7/2021. In an interview on 9/9/2021 at 12:48 p.m., the SC stated she saw Resident #1 exit the facility via the side door on 9/7/2021, at 3:00 p.m., the SC stated she tried to speak with Resident #1, but he entered the taxi he called, and left the premises. The SC stated Resident #1 returned to the facility later that same day after grocery shopping and tried to enter via the side door. SC stated she motioned for Resident #1 to come to the front door, which he did. The SC stated the ED spoke to Resident #1 outside the facility, she but did not hear the conversation. The SC stated the police arrived and had Resident #1 move across the street, which he did. The SC stated the police left and Resident #1 went to the West side patio and sat in a rocking chair. The SC stated the ED went home and notified staff Resident #1 was officially discharged and not allowed back inside the facility. In an interview on 9/9/2021 at 1:40 p.m., the SW stated Resident #1 was admitted to local mental health hospital in August 2021 because he was displaying aggressive behaviors. The SW stated Resident #1 returned to the facility about three weeks later with no marked improvement with his aggressive behaviors. The SW stated Resident #1 slammed the door to his room in the PNP's face, grabbed a housekeeper's arm, and shoved his fist in the SW's face on 9/7/2021. The SW stated staff told her Resident #1 exited the facility via the side door, she stated she went outside to look for Resident #1. The SW stated she arrived at the facility on 9/8/2021 at 8:30 a.m., and stated the ED told staff to not let Resident #1 in. The SW stated resident discharges began on the day of admission, she stated reasons for discharge included patient request, the facility not meeting their needs, resident death, and to the community. SW stated this discharge went South. In an interview on 9/14/2021 at 11:57 a.m., Resident #1, who was residing at ent at a local mental health hospital, stated he left the faciity on [DATE] at 3:30 p.m., to go shopping at Walmart. Resident #1 stated he was stopped by the police at McDonald's at 3:40 p.m. Resident #1 stated he returned to the facility around 5:00 p.m. that same day, and staff would not let him in the building. Resident #1 stated the ED told him to get off the property. Resident #1 stated on 9/7/2021, sometime after 10:00 p.m., the police escorted him into the facility so he could retrieve his vaping device. Resident #1 stated he did not get his medication or food when he was in the facility. Resident #1 stated he waited outside in the rocking chair on the West patio all night. Resident #1 stated on 9/8/2021, he was still outside the facility and watched the day shift arrive. Resident #1 stated he was told by staff he had to stay outside the facility because he was discharged . Resident #1 stated at 9:00 a.m. that same day, the police transported him to a local mental health hospital. Resident #1 stated he did not have his medication, food, or access to a restroom when he spent the night outside the facility on 9/7/2021. Resident #1 stated he had left the facility OOP in the past with no issues. Resident #1 stated he did not know why he was discharged from the facility and stated AMA discharges were not explained to him. Resident #1 stated he was angry and confused when he spent the night outside because he did not know why he was not allowed back in his home. In an interview on 9/14/2021 at 1:17 p.m., the SW stated Resident #1 started acting on edge and threw two glasses at a receptionist in July 2021. The SW stated Resident #1 was not inappropriately placed. SW stated she believed Resident #1 would benefit from the services a psychiatric facility provided. The SW stated she spoke with Resident #1 about transferring to a psychiatric hospital, but he did not want to leave the facility because it was where he felt comfortable. The SW stated she believed Resident #1 spent the night of 9/7/2021 outside because he had nowhere else to go. The SW stated Resident #1 wrote her a note which stated he did not to return to the local mental health hospital. SW stated she is the facility's resident discharge agent, and she was not involved in Resident #1's discharge. The SW stated Resident #1's discharge was not done according to policy, she stated she was told by the ED Resident #1 was discharged because he left AMA. The SW stated she did not believe Resident #1 left the facility AMA, she stated Resident #1 gave her no indication he wanted to discharge. The SW stated she does not discharge residents AMA because she tries to explain they will benefit if they stay. In an interview on 9/9/2021 at 2:21 p.m., the CN stated she spoke with Resident #1 on 9/7/2021 about his psychiatry appointment scheduled that day. The CN stated she asked Resident #1 which doctor he was seeing but he did not provide a name. The CN stated Resident #1 left the facility at 3:30 p.m. via the side door and triggered the alarm, she stated she informed the SW that Resident #1 had left the building. The CN stated she signed the resident out on pass at 3:30 p.m. that same day. The CN stated Resident #1 returned at 4:30 p.m. and she stated she had no further contact with Resident #1. In an interview on 9/16/2021 at 10:20 a.m., the PSYD stated he last spoke with Resident #1 on 9/6/2021. The PSYD stated Resident #1 had just returned from the local mental health hospital. The PSYD stated he spoke with Resident #1 in the facility day room at which time he became aggressive. The PSYD stated he was terminating services with Resident #1 because he believed he would make it worse. The PSYD stated no one from the facility contacted about Resident #1's AMA discharge. In an interview on 9/16/2021 at 10:32 a.m., the PNP stated the facility never consulted with her about Resident #1's AMA discharge. In an interview on 9/16/2021 at 10:35 a.m., the NP stated she arrived at the facility the morning of 9/7/2021. The NP stated she spoke with the ED about Resident #1's behaviors, including patting Resident #2. The NP stated Resident #1 told her he would speak to her but not the ED. The NP stated when she spoke with Resident #1 that day, he was in a manic state but alert and oriented. The NP stated she asked Resident #1 if they could draw blood for a lab to rule out medical indications for behaviors., she stated Resident #1 consented. The NP stated she had no contact with the facility until she arrived the morning of 9/8/2021. The NP stated the facility never consulted with her about Resident #1's AMA discharge. In an interview on 9/16/2021 at 1:21 p.m., the PP stated he conferred with the NP about Resident #1's behaviors prior to his AMA discharge. The PP stated he spoke with the ED about Resident #1's AMA discharge on 9/8/2021. Interview with Resident #3 on 9/16/2021 at 11:20 a.m., revealed she never had any issues with Resident #1. Resident #3 stated he was always pleasant. Resident #3 stated she recalled the day he came into her room and patted her head. Resident #3 stated Resident #1 had never done that before. Resident #3 stated the encounter was odd, but she did not feel afraid or threatened by Resident #1. Interview with Resident #4, on 9/16/2021, at 11:29 a.m. revealed she had no issues and was not afraid of Resident #1. Interview with Resident #5, on 9/16/2021, at 11:32 a.m., revealed he had no issues and was no afraid of Resident #1. Review of a document titled Transfer or Discharge, Emergency, dated 8/2018, reflected Residents will not be transferred unless: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The .resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. Under References, the document references Survey Tag Number F622. There was no policy for discharging residents AMA. Review of the facility's Admission/Transfer/Discharge log, dated 9/9/2021, reflected Resident #1 was discharged AMA on 9/7/2021. Under Discharge Reason, the documented stated Patient Request (AMA). Resident #1 was documented as having been LOA-Hospital Admission from 8/11/2021 to 8/14/2021 at St. David's Round Rock Medical Center and from 8/20/2021 to 9/1/2021 at Cross Creek. A further review reflected no additional residents were discharged AMA for 8/2021 and 9/2021. The Administrat or was notified on 9/15/21 at 5:48 PM that an IJ situation had been identified due to the above failures. The IJ template was provided to the Administrator. A Plan of Removal was submitted by the Administrator and accepted on 09/20/21 at 3:55 PM and included: Immediate action: Please accept this as a Plan of Removal to remove the IJ Identified in F600 Free from Abuse and Neglect and F622Transfer and Discharge Requirements Approach: 1. The facility will re-admit the patient to Park Valley pending the psychiatric hospital discharging the patient from their treatment and services. 2. Monitoring a. All residents discharging will be monitored to ensure they have been discharged according to CMS guidelines by the Director of Nursing and Executive Director immediately. The Regional Director of Clinical Services and Regional Director of Operations will monitor ED and DON to ensure correct discharging is being maintained by auditing 10% of discharges monthly for compliance beginning 9/13/21. The last 30 days 8/15-9/15 discharges will be reviewed by Regional Corporate staff by 9/21/21, to ensure the residents were discharged appropriately. 3. In-Services a. All staff will review the course in CantexU on Preventing, Recognizing, and Reporting Abuse by 9/21/21. Course to include a post exam. They will not be allowed to work until course is complete. b. The Social worker, Executive Director, DON, ADON(s), Rehab director, and Patient Care Coordinators, and Charge Nurses will be in-serviced beginning 9/15/21-9/21/21 by the Regional Director of Clinical Services, on the following policies below regarding discharging a resident. They will not be allowed to work until the inservice is complete. The ED and/or DON will ensure ongoing training for new interdisciplinary staff members once their training is complete. (I)The discharge process- A Patient Discharge Plan of Care must be completed for each Patient discharging to home or another Facility by the interdisciplinary team members. a. The discharge needs of each Patient are identified and result in the development of a discharge plan including the IDT recommended of discharge location and the patient's preferred discharge location. b. Include regular re-evaluation of Patient to identify changes that require modification of the discharge plan. c. Involve the interdisciplinary team in the ongoing process of developing the discharge plan. d. Consider and involve the Patient Representative's availability, capacity and capability to perform required care, as part of the identification of discharge needs. e. Document that a Patient has been asked about their interest in receiving information regarding returning to the community. f. If the Patient indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. g. The Patient comprehensive care plan and discharge plan must be updated as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. h. If discharge to the community is not feasible, the reason and who made this determination must be recorded. i. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the Patient's follow-up care and any post-discharge medical and non-medical services to prevent readmissions. (II) Discharging a Resident in an Emergency- Residents will not be transferred or discharged unless: a. transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; c. the health of individuals in the facility would otherwise be endangered; d. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies: (1) if the resident does not submit the necessary paperwork for third party payment; or (2) after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay; or the facility ceases to operate. 1. If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. 2. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented. 3. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's attending physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary. 4. Should it become necessary to transfer residents during emergency or disaster situations, transfer procedures outlined in our disaster plan will be implemented. 5. The resident's medical record must be forwarded to the medical records office within twenty-four (24) hours of the transfer or discharge. (III) Discharging a Resident without a Physicians Approval (AMA)-A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Should a resident, or his or her representative (sponsor), request an immediate discharge, the resident's attending physician will be promptly notified. 2. The order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than seventy-two (72) hours after the discharge. 3. If the resident or representative (sponsor) insists upon being discharged without the approval of the attending physician, the resident and/or representative (sponsor) must sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members. 4. Should a resident and/or representative (sponsor) request a discharge from the facility during the time the resident is on isolation (transmission-based) precautions, the charge nurse must notify the director of nursing services and the resident's attending physician of the discharge request. 5. The director of nursing services, or charge nurse, shall inform the resident, and/or representative (sponsor) of the potential hazards involved in the early discharge of the resident and shall request that the resident remain in the facility until such time as the isolation/precautionary period has ended. 6. The facility will not decide an AMA or discharge or force a resident to be discharged AMA if a resident states he or she is going to an appointment or out on pass. 7. Residents and/or patient representatives will be informed of the facility's AMA process within 72 hours of admission during the Circle of Excellence (COE) meeting. It will be documented on the COE form/assessment in the EMR. 8. All current residents and/or responsible parties will be notified of the AMA process by a facility representative by 09/21/2021. 4. Quality Assurance a. Concerns regarding appropriately discharging patients will be given to the Quality Assurance Committee for analysis and recommendations with input from the Medical Director going forward. b. All discharges will be reviewed monthly by the quality assurance committee. 5. Completion date 9/21/2021 From 9/16/2021 to 9/21/2021, the facility was monitored for compliance with the Plan of Removal. In-Services on the discharge process were conducted by RCN from 9/15/2021 to 9/17/2021. Staff, including the ED, the SW, the CN, and multiple LVN's were trained on the discharge process, discharging a resident in an emergency, and discharging a resident without a physician's approval (AMA). Staff were interviewed to ensure they understood the correct discharge process. Additionally, staff were in-serviced on recognizing, preventing, and reporting abuse, neglect, and exploitation. The Administrator was notified the IJ was removed on 9/21/2021 at 4:32 PM. However, the facility remained out of compliance at a severity of level potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions.

Based on interview and record review, the facility failed to ensure one (Resident #1) of one resident reviewed was free from abuse when they failed to provide goods and services that were necessary to avoid physical harm, pain, mental anguish, or emotional distress as evidenced by: The facility failed to follow their own discharge policy when they locked Resident #1 out of the building after he left on a day pass resulting in Resident# 1 not being able to get back into his home where he had lived in for 2 years. He did not have shelter, food, and medication for approximately 15 hours. Resident #1 was anxious and upset. He mental anguish was evidenced by his repeated attempts to break the door and glass into his home. He attempted to enter the building several times and he called the police multiple times for help. Resident #1 did not have family or friends to provide shelter and care. The facility's actions included a potential for harm to Resident #1 because he was discharged without his prescribed psychiatric medication and shelter. Resident #1 was left outside the facility for 15 hours, from 09/07/2021, at 3:30 p.m., until 09/08/2021, at 8:00 a.m. The average daily temperature for that area and time of year is 91 degrees in the daytime and 67 degrees at night. Resident #1 missed his evening and morning [MEDICATION(S)] and [MEDICATION(S)] (used to treat his mental disorders and his anxiety) dosage, as well as his evening and morning meals. These failures resulted in an Immediate Jeopardy situation on 9/15/2021 5:48 p.m. While the IJ was removed on 9/21/2021, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions. This failure placed Resident #1 at risk for serious physical harm, pain, mental anguish, and emotional distress. Findings include: Review of Resident #1's Face Sheet, printed 09/08/2021, reflected the resident was a 68-year- old male admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's MDS, dated [DATE], reflected he was cognitively intact as indicated by his BIMS score of 14. Resident #1 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 received antipsychotic, antianxiety, antidepressant, and hypnotic medication for six of the last seven days. Resident #1 exhibited no wandering behavior. Resident #1 did display verbal behaviors directed toward others. Review of Resident #1's Care Plan, dated 05 /20/2021, reflected he was taking [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Resident #1 needed supervision with his ADL's, transfers, and repositioning. Resident #1 was a fall risk as result of his medication. Resident #1 required supervision and medical care. Review of Resident #1's Behavior Monitoring Notes dated 09/01/2021 to 09/07/2021, reflected he did not experience side effects from his medications and did not display behaviors. Resident #1 did not require any behavior interventions during the time leading up to his lockout from his home. A review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was also prescribed 0.5 mgs of [MEDICATION(S)], to treat anxiety, three times per day. A review of Resident #1's Progress Notes reflected on 9/7/2021 at 3:30 p.m., the CN signed him Out on Pass. A further review of Resident #1's Progress Notes reflected an entry on 09/07/2021 at 3:30 p.m., signed by the CN which stated Resident #1 called a cab and left facility out of side door without informing staff where he was going. [Resident #1] left alert and oriented X4. In an interview on 9/14/2021, at 11:57 a.m., Resident #1, while he resided at a local mental health hospital, stated he left the faciity on [DATE], at 3:30 p.m., to go shopping at Walmart. Resident #1 stated he was stopped by the police at McDonald's at 3:40 p.m. Resident #1 stated he returned to the facility around 5:00 p.m. that same day, and staff would not let him in his home. Resident #1 stated the ED told him to get off the property. Resident #1 stated on 9/7/2021, sometime after 10:00 p.m., the police escorted him to his room so he could retrieve his vaping device. Resident #1 stated he did not get his medication or any food when he was in his home. Resident #1 stated he waited outside in a rocking chair on the West patio all night. Resident #1 stated on 9/8/2021, he was still outside the facility and watched the day shift arrive. Resident #1 stated he was told by staff he had to stay outside of the facility because he was discharged from his home. Resident #1 stated at 9:00 a.m. that same day, the police transported him to a local hospital then on to a mental health hospital. Resident #1 stated he did not have his medication, food, or access to a restroom when he spent the night outside the facility on 9/7/2021. Resident #1 stated he had left his home on pass in the past with no issues. Resident #1 stated he did not know why he was discharged from his home. Resident #1 stated that he did not understand being discharged against medical advice. Being discharged was not explained to him. Resident #1 stated he was angry and confused when he spent the night outside because he did not know why he was not allowed back in his home. In an interview on 9/9/2021, at 12:48 p.m., the Shift Coordinator (SC) stated she saw Resident #1 exit the facility via the side door on 9/7/2021, at 3:00 p.m. The SC stated she tried to speak with Resident #1, but he entered the taxi he called, and left the premises. The SC stated Resident #1 returned to the facility later that same day after grocery shopping and tried to enter via the side door, she stated she motioned for Resident #1 to come to the front door, which he did. SC stated the Executive Director (ED) spoke to Resident #1 outside the facility, but she did not hear the conversation. The SC stated the police arrived and had Resident #1 move across the street, which he did. The SC stated the police left and Resident #1 went to the West side patio and sat in a rocking chair, she stated the ED went home and notified staff Resident #1 was officially discharged and not allowed back inside the facility. In an interview on 9/9/2021, at 2:21 p.m., the Charge Nurse (CN) stated Resident #1 left the facility at 3:30 p.m. via the side door and triggered the alarm. She stated she informed the SW Resident #1 had left the building. The CN stated she signed the resident out on pass at 3:30 p.m. that same day and stated Resident #1 returned at 4:30 p.m. and she stated she had no further contact with Resident #1 that day. In an interview on 09/19/21 at 1:34 pm CN stated that she signed the resident out on pass and was later told by management to complete the AMA discharge. CN stated she was uncomfortable completing the AMA because Resident #1 was signed out on pass which she had approved earlier in that day. In an interview on 09/16/21 at 12:18 pm Resident #2 stated she felt bad for Resident #1 as he was knocking on her window the evening of 09/07/21 wanting back into his home. Resident #2 said Resident #1 was done bad and had hoped that the police would not light him up. Resident #2 stated that Resident #1 was always kind and advocated for the residents. In an interview on 9/9/2021, at 1:40 p.m., the Social Worker stated that the resident did have behaviors and his behaviors were increasing and he was becoming more agitated. The SW stated staff told her Resident #1 exited the facility via the side door on 9/7/2021, she stated she went outside to look for Resident #1. She did not see Resident #1. The SW stated she arrived at the facility on 9/8/2021 at 8:30 a.m. and the ED told staff to not let Resident #1 in. The SW stated that all resident discharges began on the day of admission, she stated reasons for discharge include patient request, the facility not meeting their needs, resident death, and to the community. The SW stated this discharge went South. When asked to elaborate, the SW stated the discharge was handled wrong and she didn't believe he was discharged appropriately. In an interview on 9/14/2021 at 1:17 p.m., the SW stated Resident #1 started acting on edge and threw two glasses at a receptionist in July 2021. The SW stated Resident #1 was not inappropriately placed and she believed Resident #1 would benefit from the services a psychiatric facility provided in conjunction with the facilities services. The SW stated she spoke with Resident #1 about transferring to a psychiatric hospital, but he did not want to leave the facility because it was where he felt comfortable. She stated she believed Resident #1 spent the night of 9/7/2021 outside because he had nowhere else to go. SW stated Resident #1 wrote her a note a few days before his discharge which stated he did not want to return to the mental health hospital it was discharged from previously. The SW stated she is the facility's resident discharge agent, and she was not involved in Resident #1's discharge. The SW stated Resident #1's discharge was not done according to policy and she was told by the ED Resident #1 was discharged because he left AMA. The SW stated she did not believe Resident #1 left the facility AMA, she stated Resident #1 gave her no indication he wanted to be discharged . The SW stated she does not discharge residents AMA because she tries to explain to them how they will benefit if they stay, the SW stated she could only recall one other resident being discharged AMA. In an interview on 09/21/21 at 2:40 p.m. stated that the resident did have behaviors and he would display aggressive behaviors from time to time. Resident #1 refused care from his psychologist. In an interview on 9/9/2021, at 9:33 a.m., the ED stated she had been at the facility for about five months. She stated on 9/7/2021, during a meeting with the SW, she was told Resident #1 patted Resident #2 on the head and told her 'she was a good resident. The ED stated Resident #2 said she felt uncomfortable but was not afraid of Resident #1. The ED stated she was aware Resident #1 had two manic episodes in the last five months. The ED stated the CN informed her Resident #1 left the facility through the side door around 3:00 p.m., on 9/7/2021. The ED stated staff attempted to redirect Resident #1, but they failed, and he left the premises via taxi. The ED stated SW notified the police at 3:30 p.m. to help locate Resident #1. The police were rerouted to a nearby McDonald's where Resident #1 was located. The ED stated she went to the McDonald's and conversed with the police; she stated the police told her they let Resident #1 leave because he answered their mental health questions appropriately. The ED stated she made the decision to discharge the Resident #1 AMA later that day because he did not go out on a therapeutic pass. The ED stated she consulted with RCN that Resident #1 left AMA because they don't know where he is. The ED stated she let the CN know Resident #1 left the facility and the CN completed his discharge paperwork. The ED stated at 5:30 p.m., that same day, the SC notified her Resident #1 was banging on the side door. The ED stated she went out to speak with Resident #1, at which time he became verbally aggressive and physically intimidating, she stated she informed Resident #1 he was discharged AMA because he left the facility without saying where he was going. The ED stated she called the police later that evening because Resident #1 was spitting on the facility's windows, rubbing his bare torso on the glass, and screaming at the staff inside. The ED stated the police told Resident #1 he could go to the local psychiatric hospital, the ER, or leave the premises at which time the resident walked to the curb across the street. The ED stated NN called the police around 11:00 p.m. because Resident #1 was attempting to break a window with an object, she stated the police asked her if they wanted to press charges, the ED said no, and the police left. The ED stated she arrived at the facility on 9/8/2021 at 7:00 a.m., and staff told her Resident #1 had been wandering the grounds the previous night and that morning. The ED stated she did not know if he had been outside all night, she stated the police arrived at 8:00 a.m. The ED stated the police tried to place the resident in a local Psychiatric Hospital, and the resident agreed to go. The ED stated she filed criminal trespassing charges against the resident. In an interview on 9/16/2021, at 9:00 a.m., the ED stated she had never discharged a resident AMA before she discharged Resident #1. She stated she was aware of one other resident who had been discharged AMA from the facility, she stated the SW handles resident discharges. The ED stated the nursing team tried to redirect Resident #1 when he attempted to exit out the side door, she stated staff had no idea where he was going when he left the facility. The ED stated she conferred with Resident #1's PNP, his physician, and his NP, the evening of 9/7/2021, and stated they supported her decision to discharge Resident #1 AMA. The ED stated she spoke to Resident #1 about discharging him AMA, and he became aggressive. The ED stated she did not know the CN signed Resident #1 out on pass on 9/7/2021 at 3:30 p.m., the ED stated she did not know where Resident #1 spent the night of 9/7/2021. In an interview on 9/16/2021, at 10:32 a.m., PNP stated the facility never consulted with her about Resident #1's AMA discharge. In an interview on 9/16/2021, at 10:35 a.m., the NP stated she arrived at the facility the morning of 9/7/2021. The NP stated she spoke with the ED about Resident #1's behaviors, including patting Resident #2's head. The NP stated Resident #1 told her he would speak to her but not the ED. The NP stated when she spoke with Resident #1 that day, he was in a manic state but alert and oriented. The NP stated she asked Resident #1 if they could draw blood for a lab to rule out medical indications for behaviors, the NP stated Resident #1 consented. The NP stated she had no contact with the facility until she arrived the morning of 9/8/2021. The NP stated the facility never consulted with her about Resident #1's AMA discharge. In an interview on 9/16/2021, at 10:20 a.m., PSYD stated he last spoke with Resident #1 on 9/6/2021. PSYD stated Resident #1 had just returned from the local mental health hospital. PSYD stated he spoke with Resident #1 in the facility day room at which time he became aggressive. PSYD stated he was terminating services with Resident #1 because he believed he would make it worse. PSYD stated no one from the facility contacted about Resident #1's AMA discharge. In an interview on 9/16/2021 at 1:21 p.m., the PP stated he conferred with NP about Resident #1's behaviors prior to his AMA discharge. The PP stated he spoke with the ED about Resident #1's AMA discharge on 9/8/2021. Interview with Resident #2 on 9/16/2021, at 11:20 a.m., revealed she never had any issues with Resident #1. Resident #2 stated he was always pleasant, she stated she recalled the day he came into her room and patted her head, she stated Resident #1 had never done that before. Resident #2 stated the encounter was odd, but she did not feel afraid or threatened by Resident #1. Interview with Resident #4 on 9/16/2021 at 11:29 a.m., revealed she had no issues and was not afraid of Resident #1. Interview with Resident #5 on 9/16/2021 at 11:32 a.m., revealed he had no issues and was not afraid of Resident #1. Interview with CNA A on 09/21/21 at 3:47 p.m. CNA stated that Resident #1 could be moody at time but isolated himself when he was in that state. CNA A stated she was not afraid of Resident #1. Interview with AD on 09/21/21 at 3:50 p.m. AD stated that Resident #1 kept to himself and she was not afraid of him. The AD stated that Resident #1 left the facility regularly to go showing or out to eat. The AD stated she is aware of a new discharge policy that was implemented after Resident #1's discharge. A review of a document titled Release of Responsibility for Discharge AMA, dated 9/7/2021, reflected the ED and the CN signed the form. A further review reflected Resident #1 did not sign the form. A review of the local Police notes reflected, on 9/7/2021 at 4:08 p.m., Resident #1 spoke with police at McDonald's and told them he wanted to go home to Park Valley. The officer stated the ED arrived at McDonald's and was informed Resident #1 could not be sent to the emergency department. The officer stated he ascertained that [Resident #1] grabbed a housekeeper's arm but she was not in fear or wanting to report it. [sic] The officer stated the ED told him since the resident left with the taxi driver, he had effectively discharged himself and was no longer allowed back at the facility (despite being a resident there for 4 years). The officer stated he told the ED he could not take custody of Resident #1 because he .did not meet the criteria based on [his] evaluation of [resident]. At 6:29 p.m. that same day, responding officers spoke with Resident #1 on facility premises. The officer stated Resident #1 refused to go to Cross Creek psychiatric hospital and was advised he did not reside at the facility any longer. The officer stated Resident #1 did not have any of his medication with him. The officer stated Resident #1 did not present a danger to himself or others. At 11:20: p.m. that same night, officers escorted Resident #1 to his room inside the facility so he could retrieve his vape pen. On 9/8/2021, at 8:06 a.m., officer stated Resident #1 was on the patio at the facility. The officer stated the resident was discharged on own accord. The officer stated, at 10:05 a.m. that same day, resident was voluntarily admitted to local mental health hospital. Review of a document titled Transfer or Discharge, Emergency, dated 8/2018, reflected Residents will not be transferred unless: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility, b. The .resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. Under References, the document references Survey Tag Number F622. There was no policy for discharging residents AMA. Review of the facility's Admission/Transfer/Discharge log, dated 9/9/2021, reflected Resident #1 was discharged AMA on 9/7/2021. Under Discharge Reason, the documented stated Patient Request (AMA). Resident #1 was documented as having been LOA-Hospital Admission from 8/11/2021 to 8/14/2021 at local hospital and from 8/20/2021 to 9/1/2021 at local mental health hospital. A further review reflected no additional residents were discharged AMA from 8/2021 through 9/2021. The Administrator was notified on 9/15/21 at 5:48 PM that an IJ situation had been identified due to the above failures. The IJ template was provided to the Administrator. A Plan of Removal was submitted by the Administrator and accepted on 09/20/2021 at 3:55 PM and included: Plan of Removal September 20, 2021 Immediate action: Please accept this as a Plan of Removal to remove the IJ Identified in F600 Free from Abuse and Neglect and F622 Transfer and Discharge Requirements Approach: 1. The facility will re-admit the patient to Park Valley pending the psychiatric hospital discharging the patient from their treatment and services. 2. Monitoring a. All residents discharging will be monitored to ensure they have been discharged according to CMS guidelines by the Director of Nursing and Executive Director immediately. The Regional Director of Clinical Services and Regional Director of Operations will monitor ED and DON to ensure correct discharging is being maintained by auditing 10% of discharges monthly for compliance beginning 9/13/21. The last 30 days 8/15-9/15 discharges will be reviewed by Regional Corporate staff by 9/21/21, to ensure the residents were discharged appropriately. 3. In-Services a. All staff will review the course in CantexU on Preventing, Recognizing, and Reporting Abuse by 9/21/21. Course to include a post exam. They will not be allowed to work until course is complete. b. The Social worker, Executive Director, DON, ADON(s), Rehab director, and Patient Care Coordinators, and Charge Nurses will be in-serviced beginning 9/15/21-9/21/21 by the Regional Director of Clinical Services, on the following policies below regarding discharging a resident. They will not be allowed to work until the inservice is complete. The ED and/or DON will ensure ongoing training for new interdisciplinary staff members once their training is complete. (I)The discharge process- A Patient Discharge Plan of Care must be completed for each Patient discharging to home or another Facility by the interdisciplinary team members. a. The discharge needs of each Patient are identified and result in the development of a discharge plan including the IDT recommended of discharge location and the patient's preferred discharge location. b. Include regular re-evaluation of Patient to identify changes that require modification of the discharge plan. c. Involve the interdisciplinary team in the ongoing process of developing the discharge plan. d. Consider and involve the Patient Representative's availability, capacity and capability to perform required care, as part of the identification of discharge needs. e. Document that a Patient has been asked about their interest in receiving information regarding returning to the community. f. If the Patient indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. g. The Patient comprehensive care plan and discharge plan must be updated as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. h. If discharge to the community is not feasible, the reason and who made this determination must be recorded. i. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the Patient's follow-up care and any post-discharge medical and non-medical services to prevent readmissions. (II) Discharging a Resident in an Emergency- Residents will not be transferred or discharged unless: a. transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; c. the health of individuals in the facility would otherwise be endangered; d. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies: (1) if the resident does not submit the necessary paperwork for third party payment; or (2) after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay; or the facility ceases to operate. 1. If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. 2. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented. 3. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's attending physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary. 4. Should it become necessary to transfer residents during emergency or disaster situations, transfer procedures outlined in our disaster plan will be implemented. 5. The resident's medical record must be forwarded to the medical records office within twenty-four (24) hours of the transfer or discharge. (III) Discharging a Resident without a Physicians Approval (AMA)-A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Should a resident, or his or her representative (sponsor), request an immediate discharge, the resident's attending physician will be promptly notified. 2. The order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than seventy-two (72) hours after the discharge. 3. If the resident or representative (sponsor) insists upon being discharged without the approval of the attending physician, the resident and/or representative (sponsor) must sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members. 4. Should a resident and/or representative (sponsor) request a discharge from the facility during the time the resident is on isolation (transmission-based) precautions, the charge nurse must notify the director of nursing services and the resident's attending physician of the discharge request. 5. The director of nursing services, or charge nurse, shall inform the resident, and/or representative (sponsor) of the potential hazards involved in the early discharge of the resident and shall request that the resident remain in the facility until such time as the isolation/precautionary period has ended. 6. The facility will not decide an AMA or discharge or force a resident to be discharged AMA if a resident states he or she is going to an appointment or out on pass. 7. Residents and/or patient representatives will be informed of the facility's AMA process within 72 hours of admission during the Circle of Excellence (COE) meeting. It will be documented on the COE form/assessment in the EMR. 8. All current residents and/or responsible parties will be notified of the AMA process by a facility representative by 09/21/2021. 4. Quality Assurance a. Concerns regarding appropriately discharging patients will be given to the Quality Assurance Committee for analysis and recommendations with input from the Medical Director going forward. b. All discharges will be reviewed monthly by the quality assurance committee. 5. Completion date 9/21/2021 From 9/16/2021 to 9/21/2021, the facility was monitored for compliance with the Plan of Removal. In-Serving on the discharge process was conducted by RCN from 9/15/2021 to 9/17/2021. Staff, including the ED, the SW, the CN, and multiple LVN's were trained on the discharge process, discharging a resident in an emergency, and discharging a resident without a physician's approval (AMA). Staff were interviewed to ensure they understood the correct discharge process. Additionally, staff were in-serviced on recognizing, preventing, and reporting abuse, neglect, and exploitation. The Administrator was notified the IJ was removed on 9/21/2021 at 4:32 PM. However, the facility remained out of compliance at a severity of level potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions.

Based on interviews, record reviews, and observations, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of six residents (Resident #1) reviewed for quality of care. The facility failed to prevent a medication error during admission medication reconciliation for Resident #1 which resulted in Resident #1 not receiving fast-acting insulin based on blood glucose levels from 3/19/21 to 3/22/21 (10 times). On 3/22/21, Resident #1 sustained a fall, resulting in a closed head injury and was later admitted to the hospital with a blood glucose level of 748. This failure resulted in an identification of an Immediate Jeopardy on 3/25/21. While the IJ was removed on 3/30/21, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. This deficient practice may affect residents who require pharmaceutical services and could result in negative health outcomes including [CONDITION(S)], [CONDITION(S)], illness, injury, hospitalization , and or death. Findings Included: A review of the Resident #1's face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #1's hospital discharge records dated 3/19/21 reflected the resident was discharged on [DATE] with discharge orders for Insulin [MEDICATION(S)] (fast-acting insulin) based on sliding scale blood glucose levels four times a day with medication orders as follows: -Administer Insulin [MEDICATION(S)] with meals based on blood glucose levels; (70-150) 0 units, (151-200) 3 units, (201-250) 6 units, (251-300) 9 units, (301-305) 12 units, 351 or greater 15 units. -Administer Insulin [MEDICATION(S)] (fast-acting insulin) 100 units per ml give per sliding scale blood sugar at night, (70-200)-0 units: (251-300) 2 units: (301-350) 3 units: 351 or greater give 4 units. -Other medications included [MEDICATION(S)] (long-acting insulin), subcutaneous, 15 units in the morning, and 10 units in the evening. Review of the Resident #1's nursing notes reflected on 3/19/21, Resident #1 was admitted to the facility at 4:00 pm. Review of Resident #1's care plan dated 3/20/21 reflected the resident was at risk for hypo (low blood sugar) and [CONDITION(S)] (high blood sugar) secondary to diabetes; blood sugars will be within normal limits within the next 90 days. Resident #1 required interventions to maintain blood sugars within normal limits including medication and labs as ordered, monitor signs and symptoms including a change in level of consciousness or mood. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Initial admission notes dated 3/19/21 reflected the resident was alert and oriented x1 (name only) and had a fall score risk of 5, not indicative of fall risk, and was a moderate risk for elopement. Review of the Resident #1's nursing notes dated 3/22/21 at 6:00 am reflected the resident was found on the floor with right-sided facial swelling and was sent to the hospital. RP (resident representative) and MP notified. Review of Resident #1's ER admission progress notes reflected the resident was seen in theER on [DATE] at 6:50 am with confusion (baseline unknown), disoriented x4 with a closed head injury, dehydration, and [CONDITION(S)]. Insulin drip started in the ER. The patient was critical with severe metabolic derangements. Hospital admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Lab results dated 3/22/21 at 10:40 am reflected glucose was 748. A review of the CDC's website article titled Diabetes reflected a normal blood sugar level is between 80 to 130. Moreover, if blood glucose levels exceed 240 or a above this could signal the early stages of diabetic ketoacidosis, which is a medical emergency and needs to be treated immediately. Ketoacidosis is when fat is broken down for energy and ketones. (https://www.cdc.gov/diabetes/managing/manage-blood-sugar.html) Resident #1's CT dated 3/22/21 0754 reflected a subarachnoid hemorrhage (bleeding between the space in the brain and the surrounding membrane), no fracture. In an interview on 3/23/21 at 4:00 pm, LVN B stated she works for a nursing agency and has worked at the facility for the last few months. LVN B stated she transcribed Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated she did not receive report from the nurse taking care of Resident #1 in the hospital. LVN B stated she tried to call the hospital twice but no one answered so she did not call again. LVN B stated she checked off each admission order from the hospital and if it was not checked she did not transcribe it and verify the order with the MP (medical provider). LVN B stated she should have continued to attempt to call the hospital to talk with the nurse taking care of Resident #1 in order to get report on the resident. LVN B stated she did remember the resident had [MEDICATION(S)] insulin (long acting insulin) and thought the provider may want the resident to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated she did not chart this in the nursing notes. LVN B stated the NP/MP did not change any of Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated once the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated the original hospital discharge orders are not faxed or emailed to the pharmacy. LVN B stated it was important for the nurse to transcribe and verify admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/23/21 at 6:00 pm RN A stated around 4:00 am he did witness the resident fell in his room, performed an assessment and then assisted the resident back to bed. RN A stated around 6:00 am while passing morning medications he overheard a female resident yelling. RN A stated he entered the resident's room and found Resident #1 on the bathroom floor but he did not witness the resident's fall. RN A stated he did assess the resident and perform neuro checks and after assisting the resident back to bed he noticed the resident had become incoherent. RN A stated he noticed Resident #1's face had swelling and he contacted the NP/MP to send the resident to the hospital. RN A stated prior to Resident #1's second fall he was notified by CNA O of a concern regarding the resident drinking hand sanitizer. RN A stated the amount of sanitizer was unchanged so he felt like it was not an issue. RN A stated he was not told by LVN B he needed to contact the NP/MP about whether Resident #1 needed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN A stated Resident #1 was on [MEDICATION(S)] Insulin (long acting insulin) and an oral medication to lower blood sugar but he did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN A stated he only worked with the resident on two different occasions and only gave [MEDICATION(S)] insulin (long acting) once on 3/21/21 around 5:00 pm. RN A stated he thought he did check Resident #1's blood sugar before he gave [MEDICATION(S)] Insulin. RN A stated he did not chart the blood sugar because there was not an order and just did it for himself. RN A stated he thought he checked Resident #1's blood sugar right after he fell on [DATE] around 4:00 am. RN A stated he thought Resident #1's blood sugar was either 109 or 119. RN A stated he did not think he charted Resident #1's blood sugar in the medical record because there was not an order to do so. RN A stated he should have charted this in the nurses notes and or on a flow sheet in the electronic medical record. RN A stated he was trained on the electronic health record by the corporate trainer and did not feel like the agency nurses were properly trained on the electronic health record system and this may have been why the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/24/21 at 3:00 pm RN A stated he worked last night and he checked the electronic medical record but he did not chart Resident #1's blood sugar. During an interview on 3/26/21 at 7:00 am RN A stated he was contacted by a corporate employee from the facility and was asked a series of questions about Resident #1's fall. RN A stated he did not chart Resident #1's blood glucose level. RN A stated he did come into the facility a few days ago to chart the vital signs he performed when Resident #1 fell as he did not chart this information during his shift. RN A stated he did not check Resident #1's blood glucose level on the morning of 3/22/21 but did check it the night before on 3/21/21 around 5:00 pm prior to administering the resident's [MEDICATION(S)] (long acting) insulin. RN A stated he had concerns about the accuracy of the glucometer on the [NAME] (post-acute medical) unit because it was never calibrated. During review of Resident #1 Treatment Medication Record dated March 2021 there was no record of Resident #1's blood glucose level on 3/19/21 to 3/22/21 on the treatment record, Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/24/21 at 2:00 pm CNA O stated she worked with Resident #1 on 3/20/21 and on 3/21/21 on the 10:00 pm to 6:00 am shift. CNA O stated LVN B gave her a quick update on 3/21/21 and told her Resident #1 does everything for himself but needed to be monitored because he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA O stated she did not see RN A check Resident #1's blood sugar and was present when RN A entered Resident #1's room after the residents fall at 4:00 am. CNA O stated on 3/22/21 between 3:00 am to 4:00 am Resident #1 became more agitated and confused. CNA O stated after the resident fell around 4:00 am, the resident walked in the hallway and she saw him trying to drink a bottle of hand sanitizer which was sitting on a table. CNA O stated she reported this to RN A but stated he told her the amount of hand sanitizer in the bottle was unchanged, so RN A told her to assist the resident back to his room. CNA O stated both she and RN A redirected Resident #1 back to his room several times, but the resident kept getting up. CNA O stated on 3/22/21 around 5:00 am she heard another resident yell and RN A went to assist Resident #1 while she went to help another resident around 6:00 am. CNA O stated on 3/21/21 Resident #1 slept through the night and did not get up through the night, so this was a change in the resident's behavior. During an interview on 3/24/21 at 4:00 pm LVN C stated she worked with Resident #1 on 3/19/21. LVN C stated she was passing medications on the post-acute medical unit (14-day observation unit) when Resident #1 was admitted . LVN C stated there were four admissions assigned to the [NAME] (Post-Acute Medical Unit) unit that afternoon. LVN C stated she worked with an agency and had on the job training for using the electronic medical record. LVN C stated she did not administer any medications for Resident #1 because the medications had not arrived from pharmacy prior to 2pm to 10pm shift. LVN C stated she was not aware of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1. LVN C stated residents who are newly admitted do not get medications until the next day, but [MEDICATION(S)] Insulin is kept in the emergency kit on the unit and could have been administered to a resident right away. LVN C stated the Administrator asked her to flow to another unit during her shift but she refused because LVN B had four admissions on the 2pm to 10pm shift and she did not think it was safe to leave LVN B. During an observation on 3/24/2021 at 9:00 am, Resident #1 was observed in the intensive care wing of the hospital. Resident #1 had a purplish bruise above his right eyelid and multiple purplish bruises to both arms. Resident #1 was receiving intravenous fluids and was unable to answer questions. Resident #1 was alert to verbal stimuli but would drift back to sleep during the interview after a few minutes. During an interview on 3/24/21 1:00 pm NP J stated she was the attending NP for Resident #1 from 3/19/21 to 3/22/21. NP J stated she did not discontinue any of the discharge orders from the hospital. NP J stated she did not see Resident #1 as he was admitted over the weekend and when she came to the facility to see the resident he had been discharged to the hospital. NP J stated she expected nurses to correctly transcribe all discharge orders from the hospital and to verify the orders with her on admission. NP J stated this was important to reduce the risk of medical errors. Interview on 3/25/21 at 12:30 pm NP N stated he was the attending NP for Resident #1 in the hospital. The NP stated he specializes in neurology/trauma. NP N stated he thought Resident #1's fall was directly related to the resident's hyperglycemic state (high blood sugar). The NP stated Resident #1 came to the hospital in a hyperosmolar/hyperglycemic state. NP N stated in a hyperglycemic state/hyperosmolar state, the resident would have major fluctuations in his blood pressure with position changes, and this could cause dizziness, thus increasing the risk for falling. NP N stated the resident had a hemorrhage in his brain, and the CT scans point to the hemorrhage being acute and not from a past injury. NP N stated if he was the clinician taking care of Resident #1 and did not administer fast acting insulin based on a sliding scale and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 3/25/21 at 6:00 pm Resident #1's wife stated she was not sending her husband back to the facility due to the poor care he received. Resident #1's wife stated her husband was sent to the facility to manage his blood sugars. Resident #1's wife stated she checked her husband's blood sugars four times a day and called the ambulance on 3/14/20 because her husband became more confused, so she took his blood glucose level and it was so high the glucometer just registered high. Resident #1's wife stated RN A contacted her when her husband was sent to the ER (emergency room ) on 3/19/21 but only said her husband was more confused. Resident #1's wife stated she assumed the facility was checking her husband's blood sugars. Interview on 03/30/21 at 12:00 pm the MD (who was the primary care provider while the resident was living at home with his wife) stated Resident #1 was a brittle diabetic, and his blood sugars fluctuated from high to low. The MD stated he advised the resident's wife to check Resident #1's blood glucose levels 3 to 4 times a day to make sure he did not have a critical blood sugar reading. The MD stated the last time he saw Resident #1 was on 3/10/20. The MD stated Resident #1 was taking 45 units of [MEDICATION(S)] (long-acting insulin) in the morning and 5 units at night and [MEDICATION(S)] 100mg by mouth, once daily (an oral blood sugar-lowering agent). During an interview on 3/24/21 at 2:00 pm NP K, stated she was the assigned NP for the facility but was on vacation during 3/19/21 to 3/22/21 so another NP was on call for her. NP K stated on admission the normal process is the discharge orders from the hospital are not changed. NP K stated the NP visits newly admitted residents on Monday or Tuesday to assess how they are doing and would make changes to these orders, depending on how the resident was doing. NP K stated if a resident's blood sugar was high the resident may have symptoms of agitation. During an interview on 3/24/21 at 9:00 am, RN T who was the attending nurse in the intensive care unit, stated he thought the residents high blood sugars may have contributed to Resident #1's fall while in the facility. The RN stated [CONDITION(S)] (high blood sugar) may increase agitation and confusion. RN T stated he felt like the resident's hospitalization may have been prevented if the resident received fast acting insulin based on blood glucose checks while in the nursing facility. During a phone interview on 3/24/21 at 3:30 pm the Regional Director of Clinical Operations stated the facility does not have an acting DON at this time but she had hired a DON who was scheduled to start on 4/05/21. The Director of Clinical Operations stated she expected nurses to check all hospital discharge orders with the MP and verify all these orders. The Regional Nurse Consultant stated the facility does not currently have a recheck procedure to ensure new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Director of Clinical Operations stated that in the event that the DON is not available the ADON would be responsible to ensure policies were followed. During an interview on 3/25/21 at 4:00 pm the Administrator stated she expected nurses to correctly transcribe admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated this was important to prevent medication errors. Review of Resident #1's Accident/Incident Report dated 3/26/21 reflected [MEDICATION(S)] insulin order based on sliding scale blood glucose was missed on the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor stated she talked with the NP, stated she did not discontinue the medication. Interviewed Charge Nurse LVN B, stated she did not see a sliding scale order on the discharge medication list, stated was a question she had listed to follow up on. LVN B stated she passed it on to the oncoming nurse. LVN B stated she verified all the other orders. RN A stated he did not recall being passed on any information for follow-up. The patient was currently in the hospital. Licensed staff and Nurse Managers to be in-serviced on the certification of medications upon admission with the provider. Review of the facilities' policy on 3/25/21 titled Admission Protocol reflected the nurse is responsible to ensure orders were completed and to verify physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facilities' policy titled Accidents/Incidents dated May 2016, reflected the following: -An accident/incident must be completed immediately upon Facility staff becoming aware of the occurrence including medication errors. -A head to toe assessment must be completed at the time of the accident/incident. -An investigation of injury of unknown origin must be completed in addition to the accident/incident report when staff discovers an injury and they are unable to determine the origin of the injury. The Administrator and the Regional Director of Clinical Operations were notified on 3/25/21 at 5:30 pm an Immediate Jeopardy situation had been identified due to above failure and a plan of removal was requested. The IJ template was provided to the Administrator and the Regional Director of Clinical Operations on 3/26/21 at 7:00 pm. The following Plan of Removal was submitted by the Regional Director of Clinical Operations on 3/26/21 and accepted at 1:40 pm. The Plan of Removal reflected the following: 1. Assessment a. All residents admitted from 3/18/21 to current meds were reconciled against the discharge orders. b. All new admissions will have orders reviewed with the assigned nurse practitioner, physician, or physician assistant against the discharge orders for verification by the admitting nurse immediately upon admission and the charge nurse/admitting nurse will document any changes given by the provider if applicable in the medical record. c. The nurse managers will reconcile all new admissions against the discharge medication list within 24 hours of admission. When an admission occurs over the weekend, the weekend supervisor will conduct the medication reconciliation; in her absence, the charge nurse will scan or fax the discharge med list to the nurse manager on call and DON so they can complete the medication reconciliation within 24 hours. The DON and or designee will ensure the process is being followed daily by performing a medication reconciliation. They will verify the discharge medication list against the medication orders entered into the electronic health record and verify and resolve any discrepancies with the nurse practitioner or physician. 2. In-Services a. RNs and LVNs were in-serviced by the Regional Director of Clinical Services and the nurse managers beginning 3/25/21-3/26/2021 on the following: i. Verification of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a) When the admitting nurse receives a new patient, they will review the discharge medication list with the provider and the charge nurse/admitting nurse will document any changes given by the provider if applicable in the medical record. The orders will then be immediately entered/transcribed into the electronic medical record, so they can be administered as ordered. Once complete the orders will be faxed or scanned to the pharmacy so the medications can be filled. b) The nurse manager will reconcile all orders within 24 hours of admission against the discharge med list. When an admission occurs over the weekend, the weekend supervisor will conduct the medication reconciliation, and in her absence, the charge nurse will scan or fax the discharge med list to the nurse manager on call and DON so they can complete the medication reconciliation within 24 hours. c) The nurse managers to be in-serviced by the regional director of clinical services with return demonstration on performing medication reconciliations. 3. Quality Assurance a. Quality of Care concerns regarding physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. A reconciliation report will be ran weekly to ensure the reconciliation process is being followed. 4. Completion date 3/26/21 Monitoring of the facility's Plan of Removal was conducted from 3/27/21 - 3/30/21. Review of In-service Training Report dated 03/25/21 reflected staff were educated on Order Reconciliation which included the following: -The following day the nurse manager will reconcile the orders against the discharge medication list and review any discrepancies with the charge nurse/provider -On the weekends, the weekend supervisor will complete the order reconciliation, when not available the charge nurses will fax the orders to the DON and the nurse manager on call so they can complete the order reconciliation process. Review of the In-Service Training Report dated 03/25/21 reflected staff were educated on Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Upon receipt of the patient the nurse is to review the discharge medication list with the provider. You are to review each medication and ask the provider if the medication is to be continued or discontinued. -The following day the nurse manager will reconcile the orders against the discharge medication list and review any discrepancies with the charge nurse/provider. -On the weekends, the weekend supervisor will complete the order reconciliation, when not available the charge nurse will fax the orders to the DON and the nurse manger on call, so they can complete the order reconciliation process. Review of the in-service training report dated 03/25/21 titled Admission order verification reflected the following: -All new admissions will have orders reviewed with the assigned nurse practitioner, physician, or physician assistant against the discharge orders for verification by the admitting nurse will document any changes given by the provider if applicable in the medical record. -On the weekends the admitting nurse will document any changes given by the provider if applicable in the medical record. On the weekends the admitting nurse will follow the above process in addition will scan over the orders to the nurse on call and the DON so they can reconcile the orders. Interview on 03/27/21 at 06:45 am LVN D stated she had not been trained on the new admission process and thought the admission process had not changed. LVN D stated she was told by the admission coordinator she did not need to know this because the facility was not taking new admissions over the weekend. Interview on 03/27/21 at 09:00 LVN E stated she was helping from a sister facility and was only working weekend. LVN E stated she was told there was a new recheck process for new admissions. LVN E stated she did not know who she would contact to perform the recheck process for new admissions. During an observation on 03/27/21 at 8:00 reflected LVN E LVN E calibrated two separate glucometers and both high/low readings were within normal limits. Review of the record tiled glucometer log tracking for the [NAME] unit, dated October 2020, reflected the last glucometer calibration reading was performed on 10/26/20 on the [NAME] unit. During an interview on 03/29/21 at 11:00 am with ADON who stated that the facilities policy was to calibrate the glucometer when opening a new bottle of blood glucose strips, if the glucometer is dropped, or if clinicians are getting abnormal blood glucose levels. ADON stated that she was aware of the new admission plan of removal and she was responsible for rechecking medication orders on admission. The ADON stated on the weekends the nurses would send her the information and she would check these orders at home within 24 hours after admission. During an email correspondence on 03/27/21 at 4:30 pm between the surveyor and Administrator stated the following: -We started in-servicing staff members on the [NAME] unit regarding Glucometer calibration per the facility policy. We are continuing education for retention of the admission process. -We have placed signs throughout the facility for contact information for the Executive Director, Assistant Executive Director, ADON, and the staffing on call phone number. Interview on 03/28/21 at 11:45 am LVN E (working on the [NAME] unit) stated she had been trained on the new admission process (plan of removal) and was aware she needed to contact the ADON when a resident is admitted to recheck new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 03/28/21 at 12:00 pm LVN G stated she had been in-serviced on the new admission process (plan of removal) and was aware she needed to contact the ADON when a resident is admitted to recheck new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 03/28/21 at 12:15 pm LVN H stated he had been in-serviced on the new admission process (plan of removal) morning and was aware he needed to contact the ADON when a resident is admitted to recheck new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 03/29/21 at 7:00 am LVN F stated he had not been in-serviced on the new admission process and was not aware of new procedure with the new admission process. Interview on 03/29/21 at 7:10 am LVN P stated she had not been in-serviced on the new admission process and was not aware of new procedure with the admission process. Interview on 03/29/21 at 11:15 pm LVN D stated she had been in-serviced on the new admission process (plan of removal) and was aware she needed to contact the ADON when a resident is admitted to recheck new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 03/29/21 at 11:25 pm LVN Q stated she had been in-serviced on the new admission process (plan of removal) and was aware she needed to contact the ADON when a resident is admitted to recheck new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 03/29/21 at 11:35 pm LVN R stated she had been in-serviced on the new admission process (plan of removal) and was aware she needed to contact the ADON when a resident is admitted in order to recheck new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 03/29/21 at 11:00 pm revealed laminated cards were posted on each unit and each nurse had a copy relating to the facilities' plan of removal. During an interview on 03/30/21 at 10:00 am LVN P stated she had been in-serviced on the new admission process (plan of removal) and was aware she needed to contact the ADON when a resident is admitted in order to recheck new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Administrator and the Regional Director of Clinical Operations was notified on 03/30/21 at 10:45 am the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of actual harm with the potential for more than minimal harm and a scope identified as isolated.

Based on interviews and record review, the facility failed to ensure residents were free of significant medication errors for one of four residents (Resident #1) reviewed for medication errors. The facility failed to ensure nursing staff (LVN A) transcribed an order during admission for [MEDICATION(S)] Insulin based on sliding scale insulin for Resident #1 which resulted in the resident not receiving fast acting insulin administration based on blood glucose checks (10 times). On 3/22/21 Resident #1 sustained a fall with injury and was admitted to the hospital in critical condition with a blood glucose level of 748. This failure could affect residents in the facility who require assistance with medication administration and require blood glucose checks to manage high or low blood sugars. This deficient practice may affect residents in the family who require pharmaceutical services and could result in negative health outcomes including [CONDITION(S)], [CONDITION(S)], illness, injury, hospitalization , and or death. Findings Included: A review of the Resident #1's face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #1's hospital discharge records dated 3/19/21 reflected the resident was discharged on [DATE] with discharge orders for Insulin [MEDICATION(S)] (fast-acting insulin) based on sliding scale blood glucose levels four times a day with medication orders as follows: -Administer Insulin [MEDICATION(S)] with meals based on blood glucose levels; (70-150) 0 units, (151-200) 3 units, (201-250) 6 units, (251-300) 9 units, (301-305) 12 units, 351 or greater 15 units. -Administer Insulin [MEDICATION(S)] (fast-acting insulin) 100 units per ml give per sliding scale blood sugar at night, (70-200)-0 units: (251-300) 2 units: (301-350) 3 units: 351 or greater give 4 units. -Other medications included [MEDICATION(S)] (long-acting insulin), subcutaneous, 15 units in the morning, and 10 units in the evening. Review of the Resident #1's nursing notes reflected on 3/19/21, Resident #1 was admitted to the facility at 4:00 pm. Review of Resident #1's care plan dated 3/20/21 reflected the resident was at risk for hypo (low blood sugar) and [CONDITION(S)] (high blood sugar) secondary to diabetes; blood sugars will be within normal limits within the next 90 days. Resident #1 required interventions to maintain blood sugars within normal limits including medication and labs as ordered, monitor signs and symptoms including a change in level of consciousness or mood. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Initial admission notes dated 3/19/21 reflected the resident was alert and oriented x1 (name only) and had a fall score risk of 5, not indicative of fall risk, and was a moderate risk for elopement. Review of the Resident #1's nursing notes dated 3/22/21 at 6:00 am reflected the resident was found on the floor with right-sided facial swelling and was sent to the hospital. RP (resident representative) and MP notified. Review of Resident #1's ER admission progress notes reflected the resident was seen in theER on [DATE] at 6:50 am with confusion (baseline unknown), disoriented x4 with a closed head injury, dehydration, and [CONDITION(S)]. Insulin drip started in the ER. The patient was critical with severe metabolic derangements. Hospital admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital Lab results dated 3/22/21 at 10:40 am reflected glucose was 748. A review of the CDC's website article titled Diabetes reflected a normal blood sugar level is between 80 to 130. Moreover, if blood glucose levels exceed 240 or a above this could signal the early stages of diabetic ketoacidosis, which is a medical emergency and needs to be treated immediately. Ketoacidosis is when fat is broken down for energy and ketones. (https://www.cdc.gov/diabetes/managing/manage-blood-sugar.html) Resident #1's CT dated 3/22/21 0754 reflected a subarachnoid hemorrhage (bleeding between the space in the brain and the surrounding membrane), no fracture. In an interview on 3/23/21 at 4:00 pm, LVN B stated she works for a nursing agency and has worked at the facility for the last few months. LVN B stated she transcribed Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated she did not receive report from the nurse taking care of Resident #1 in the hospital. LVN B stated she tried to call the hospital twice but no one answered so she did not call again. LVN B stated she checked off each admission order from the hospital and if it was not checked she did not transcribe it and verify the order with the MP (medical provider). LVN B stated she should have continued to attempt to call the hospital to talk with the nurse taking care of Resident #1 in order to get report on the resident. LVN B stated she did remember the resident had [MEDICATION(S)] insulin (long acting insulin) and thought the provider may want the resident to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated she did not chart this in the nursing notes. LVN B stated the NP/MP did not change any of Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated once the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B stated the original hospital discharge orders are not faxed or emailed to the pharmacy. LVN B stated it was important for the nurse to transcribe and verify admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/23/21 at 6:00 pm RN A stated around 4:00 am he did witness the resident fell in his room, performed an assessment and then assisted the resident back to bed. RN A stated around 6:00 am while passing morning medications he overheard a female resident yelling. RN A stated he entered the resident's room and found Resident #1 on the bathroom floor but he did not witness the resident's fall. RN A stated he did assess the resident and perform neuro checks and after assisting the resident back to bed he noticed the resident had become incoherent. RN A stated he noticed Resident #1's face had swelling and he contacted the NP/MP to send the resident to the hospital. RN A stated prior to Resident #1's second fall he was notified by CNA O of a concern regarding the resident drinking hand sanitizer. RN A stated the amount of sanitizer was unchanged so he felt like it was not an issue. RN A stated he was not told by LVN B he needed to contact the NP/MP about whether Resident #1 needed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN A stated Resident #1 was on [MEDICATION(S)] Insulin (long acting insulin) and an oral medication to lower blood sugar but he did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN A stated he only worked with the resident on two different occasions and only gave [MEDICATION(S)] insulin (long acting) once on 3/21/21 around 5:00 pm. RN A stated he thought he did check Resident #1's blood sugar before he gave [MEDICATION(S)] Insulin. RN A stated he did not chart the blood sugar because there was not an order and just did it for himself. RN A stated he thought he checked Resident #1's blood sugar right after he fell on [DATE] around 4:00 am. RN A stated he thought Resident #1's blood sugar was either 109 or 119. RN A stated he did not think he charted Resident #1's blood sugar in the medical record because there was not an order to do so. RN A stated he should have charted this in the nurses notes and or on a flow sheet in the electronic medical record. RN A stated he was trained on the electronic health record by the corporate trainer and did not feel like the agency nurses were properly trained on the electronic health record system and this may have been why the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/24/21 at 3:00 pm RN A stated he worked last night and he checked the electronic medical record but he did not chart Resident #1's blood sugar. During an interview on 3/26/21 at 7:00 am RN A stated he was contacted by a corporate employee from the facility and was asked a series of questions about Resident #1's fall. RN A stated he did not chart Resident #1's blood glucose level. RN A stated he did come into the facility a few days ago to chart the vital signs he performed when Resident #1 fell as he did not chart this information during his shift. RN A stated he did not check Resident #1's blood glucose level on the morning of 3/22/21 but did check it the night before on 3/21/21 around 5:00 pm prior to administering the resident's [MEDICATION(S)] (long acting) insulin. RN A stated he had concerns about the accuracy of the glucometer on the [NAME] (post-acute medical) unit because it was never calibrated. During review of Resident #1 Treatment Medication Record dated March 2021 there was no record of Resident #1's blood glucose level on 3/19/21 to 3/22/21 on the treatment record, Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/24/21 at 2:00 pm CNA O stated she worked with Resident #1 on 3/20/21 and on 3/21/21 on the 10:00 pm to 6:00 am shift. CNA O stated LVN B gave her a quick update on 3/21/21 and told her Resident #1 does everything for himself but needed to be monitored because he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA O stated she did not see RN A check Resident #1's blood sugar and was present when RN A entered Resident #1's room after the residents fall at 4:00 am. CNA O stated on 3/22/21 between 3:00 am to 4:00 am Resident #1 became more agitated and confused. CNA O stated after the resident fell around 4:00 am, the resident walked in the hallway and she saw him trying to drink a bottle of hand sanitizer which was sitting on a table. CNA O stated she reported this to RN A but stated he told her the amount of hand sanitizer in the bottle was unchanged, so RN A told her to assist the resident back to his room. CNA O stated both she and RN A redirected Resident #1 back to his room several times, but the resident kept getting up. CNA O stated on 3/22/21 around 5:00 am she heard another resident yell and RN A went to assist Resident #1 while she went to help another resident around 6:00 am. CNA O stated on 3/21/21 Resident #1 slept through the night and did not get up through the night, so this was a change in the resident's behavior. During an interview on 3/24/21 at 4:00 pm LVN C stated she worked with Resident #1 on 3/19/21. LVN C stated she was passing medications on the post-acute medical unit (14-day observation unit) when Resident #1 was admitted . LVN C stated there were four admissions assigned to the [NAME] (Post-Acute Medical Unit) unit that afternoon. LVN C stated she worked with an agency and had on the job training for using the electronic medical record. LVN C stated she did not administer any medications for Resident #1 because the medications had not arrived from pharmacy prior to 2pm to 10pm shift. LVN C stated she was not aware of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1. LVN C stated residents who are newly admitted do not get medications until the next day, but [MEDICATION(S)] Insulin is kept in the emergency kit on the unit and could have been administered to a resident right away. LVN C stated the Administrator asked her to flow to another unit during her shift but she refused because LVN B had four admissions on the 2pm to 10pm shift and she did not think it was safe to leave LVN B. During an observation on 3/24/2021 at 9:00 am, Resident #1 was observed in the intensive care wing of the hospital. Resident #1 had a purplish bruise above his right eyelid and multiple purplish bruises to both arms. Resident #1 was receiving intravenous fluids and was unable to answer questions. Resident #1 was alert to verbal stimuli but would drift back to sleep during the interview after a few minutes. During an interview on 3/24/21 1:00 pm NP J stated she was the attending NP for Resident #1 from 3/19/21 to 3/22/21. NP J stated she did not discontinue any of the discharge orders from the hospital. NP J stated she did not see Resident #1 as he was admitted over the weekend and when she came to the facility to see the resident he had been discharged to the hospital. NP J stated she expected nurses to correctly transcribe all discharge orders from the hospital and to verify the orders with her on admission. NP J stated this was important to reduce the risk of medical errors. Interview on 3/25/21 at 12:30 pm NP N stated he was the attending NP for Resident #1 in the hospital. The NP stated he specializes in neurology/trauma. NP N stated he thought Resident #1's fall was directly related to the resident's hyperglycemic state (high blood sugar). The NP stated Resident #1 came to the hospital in a hyperosmolar/hyperglycemic state. NP N stated in a hyperglycemic state/hyperosmolar state, the resident would have major fluctuations in his blood pressure with position changes, and this could cause dizziness, thus increasing the risk for falling. NP N stated the resident had a hemorrhage in his brain, and the CT scans point to the hemorrhage being acute and not from a past injury. NP N stated if he was the clinician taking care of Resident #1 and did not administer fast acting insulin based on a sliding scale and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 3/25/21 at 6:00 pm Resident #1's wife stated she was not sending her husband back to the facility due to the poor care he received. Resident #1's wife stated her husband was sent to the facility to manage his blood sugars. Resident #1's wife stated she checked her husband's blood sugars four times a day and called the ambulance on 3/14/20 because her husband became more confused, so she took his blood glucose level and it was so high the glucometer just registered high. Resident #1's wife stated RN A contacted her when her husband was sent to the ER (emergency room ) on 3/19/21 but only said her husband was more confused. Resident #1's wife stated she assumed the facility was checking her husband's blood sugars. Interview on 03/30/21 at 12:00 pm the MD (who was the primary care provider while the resident was living at home with his wife) stated Resident #1 was a brittle diabetic, and his blood sugars fluctuated from high to low. The MD stated he advised the resident's wife to check Resident #1's blood glucose levels 3 to 4 times a day to make sure he did not have a critical blood sugar reading. The MD stated the last time he saw Resident #1 was on 3/10/20. The MD stated Resident #1 was taking 45 units of [MEDICATION(S)] (long-acting insulin) in the morning and 5 units at night and [MEDICATION(S)] 100mg by mouth, once daily (an oral blood sugar-lowering agent). During an interview on 3/24/21 at 2:00 pm NP K, stated she was the assigned NP for the facility but was on vacation during 3/19/21 to 3/22/21 so another NP was on call for her. NP K stated on admission the normal process is the discharge orders from the hospital are not changed. NP K stated the NP visits newly admitted residents on Monday or Tuesday to assess how they are doing and would make changes to these orders, depending on how the resident was doing. NP K stated if a resident's blood sugar was high the resident may have symptoms of agitation. During an interview on 3/24/21 at 9:00 am, RN T who was the attending nurse in the intensive care unit, stated he thought the residents high blood sugars may have contributed to Resident #1's fall while in the facility. The RN stated [CONDITION(S)] (high blood sugar) may increase agitation and confusion. RN T stated he felt like the resident's hospitalization may have been prevented if the resident received fast acting insulin based on blood glucose checks while in the nursing facility. During a phone interview on 3/24/21 at 3:30 pm the Regional Director of Clinical Operations stated the facility does not have an acting DON at this time but she had hired a DON who was scheduled to start on 4/05/21. The Director of Clinical Operations stated she expected nurses to check all hospital discharge orders with the MP and verify all these orders. The Regional Nurse Consultant stated the facility does not currently have a recheck procedure to ensure new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Director of Clinical Operations stated that in the event that the DON is not available the ADON would be responsible to ensure policies were followed. During an interview on 3/25/21 at 4:00 pm the Administrator stated she expected nurses to correctly transcribe admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated this was important to prevent medication errors. The surveyor requested the last medication audit sheet from the Administrator but the facility failed to provide this documentation prior to the exiting on 03/30/21. During an interview with the administrator on 03/24/21 at 5:00 pm stated that she did not have the last copy of the medication audit for the last quarter but she would request this document from the pharmacy. Review of Resident #1's Accident/Incident Report dated 3/26/21 reflected [MEDICATION(S)] insulin order based on sliding scale blood glucose was missed on the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor stated she talked with the NP, stated she did not discontinue the medication. Interviewed Charge Nurse LVN B, stated she did not see a sliding scale order on the discharge medication list, stated was a question she had listed to follow up on. LVN B stated she passed it on to the oncoming nurse. LVN B stated she verified all the other orders. RN A stated he did not recall being passed on any information for follow-up. The patient was currently in the hospital. Licensed staff and Nurse Managers to be in-serviced on the certification of medications upon admission with the provider. Review of the facilities' policy on 3/25/21 titled Admission Protocol reflected the nurse is responsible to ensure orders were completed and to verify physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facilities' policy titled Accidents/Incidents dated May 2016, reflected the following: -An accident/incident must be completed immediately upon Facility staff becoming aware of the occurrence including medication errors. -A head to toe assessment must be completed at the time of the accident/incident. -An investigation of injury of unknown origin must be completed in addition to the accident/incident report when staff discovers an injury and they are unable to determine the origin of the injury.

Based on interview and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for oxygen therapy for one of four residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1 received oxygen as ordered on [DATE]. Resident #1 died on [DATE] in respiratory distress. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:26 P.M. While the IJ was removed on [DATE] at 4:30 P.M., the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents for could result in discomfort, physical and psychosocial decline, and death. Findings include: Review of Resident #1's face sheet, undated, revealed she was a [AGE] year-old female with an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission MDS dated [DATE] revealed a BIMS score of 00, indicating she was rarely or never understood. Review of Resident #1's Care Plan revealed targeted area of; incontinence, falls, COVID psychosocial wellbeing due to restriction of visitors, [CONDITION(S)], [CONDITION(S)] medications, antibiotic therapy, allergies, pressure ulcer, risk for skin breakdown, Foley catheter, DNR status and extensive assistance with eating, dressing, toileting, bathing and transfers. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] > (greater than) 92%. Review of NP -A's Progress Note for Resident #1, dated [DATE] revealed the following; 1. COVID-19: COVID + [DATE] Sao2 90% on RA. Respirations symmetrical and unlabored. Ordered O2 to keep SaO2 >92%. Add [MEDICATION(S)] (Steroid that prevents the release of substances that cause inflammation) 6mg daily x10 days. She is nonverbal at baseline, does not follow commands. Orders for vs q shift and droplet precautions. Monitor closely. 2. Acute respiratory failure: SaO2 90%. Ordered O2 to keep SaO2 92% Monitor closely GENERAL Note >25 min spent reviewing diagnostic data, evaluating patient, coordinating care with nursing. Review of NP-A's Progress Note for Resident #1 dated [DATE] revealed the following; Active Medical Problems o [CONDITION(S)] o Benign neuroendocrine tumor of lung o Paraneoplastic encephalitis o Essential hypertension o [CONDITION(S)] o [CONDITION(S)] o [CONDITION(S)] o [CONDITION(S)] o COVID-19 o Acute respiratory failure And; ASSESSMENT AND PLAN 1. Acute respiratory failure: SaO2 70% Ordered [MEDICATION(S)] 6mg daily x10 days. She is nonverbal, Ordered O2 to keep SaO2 92%, not place on O2 yesterday baseline, does not follow commands. Send out to ER for higher level of care. VS q shift and droplet precautions ordered. 2. COVID-19: COVID + [DATE] Send to ER for higher level of care. Sao2 70% on RA. Respirations labored, lungs coarse. DISPOSITION Disposition Expired Review of Resident #1's O2 sat levels documented by nursing staff revealed the following; [DATE] at 4:23 am 96% [DATE] at 4:59 pm has 91% and 93% documented for same date and time. [DATE] at 10 pm 93% [DATE] at 12:39 am 96% [DATE] at 4:41 am 97% Review of all Resident #1's Nurses Notes for [DATE] through [DATE] revealed: .[DATE] at Resident #1's urinary catheter tubing was replaced after the nurse was not able to flush the tubing. The resident had blood tinged urine and the NP was notified. There were no notes for [DATE]. On [DATE] at 1:21 pm patient received on shift alert and breathing. At around 10 am NP/[name] was in and saw patient and gave order for oxygen put on her for low SATS and to send to ER. Patient was administered oxygen and upon re-assessing patient after calling 911 she was noted no pulse. (!! EMS was present and started CPR and was told she is a DNR and CPR was stopped and pronounced died 1105 am . Interview on [DATE] at 11:30 A.M. and 3:45 P.M. with the Regional Director of Clinical Services (RDCS) revealed that she was working at the facility on [DATE]. She stated she was told LVN A wanted to speak to her or the DON and that LVN A was upset. RDCS stated she saw that LVN A was in the Chapel talking to the DON, so she did not speak with her on that day. She later asked the DON if everything was okay and was told LVN A was mad, but she had taken care of it. RDCS stated she was doing a death review on [DATE] when she found NP-A's Progress Note dated [DATE] that stated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RDCS stated the NP told her she had told LVN A to start Resident #1 on oxygen and the next day she found out it hadn't been started. RDCS stated she realized this was reportable and she notified the Administrator and the DON. Interview on [DATE] at 5:13 P.M. with NP-A revealed she assessed Resident #1 on [DATE] because she had been diagnosed as COVID positive. NP-A stated Resident #1's O2 sat was ,d+[DATE]% which is borderline. Because of Resident #1's many comorbidities she knew the resident would not do well with COVID. NP-A stated she told LVN A to start Resident #1 on oxygen. NP-A stated that she assumed her order would be implemented so she was surprised when she came in the next day and the resident was not on oxygen. NP-A stated Resident #1 was obviously in respiratory distress. NP-A stated she checked Resident #1's O2 sat and it was at 70%. She stated she went out of the room saw LVN A there and told her Resident #1 was actively dying why hadn't she started her on oxygen the day before. NP-A stated that LVN A said she had not been able to find an O2 concentrator. NP-A asked LVN A why she had not contacted her or the DON or the Administrator, LVN A said why, it wouldn't do any good. NP-A stated she told LVN-A and LVN-E to start oxygen and send Resident #1 to the hospital. NP-A stated that they did get the oxygen started but the resident died shortly after. When the EMS arrived to take Resident #1 she was without a pulse. NP-A stated she notified the Medical Director of what had happened. When asked if she considered it neglect she stated the orders weren't followed and it wasn't right. When asked if the lack of oxygen contributed to Resident #1's death, NP-A stated she couldn't say for sure that it did, but it did make Resident #1 death more uncomfortable than it had to be, and it is possible Resident #1 died earlier than she would have if she had the oxygen in use. Interview on [DATE] at 5:22 P.M. with LVN A revealed she worked Resident #1's hall on [DATE]. She stated it was a busy day she was the only nurse for about 26 residents and the state was in the building wanting to watch her do wound care. LVN A stated that towards the end of her shift NP-A came up to her and told her Resident #1's O2 sat was 91% and she wanted her to have oxygen. LVN A stated NP-A told her put the oxygen on and she was going to the other side of the building and she would put the order in the computer over there. LVN A stated 91% is not that low they usually don't start oxygen until a person is below 90%. She didn't feel it was an emergency, so she told the nurse coming on duty for the ,d+[DATE] shift about the order and to be watching for it. LVN A stated that soon after she arrived at work on [DATE], NP-A came up to her yelling at her I told you to put her on oxygen she's in there dying. LVN A denies that she told the NP that she couldn't find a concentrator. LVN A stated on [DATE] she went and started oxygen for Resident #1 and called 911 to send her out to the hospital as ordered by NP-A. LVN A stated she was really upset so she went and told the Administrator she needed to go home. LVN A stated she did not tell the Administrator what happened, but he told her to talk to the DON before she left to see if they could get things sorted out. LVN A stated she found the DON and they went to the Chapel to talk, she stated she was too upset to talk much so the DON told her to go home. She did not tell the DON the NP had yelled at her, or that oxygen had not been started. Interview on [DATE] at 10:26 A.M. with the facility Medical Director (MD) revealed she was in the building on [DATE]. The MD stated NP-A had notified her the night before that she was going to start Resident #1 on oxygen. On [DATE], NP-A told her that the oxygen hadn't been started and she was going to send the resident to the hospital. MD stated she went to check on Resident #1 and EMS was in the room with Resident #1 on the floor, not breathing. Interview on [DATE] at 10:41 A.M. with CNA E revealed she had worked on [DATE] on the ,d+[DATE] shift. CNA E stated she had not worked on Resident #1's hall. She stated when LVN A came in at about 9:30 A.M. she asked LVN E how Resident #1 was doing. LVN A went into Resident #1's room later and became angry with LVN E because she felt like she had lied to her. LVN A checked on Resident #1 and she had a very faint pulse and did not have oxygen on. Interview on [DATE] at 11:21 A.M with LVN E revealed she worked on [DATE] on the ,d+[DATE] shift, she did know the resident was positive for COVID but was not aware that Resident #1 was supposed to be on oxygen and had not been told in report. LVN E stated she and LVN H, who was in training, were working 4 halls. LVN E stated sometime between 9 A.M. and 10 A.M. she counted off medications with LVN A and gave her the keys to take over 700 (Resident #1's hall) and 800 halls. LVN E stated that she had seen Resident #1 from her doorway but had not gone in the room because Resident #1 was COVID positive and she was saving working with her last. LVN E stated NP-A came on the unit and asked her for her pulse oximeter while she was in another resident's room. LVN E stated that when she went to the nurses' station NP-A was upset Resident #1 was not on oxygen. LVN E stated she went to get a concentrator and when she returned with it LVN A already had Resident #1 on oxygen. LVN E stated she went to work on her halls, while LVN A was doing paperwork to send Resident #1 to the hospital. LVN E stated LVN A was upset and said she wanted to leave. LVN E stated she took over the paperwork and at that time EMS arrived. EMS found the resident without a pulse and put her on the floor to do CPR but she told them Resident #1 had a DNR so EMS staff stopped CPR. LVN E stated new orders are passed on to the next shift. But if the NP tells us the order verbally, the nurse is supposed to go in and confirm that they carried out the order. Normally you would initiate a verbal order before you leave. LVN E stated she did tell Administration that Resident #1 had died but she had not said anything about the order not being followed. Interview on [DATE] at 11:33 A.M. with LVN H revealed her first day to work at the facility was [DATE]. She stated she was following LVN E. LVN H stated that she had been in a room getting a resident's vital signs and when she came out of the room she saw LVN E counting the medication with LVN A. LVN H stated they had not taken the vital signs for Resident #1 they had been working their way towards her. Soon after the medication count NP-A came out of Resident #1's room and said the resident wasn't doing well, and why didn't she have on the oxygen ordered the day before. The NP had also said the resident needed to be sent out. NP-A left, LVN E asked LVN A if she needed help to send the resident out, LVN A said there was not an order to send her out. LVN E and I told LVN A that NP-A had said to send her out. LVN H stated the next thing she knew EMS was there and one came out of the room asking if Resident #1 was a DNR because she didn't have a pulse. We gave them the copy of the DNR order. LVN A left. Interview on [DATE] at 2:29 P.M. with the DON revealed the Procedure was to check COVID residents' O2 sats every four hours. Her expectation was that any LVN should implement a verbal order they are given and that the LVN taking the order off should ensure the order had been implemented. The shift report should document that a new order was received. The DON stated she was not told about the oxygen order having not been followed for Resident #1 on [DATE]. She stated she talked to LVN A who was upset because she stated NP-A yelled at her. The DON stated she did not know about the oxygen until [DATE] when the RDCS notified her and the Administrator. She stated that the incident should have been reported by multiple people as it is neglect that Resident #1 did not receive oxygen as ordered. DON stated that there was never an issue with the availability of oxygen they have and oxygen room kept with oxygen available. There are 2 concentrators that they keep as extra if one is used they replace with another one the next day Interview on [DATE] at 10:20 P.M. with RN-C, who worked the overnight shift on [DATE], revealed that he had been given report from LVN F who had worked ,d+[DATE] pm. RN-C stated that he did not know that Resident # 1 was supposed to have been on oxygen. He stated LVN F had told him about Resident #1 testing positive for COVID. RN-C stated that he had worked with Resident #1 several times that night and was checking her V/S regularly because she was COVID positive, he did not see her in any distress and her O2sats were at her baseline of ,d+[DATE]%. Interview on [DATE] at 1:05 pm with LVN F revealed she had worked at the facility on [DATE]. LVN F stated she did receive report from the previous shift and was aware that there were a lot of orders to take off. LVN F stated she asked LVN A if she was going to implement the orders and she didn't answer but she thought she would. LVN F stated she took the order off in the system and she assumed Resident #1 had oxygen on. When asked if she worked with Resident #1 she stated she had but because the resident was COVID positive staff put a mask on Resident #1 while they worked with her, so she couldn't tell if she had oxygen on or not. When asked if she looked around or under the mask she stated she had not she just assumed the oxygen was there. LVN F stated she did check O2 sats and Resident #1's was ,d+[DATE]%. LVN F stated she did not put the order on the shift report like she normally would, but the overnight shift should have seen the order because it populates on the TAR. Review of the Policy titled Physician Orders/Verbal Orders dated ,d+[DATE] revealed that verbal orders are only to be given in an emergency or when attending physician is not available to sign. Verbal orders will always be based on verbal exchange with the prescribing practitioner or on approved written protocols. The DON was notified on [DATE] at 5:26 P.M. an Immediate Jeopardy situation had been identified due to above failure. The IJ template was provided to the DON on [DATE] at 5:57 P.M. A Plan of Removal was first submitted by the Regional Director of Clinical Services on [DATE] at 11:03 P.M. and the following POR was accepted on [DATE] at 4:30 p.m. Immediate action: Please accept this as a Plan of Removal to remove the IJ Identified in Respiratory/[CONDITION(S)] care initiated on [DATE] at: 5:57 P.M. Systematic Approach: 1. Assessment a. All residents had respiratory assessments conducted to check for abnormalities on [DATE]. 2. Monitoring a. All residents orders will be reviewed in the facility stand up meeting daily overseen by the Director of Nursing and Executive Director. Any patient with oxygen orders will be followed up on by the Director of Nursing or designee to ensure the order was carried out as ordered by the provider. b. The DON or designee will monitor all residents who are receiving ordered oxygen daily x 2 weeks beginning [DATE], then once weekly x 30 days, then monthly thereafter to ensure compliance. 3. Oxygen Equipment a. An audit was conducted by the facility on all oxygen concentrators and cylinders on [DATE]. An adequate supply was found. 4. In-Services a. RNs and LVNs were in-serviced by the Regional Director of Clinical Services and the DON beginning [DATE]-[DATE] on the following: i. Carrying out physician orders- a) When a nurse receives a verbal order, the order will be carried out and immediately, it will then be put into the EMR and written on a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The charge nurse will then put in a clinical note stating who gave the order and why and notify the responsible party. If any questions or clarifications are needed about the order the nurse receiving the order will notify the physician for clarification. b) When a nurse receives a telephone order it will be placed on physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The charge nurse will then put in a clinical note stating who gave the order and why and notify the responsible party. If any questions or clarifications are needed about the order the nurse receiving the order will notify the physician for clarification. c) When a provider enters an order into the EMR system the order appears on the smartboard in draft, the charge nurse on the assigned shift will need to activate the orders, carry them out, and charge nurse will then put in a clinical note stating who gave the order and why and notify the responsible party. ii. Utilizing the 24 hour report and reviewing orders during the change of shift report. During change of shift report the nurses will be conducting walking rounds and reviewing orders and changes for patients. At this time if a new oxygen order was received it will be verified that the order was carried out. All patients that are currently on oxygen will also be checked on by both nurses to ensure the patients are receiving the required ordered oxygen. The Director of Nursing will oversee and ensure the process is being followed. iii. The location of oxygen concentrators and cylinders, and what to do if they are not able to locate a concentrator. iv. Reconciling physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. An in-service on the importance of applying oxygen when needed promptly beginning on [DATE]. c. No facility staff will be allowed to return to active duty until such a time as the education described above is completed. 5. Quality Assurance a. Quality of Care concerns regarding the follow through of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. All patients with oxygen orders will reviewed monthly by the quality assurance committee. 6. Completion date [DATE] Monitoring of the facility's Plan of Removal was conducted from [DATE] - [DATE]. Observation on [DATE] from 9:30 P.M. through 10:20 P.M. of the 500- 800 halls shift change revealed that the two-nursing staff did review the shift report which contained new orders for the day. The nurses also walked the halls doing walking rounds to check on the residents. Observation on [DATE] at 10:35 P.M. of the ,d+[DATE] halls revealed the nurse had revealed the previous shift had a copy of the shift report on the desk. The shift report contained new orders for the day. Observation on [DATE] from 1:30 P.M. through 2:20 P.M. on the ,d+[DATE] halls revealed that the two nurses leaving, and the two oncoming nurses walked their assigned hall with a copy of the shift report and at a residents' room that had received an order that day the off going nurse pointed out the order to the oncoming nurse. Observation on [DATE] at 3:10 P.M. of the oxygen supply room revealed that there was enough oxygen available and 2 concentrators available. Interviews on [DATE] and [DATE] at various times with 6 nurses working the floor revealed all had received the facility in-service and were aware the shift report had to be reviewed and that all orders were to be checked by the oncoming nurse and the nurse leaving. All nurses reported they were told that verbal orders were to be implemented immediately and where the oxygen storage room was, in addition all knew reporting requirements. Review of policy titled Verbal Orders, revised, undated, revealed that verbal orders are only to be given in an emergency or when attending physician is not available to sign. Verbal orders will always be based on verbal exchange with the prescribing practitioner or on approved written protocols. It is noted to be the responsibility of the licensed nursing staff who received the order to ensure it is implemented. Review of the facility Nursing Procedure training policy and in-services for current nurses on training started on [DATE] revealed during shift change nurses outgoing and oncoming are to review the shift report, which contains new orders and do physical rounds checking on the residents. The administrator was informed on [DATE] at 4:30 P.M. the Immediate Jeopardy was removed, and that the facility remained out of compliance at a severity of actual harm with the potential for more than minimal harm and a scope identified as isolated.