Every finding on record at Parkway Pavilion Health and Rehabilitation Center

Based on clinical record review, facility documentation/policy, observation, and interviews for one (1) of three (3) sampled residents (Resident #3) reviewed for diet consistency, the facility failed to ensure food provided to a severely cognitively impaired resident was consistent with the physician-ordered mechanically altered diet. Specifically, Resident #3, who had dysphagia and was prescribed a mechanical soft diet, was observed consuming a lollipop, while reclined to approximately 45 degrees in a wheelchair, which was not compatible with the prescribed diet, placing the resident at risk for choking or aspiration. The findings include:Resident #3's diagnoses included protein calorie malnutrition, generalized muscle weakness, dysphagia, lack of coordination, and Alzheimer's Disease.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 as severely cognitively impaired. Resident #3 was dependent on staff for all daily living skills including eating.The Resident Care Plan (RCP) dated 7/7/26 identified Resident #3 was at nutritional risk due to dysphagia. Interventions directed a mechanically soft altered diet.The physician's order dated 7/17/26 directed a regular mechanical soft diet with thin liquids and close supervision during meals to ensure consistent tolerance of food and to provide cues for general safe swallow strategies.The physician's note dated 7/28/26 at 8:15 AM by APRN #1 (the facility Advanced Practice Registered Nurse) identified Resident #3's diet as regular, mechanical soft with regular thin fluids. The directions further identified close supervision during meals to ensure consistent tolerance of food and general safe swallow strategies.Observation on 8/26/26 at 2:00 PM identified Resident #3 seated in a wheelchair, tilted back approximately forty-five (45) degrees, at that nurse's station with a lollipop in his/her mouth.Interview with LPN #1 (the 7:00 AM to 3:00 PM charge nurse) on 8/26/26 at 2:00 PM identified she was assigned to provide care for Resident #3 on 8/26/26. LPN #1 identified Resident #3 was sucking on a lollipop. LPN #1 further identified that Resident #3 was prescribed a mechanical soft diet and that Resident #3's family member had given Resident #3 the lollipop. LPN #1 further identified the family member provided a container of lollipops to Resident #3 several days prior and gave them to Resident #3 on a regular basis. Despite reviewing the prescribed diet with LPN #1, she did not remove the lollipop.Interview with RN #1 (the 7:00 AM to 3:00 PM supervisor) on 8/26/26 at 2:15 PM identified that physician's orders directed a Regular mechanical soft diet but since Resident #3 was on hospice, Resident #3 should be permitted to eat foods for comfort. RN #1 was unable to identify an order or directive in the clinical record which permitted food for comfort. RN #1 was unable to identify if a lollipop was permitted on a mechanical soft diet. RN #1 was uncertain of whether it was safe for Resident #3 to eat a lollipop on a prescribed mechanical soft diet while reclined in a modified wheelchair. Despite reviewing the prescribed diet and reclined position with RN #1, she did not remove the lollipop. Subsequent to surveyor request, RN #1 removed the lollipop from Resident #3's mouth.Interview with the Director of Nursing (DON) on 8/26/26 at 2:25 PM identified lollipops were not permitted on a mechanical soft diet, and that Resident #3 should be seated in an upright position at all times when eating due to a risk of aspiration due to dysphagia. The DON thought the Social Worker educated the family member on the importance of not providing certain food items to the resident and agreed that the role of education to the family regarding a therapeutic diet should come from the nurse or physician. The DON further identified the staff were not following the physician's orders and best practice standards pertaining to Resident #1's diet.The facility policy on Therapeutic Diets identified that a therapeutic diet must be prescribed by the resident's attending physician and if a mechanically altered diet was ordered the provider would specify the texture. The facility policy for External Food Management identified the nurse in charge would visually inspect the food product brought in from external food sources including visitors to ensure the received food texture/restrictions were compatible with the resident's orders.

Based on interviews, observations, facility documentation review, facility policy review, and interviews reviewed for Resident Council, the facility failed to ensure residents were informed of their rights, of all the rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. The findings include: Review of Resident Council meeting minutes from 1/29/2025 through 3/26/2026 failed to provide documentation that residents were informed of their rights or educated on the rules and regulations governing resident's conduct and responsibilities during their stay in the facility.On 4/8/2026 at 10:17 AM, a Resident Council meeting was held with Residents #30, #35, #37, #73, #75, #76, #88, #105, and #120 in attendance. The residents identified that facility staff had not reviewed or discussed Resident Rights with them. The residents further identified they had not received education regarding facility rules or policies governing resident conduct and responsibilities. The residents identified although Resident Rights are posted in a glass cabinet outside of the recreation room, they are not accessible because the posting is positioned too high for individuals in wheelchairs, and too small to read. Resident #75 indicated he/she received a package that had been opened and he/she was not aware one of his/her rights is to receive unopened mail. Interview with the Administrator on 4/8/26 at 11:02 AM identified she was as the facility's social worker from May 2025 until six weeks ago. The Administrator stated she had not discussed resident rights or the rules and regulations governing resident conduct and responsibilities at Resident Council meetings since May 2025. The Administrator indicated, in the past, she answered residents' questions about their rights when asked. The Administrator indicated the Resident Rights policy was posted in the glass cabinet outside the recreation room. An observation with the Administrator of the locked glass cabinet outside the recreation room identified that the Resident Rights policy was not posted inside or outside the cabinet.Review of the facility Resident Rights Policy identified federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to be informed about what rights and responsibilities he/she has. Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his/her rights to ensure that the resident is always treated with respect, kindness, and dignity. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee upon hire.

Based on clinical record reviews, facility documentation, facility policy, and interviews for 4 of 6 residents (Resident #2, #12, #98, and #104) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the appropriate state agency was updated subsequent to the residents' new psychiatric diagnoses. The findings included:1.Resident #2's diagnosis includes psychotic disorder with delusions. The quarterly Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #2 had severe cognitive impairment. An interview and record review with 04/13/2026 with the Administrator (previous social worker at the facility) indicated no PASRR documents were in the clinical record and would need to go to the electronic PASSR screening management site to access the documents. Preadmission Screening and Resident Review (PASRR) Level 1 screen dated 04/25/2019 indicated no major mental illnesses (MMI) including Psychotic/Delusional Disorder and had anxiety and depression mental disorders, was taking psychotropic medication and had a diagnosis of dementia. The findings concluded that the Level 1outcome was negative as the current information/diagnosis' provided had not met the criteria needed to pursue a level 2 PASRR screen. 2.Resident #12 had diagnoses that included mild or situational depression and anxiety. The Preadmission Screening and Resident Review dated 8/15/13 identified Resident #12 did not have a major mental health diagnosis but had a history of inpatient psychiatric hospitalization in June 2013. The assessment further identified Resident #12 had diagnoses of anxiety and mild or situational depression, with no dementia present. The outcome indicated there was insufficient evidence of serious mental illness. Review of the clinical record identified Resident #12's diagnosis of bipolar disorder was added on 9/2/2020. A physician's order dated 10/19/24 directed to administer Lamotrigine (mood stabilizer for the treatment of bipolar disorder) 25 milligram (mg) tablet every morning, 2 tablets every evening, and 2 tablets at bedtime. The 5-day admission [NAME] Data Set (MDS) dated [DATE] identified Resident #12 had intact cognition and active diagnoses of anxiety disorder, depression, and bipolar disorder. The Resident Care Plan (RCP) dated 10/24/25 identified Resident #12 had a self-care performance deficit related to his/her bipolar disorder. Interventions include providing assistance as needed to perform activities of daily living such as bed mobility, personal hygiene, dressing, transferring, and toileting. Review of a physician history and physical note dated 10/24/24 identified Resident #12 had diagnoses that included depression, bipolar, and anxiety. The psychiatric psychological note dated 10/28/24 identified Resident #12 had a diagnosis of bipolar disorder and an anxiety disorder. Review of the clinical record failed to identify the PASSR contracted agency was notified of the new psychiatric diagnoses of bipolar disorder from 9/2/26 through 4/8/26 in order to conduct an additional Level 1 and Level 2 screen. Interview and clinical record review with the Administrator (who was the social worker until approximately six weeks prior, beginning May 2025) on 4/8/26 at 9:10 AM indicated she was responsible for reviewing PASRRs for all new admissions and ensuring updates were submitted to the state agency when a resident received a new mental health diagnosis. The Administrator indicated psychiatric providers typically notified her of changes such as new diagnoses or psychiatric admissions, which would prompt PASRR updates in the state system. The Administrator identified Resident #12's bipolar disorder diagnosis from 9/2/2020 was not reflected in the PASRR record. The Administrator further identified the last PASRR update for Resident #12 reflected the diagnoses of anxiety and depression from 2013 and did not include bipolar disorder. The Administrator stated that when Resident #12 was diagnosed with bipolar disorder so Resident #12 could be reevaluated for any potential changes in PASRR recommendations. 3.Resident #98's diagnosis included major depressive disorder. The quarterly Minimum Data Set (MDS) assessment indicated Resident #98 was taking an antidepressant. The RCP dated 3/19/2026indicated Resident #98 had a potential mood problem related to depression. Interventions included administering psychotropic medications as ordered, observe for mood changes and notifying the physician, and encouraging psychiatric services as needed. The care plan further indicated Resident #98 had a negative Level 1 PASSR which recommended rehabilitation services/supports. A clinical record review and interview with the Administrator on 4/14/2026 at 11:07 AM indicated she/he had been a previous social worker at the facility and social workers had come and gone at the facility since the current social worker new to the role 2 weeks ago. She also indicated the new Social Service Director has just started and was in orientation. The administrator also indicated not being able to locate any PASSRR's in Resident #98's clinical record or the PASSRR screening site and would need to contact the management site directly by phone to obtain the records. The administrator indicated a new PASRR screen should have been completed by the facility social worker with the addition of the diagnosis of major depressive disorder as this would indicate a need for a potential level 2 screen to be completed by the PASSR management company. The administrator indicated the need to reach out to the management company but had not done so by the end of the survey. 4. Resident #104 admitted on [DATE] with a diagnosis of psychosis. The quarterly MDS dated [DATE] indicated resident #104 had severe cognitive impairment. The RCP dated 01/27/2026 indicated Resident #104 had impaired cognitive status due to dementia with interventions including explaining all care and to face when speaking. A clinical record review and interview with the administrator( previous social worker) on 04/13/2026 at 12:07 PM found no Level 1 PASRR in the clinical record. The administrator accessed the management site, finding a Level of care and a negative level 1 screen completed on 06/20/2024 both completed in retrospect due to no level 1 was obtained prior to admission to the facility(16 days earlier). The 06/20/2024 Level 1 screen indicated Resident #104 was approved for long term care based on the diagnosis' submitted which included dementia but not psychosis The administrator (previous social worker at the facility) indicated the management facility should have been made aware of the psychosis diagnosis by the nursing facility to accurately screen the resident. Review of the facility PASRR Policy and Procedure Policy identified the facility will have a policy, process, and resources in place to ensure PASRRs are available upon admission and per process and available in the medical record. All residents being admitted to the facility requires a PASRR, either level 1 or level 2. Admissions or designee will upload the PASRR in the documents section of the electronic medical record. Social services are responsible for maintaining a list of when residents are due to be renewed or updated in state agency web site.

Based on review of the clinical records, facility documentation, facility policy, and interviews for four of six residents (Resident #24, Resident #55, Resident #56, and Resident # 118) reviewed for vision, the facility failed to ensure vision services were provided in a timely manner. The findings include1.Resident #24 had diagnoses that included glaucoma and hypertension.The physician's order dated 11/8/2024 directed dental, optometry, audiology, and podiatry consults and treat as needed. The Resident Care Plan (RCP) dated 11/21/2024 identified Resident #24 had a self-care deficit. Interventions included to provide assistance for personal hygiene, bathing, and dressing. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 had a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment and did not require corrective lenses. A Doctor of Optometry (OD) note dated 12/26/2024 identified Resident #24 had an initial examinate and was glaucoma ( eye condition that damage the optic nerve, which is crucial for vision often associated with high pressure inside the eye). The plan indicated a priority comprehensive exam was needed on 4/09/2025. A Social Service note dated 2/21/2025 identified Resident #24's care plan meeting was held and Resident #24's eye exam was 12/26/2025. A Social Services note dated 8/26/2025 identified Resident #24's care plan meeting was held, and Resident #24's responsible party agreed to referrals for dental, podiatry, and optometry.Review of the clinical record identified Resident #24 had not received ophthalmology follow-up after 12/26/2024 (1 year and 4 months).A Social Services note dated 8/26/2025 identified Resident #24 had a care plan meeting, and his/her Responsible Party had agreed to a referral to Dental, Podiatry, and Optometry.Interview with the Medical Director on 4/14/2026 at 11:17 AM identified his expectation is for staff to schedule follow-up visits for residents with specialists including ophthalmology appointments. The [NAME] Director indicated the lack of a follow-up appointment for Resident #24's glaucoma could lead to increased eye pressure, vision loss, or blurry vision.Interview on 4/14/2026 at 12:54 PM with Medical Doctor (MD) #1 identified Resident #24 should have had a priority comprehensive eye exam on 4/09/2025 to recheck eye pressures due to glaucoma. MD #1 indicated a failure to recheck eye pressures as indicated could result in permanent vision loss. MD #1 identified residents with certain comorbidities, such as cardiovascular issues, could experience increased eye pressures that could become out of control and potentially cause blindness very quickly, even within a single day. 2. Resident #55 had diagnoses that included age related cataract bilateral, myopia of the left eye, and dementia.The physician's order dated 8/25/2024 directed dental, optometry, audiology, and podiatry consults and treat as needed.The RCP dated 11/15/2024 identified Resident #55 had had the potential for impaired vision due to cataracts. Interventions included vision consult as needed, observe/document/report to the MD signs and symptoms of eye problems: sudden visual loss, pupils dilated, double vision, tunnel vision, blurred or hazy vision.The quarterly MDS assessment dated [DATE] identified Resident #55 had BIMS score of three (3) indicating severe cognitive impairment, required maximal assistance with personal hygiene, dependent with putting on/taking off footwear, and had corrective lenses for vision.A Doctor of Optometry (OD) note dated 12/26/2024 identified Resident #55 was evaluated for an initial examination for pseudophakia (implantation of an artificial lens). The plan indicated follow-up was needed in three to four months. Review of the clinical record identified Resident #55 had not received ophthalmology follow-up after 12/26/2024 (1 year and 4 months). 3. Resident #56 had diagnoses that included normal pressure hydrocephalus, parkinsonism, and hypothyroidism.The physician's order dated 11/19/2024 directed receive dental, optometry, audiology, and podiatry consults and treat as needed.The RCP dated 11/29/2024 identified Resident #56 had impaired visual function. Interventions included arranging consultation with eye care practitioners as required, ensuring glasses are washed and clean prior to application, and altering the environment for visual assistanceThe quarterly MDS assessment dated [DATE] identified Resident #56 had a BIMS score of four (4) indicating severe cognitive impairment, required maximal assistance with personal hygiene, dependent with putting on/taking off footwear, and had corrective lenses for vision. A Doctor of Optometry (OD) note dated 12/26/2024 identified Resident #56 was evaluated for an initial examination for pseudophakia (implantation of an artificial lens). The plan indicated follow-up was needed in three to four months. A consent form dated 9/8/2025 signed by Resident #56's responsible party identified he/she authorized Resident #56 to be enrolled in the facility's dental, optometry, audiology, and podiatry program.Review of the clinical record identified Resident #56 had not received ophthalmology follow-up after 12/26/2024 (1 year and 4 months). 4. Resident #118 had diagnoses that included dementia and difficulty in walking. The physician's order dated 1/15/2024 directed dental, optometry, audiology, and podiatry consults and treat as needed.The RCP dated 2/27/2024 identified Resident #118 had a self-care deficit. Interventions included providing morning and nighttime assistance with personal hygiene, bathing, and dressing.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #118 had a Brief Interview of Mental Status (BIMS) score of three (3) indicating severe cognitive impairment and did not require corrective lenses.A Doctor of Optometry (OD) note dated 04/09/2024 identified Resident #118 was evaluated for an initial examination for pseudophakia (implantation of an artificial lens). The plan indicated follow-up was needed on 4/09/2025 for a comprehensive examination. A consent form dated 3/17/2025 signed by Resident #56's responsible party identified he/she authorized Resident #56 to be enrolled in the facility's dental, optometry, audiology, and podiatry program.Review of the clinical record identified Resident #118 had not received ophthalmology follow-up after 04/09/2024 (a one-year delay in follow-up).Interview on 4/13/2026 at 2:14 PM with Social Worker (SW) #1 and SW #2 identified they are responsible for faxing referral requests to ophthalmology when residents need to be seen. SW #2 identified that nursing staff, residents, or residents' family members may initiate an ophthalmology referral. Interview with the Director of Nursing Services (DNS) on 4/14/2026 9:05 AM identified she is responsible for ensuring residents requiring ophthalmology services are scheduled for appointments. The DNS indicated she relied on Social Workl and the Resident Care Conferences as the only mechanisms for identifying and tracking residents in need of follow-up ophthalmology appointments. The DNS was unable to explain why the residents were not scheduled for follow-up appointments with ophthalmology. The DNS identified Resident #24, Resident #55, Resident #56, and Resident #118 should have been scheduled for follow-up appointments with ophthalmologists. Interview with the Administrator (formerly the facility's Social Worker) on 4/14/2026 at 9:47 AM identified she was notified by nursing when a resident required ophthalmology services. The Administrator indicated that potential ophthalmology needs were also discussed during Care Conference meetings. The Administrator was unable to explain why residents were not receiving follow-up appointments with ophthalmology. The Administrator identified that optometry follow-up visits should have been scheduled. Review of the facility Physician Services Policy identified in part the attending physician will determine the relevance of any recommended interventions from any discipline.

Based on review of the clinical records, facility documentation, facility policy, observations, and interviews for four of six residents (Resident #24, Resident #55, Resident #56, and Resident # 118) reviewed for foot care, the facility failed to ensure podiatry services were provided in a timely manner. The findings include:1.Resident #24 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction, atherosclerotic heart disease of native coronary artery, and dementia.The physician's order dated 11/8/2024 directed dental, optometry, audiology, and podiatry consults and treat as needed. The Resident Care Plan (RCP) dated 11/21/2024 identified Resident #24 had a self-care deficit. Interventions included to provide assistance for personal hygiene, bathing, and dressing. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 had a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment and required maximal assistance with personal hygiene and putting on/taking off footwear. A podiatry note dated 1/21/2025 identified Resident #24 had multiple hammertoes, with toenails noted to be elongated, dystrophic, and approximately 5 millimeters thick. The podiatry noted indicated non-professional treatment of Resident #24's feet was hazardous to his/her podiatric care.A Social Services note dated 2/21/2025 identified Resident #24's care plan meeting was held and Resident #24's last podiatry visit occurred on 1/21/2025.A Social Services note dated 8/26/2025 identified Resident #24's care plan meeting was held, and Resident #24's responsible party agreed to referrals for dental, podiatry, and optometry.Observation on 4/7/2026 at 10:57 AM identified Resident #24 was lying in bed with the right foot uncovered. The toenails on the right foot were observed to be thickened, with some toenails extending over the top of the foot.Observation and interview on 4/13/2026 at 1:09 PM with Licensed Practical Nurse (LPN) #9 revealed Resident #24 had long, thickened toenails on both feet measuring up to approximately 1.5 inches in length, with some nails curling over the tops of the toes. LPN #9 indicated the nurse aides are responsible for notifying nursing staff when residents' toenails are long.Review of the clinical record identified Resident #24 had not received podiatry follow-up or had his/her toenails cut after 1/21/2025 (1 year and 3 months).2. Resident #55 had diagnoses that included spinal stenosis, dementia, and basal cell carcinoma of the skin.The physician's order dated 8/25/2024 directed dental, optometry, audiology, and podiatry consults and treat as needed.The RCP dated 11/15/2024 identified Resident #55 had a self-care deficit with interventions that included to provide the assistance of one with personal hygiene and eating. The quarterly MDS assessment dated [DATE] identified Resident #55 had BIMS score of three (3) indicating severe cognitive impairment, required maximal assistance with personal hygiene, and was dependent for putting on/taking off footwear. A podiatry note dated 12/21/2024 identified Resident #55 had thickened yellow toenails approximately 5 millimeters in thickness. The podiatry note indicated non-professional treatment of Resident #55's feet was hazardous to his/her podiatric care.Review of the clinical record identified Resident #55 had not received podiatry follow-up or had his/her toenails cut after 12/21/2024 (1 year and 4 months). 3. Resident #56 had diagnoses that included unsteadiness on feet, parkinsonism, and need for assistance with personal care.A physician's order dated 11/19/2024 directed receive dental, optometry, audiology, and podiatry consults and treat as needed.The RCP dated 11/29/2024 identified Resident #56 had a self-care deficit with interventions that included providing assist of one with personal hygiene, bathing, and dressing. The quarterly MDS assessment dated [DATE] identified Resident #56 had a BIMS score of four (4) indicating severe cognitive impairment, required maximal assistance with personal hygiene, and was dependent for putting on and taking off footwear. A podiatry note dated 12/21/2024 identified Resident #56 had elongated, thickened and yellow toenails approximately 5 millimeters in thickness. The podiatry note indicated non-professional treatment of Resident #56's feet was hazardous to his/her podiatric care.A consent form dated 9/8/2025 signed by Resident #56's responsible party identified he/she authorized Resident #56 to be enrolled in the facility's dental, optometry, audiology, and podiatry program.Review of the clinical record identified Resident #56 had not received podiatry follow-up or had his/her toenails cut after 12/21/2024 (1 year and 4 months). 4. Resident #118 had diagnoses that included dementia, difficulty in walking, and chronic systolic heart failure.The physician's order dated 5/14/2024 directed dental, optometry, audiology, and podiatry consults and treat as needed.The quarterly MDS assessment dated [DATE] identified Resident #118 had a BIMS score of four (4) indicating severe cognitive impairment and required set-up assistance with personal hygiene, and moderate assistance with putting on/taking off footwear. The RCP dated 11/13/2024 identified Resident #118 had a self-care deficit. Interventions included providing morning and nighttime assistance with personal hygiene, bathing, and dressing.A podiatry note dated 11/19/2024 identified Resident #118 had elongated, thickened yellow toenails approximately 5 millimeters in thickness. The podiatry note indicated non-professional treatment Resident #118's feet was hazardous to his/her podiatric care. A consent form dated 3/17/2025 signed by Resident #118's responsible party identified he/she authorized Resident #118 to be enrolled in the facility's dental, optometry, audiology, and podiatry program.Review of the clinical record identified Resident #118 had not received podiatry follow-up or had his/her toenails cut after 12/21/2024 (1 year and 5 months).Interview on 4/13/2026 at 2:14 PM with Social Worker (SW) #1 and SW #2 identified they are responsible for faxing referral requests to podiatry when residents need to be seen. SW #2 identified that nursing staff, residents, or residents' family members may initiate a podiatry referral. Interview with the Director of Nursing Services (DNS) on 4/14/2026 9:05 AM identified she is responsible for ensuring residents requiring podiatry services are scheduled for appointments. The DNS indicated she relied on Social Workl and the Resident Care Conferences as the only mechanisms for identifying and tracking residents in need of follow-up podiatry appointments. The DNS was unable to explain why the residents were not scheduled for follow-up appointments with podiatry. The DNS identified Resident #24, Resident #55, Resident #56, and Resident #118 should have been scheduled for follow-up appointments with podiatry. Interview with the Administrator (formerly the facility's Social Worker) on 4/14/2026 at 9:47 AM identified she was notified by nursing when a resident required podiatry services. The Administrator indicated that potential podiatry needs were also discussed during Care Conference meetings. The Administrator was unable to explain why residents were not receiving follow-up appointments with podiatry. The Administrator identified that podiatry follow-up visits should have been scheduled. Review of the facility Physician Services Policy identified in part the attending physician will determine the relevance of any recommended interventions from any discipline.

Based on observations, interviews, review of facility documentation and policy, the facility failed to ensure residents were free from potential burns after high water temperatures were identified and failed to take action directed toward resident safety timely. The findings include:Observation on 4/8/2026 at various times identified hot water temperatures exceeded 120 degrees Fahrenheit (F) in multiple areas including resident rooms observed. Water temperatures ranged from 120.1 degrees F to 120.9 degrees F.Review of the facility water temperature logs from 1/12/2026 through 4/8/2026 identified the hot water temperatures exceeded 120.0 degrees Fahrenheit (F) on 61 days out of 87 days. Water temperatures ranged from 120.1 degrees F to 143.4 F.Interviews with Maintenance Director #2 (from a sister facility) on 4/8/26 at 1:10 PM and 2:30 PM identified on 4/7/26 that he came to assist the Maintenance Director with survey preparation, as the facility was in its survey window. He noticed that the hot water temperature logbook recorded temperatures above 120 F and called the HVAC company for repairs. He and the facility's maintenance team attempted to adjust the aquastats (thermostats) on the water boilers. He indicated in January 2026, a couple of quotes were obtained for mixing valves and boiler system repairs, and he forwarded the quotes for approval to the corporate office via email. He identified while the water temperatures can be adjusted on the roof, where the hot water boilers are located, However, the HVAC vendor advised against anyone going onto the roof due to safety concerns. The HVAC vendor also stated that if adjusting the boilers did not resolve the temperature fluctuations, a faulty sensor might need replacement. He indicated on 4/7/26 that the Maintenance Director contacted the HVAC vendor again after initially reaching out on 4/6/26. He identified on 4/7/26 that the HVAC vendor came to the facility. He and the Maintenance Director went up onto the roof with the HVAC vendor, adjusted the boilers which typically takes 24-48 hours to see any changes in water temperature. He indicated that since the adjustments were made, the hot water temperatures have remained around 120.0 degrees F.Review of facility's Heating Ventilation and Air Conditioning (HVAC) vendor invoice dated 4/7/26 revealed that the vendor was called to address high water temperatures throughout the building. The Maintenance Director requested guidance on adjusting the temperatures. The visit resolution note showed that the issue was traced to the indirect tanks. The Maintenance Director was instructed on how to adjust the output temperature using the aquastat (thermometer) located at the bottom of the tank. The temperature was lowered by 10 degrees as a temporary measure.Interview with the Maintenance Director of the facility on 4/8/26 at 2:32 PM identified that he was aware the facility had an ongoing issue with high hot water temperatures since January 2026. The Maintenance Director indicated that water temperatures were randomly checked daily throughout the facility, and if identified as high (exceeding 120 degrees F), the water holding tanks aquastats (thermostat) were adjusted. Following the adjustments, he never rechecked the temperatures in the areas in which temperatures exceeded 120 degrees F to ensure normalization occurred and did not notify residents, staff, or visitors to use caution due to the potential for burns, when using hot water. The Maintenance Director indicated in January 2026 that when the hot water temperatures were high, he notified the prior Administrator. He indicated he initially informed the prior Administrator at the time the high-water temperatures were first identified but failed to report findings of subsequent high-water temperature readings to the Administrator.Interview with the Administrator (former social worker at the facility) on 4/8/26 at 2:38 PM identified that she was not aware of the ongoing issue with the high hot water temperatures. The Administrator indicated that she had not received any reports of residents experiencing burns or other issues related to high water temperatures. The Administrator indicated that it was the responsibility of the Maintenance Department to monitor and ensure water temperatures were in the acceptable range and that she should have been made aware of the high hot water temperatures. The Administrator identified had she been aware of the elevated hot water temperatures, she would have immediately followed up to ensure the valves were ordered and escalated the issue if necessary to resolve the problem.Observations on 4/10/26 at 2:21 PM identified hot water temperatures ranged from 100.4 degrees F to 119.5 degrees F on all units in the resident rooms observed.Review of the facility's Safety of Water Temperatures policy, dated 9/13/17, directed the tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 105-120 degrees Fahrenheit, for maximum allowable temperature per state regulation.

Based on review of the clinical records, facility documentation, facility policy, observations, and interviews for four of six residents (Resident #24, Resident #55, Resident #56, and Resident # 118) reviewed for dental, the facility failed to provide dental services in a timely manner. The findings include: 1. Resident #24 had diagnoses that included dysphagia following cerebral infarction, atherosclerotic heart disease of native coronary artery, and dementia.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #24 had a Brief Interview of Mental Status (BIMS) score of 00 indicative severe cognitive impairment, was dependent with eating and oral hygiene. The Resident Care Plan (RCP) dated 5/22/2024 identified Resident #24 had a self-care deficit with interventions that included oral care daily and as needed with the assistance of 1 to brush teeth, clean gums with toothette, and rinse mouth with wash. The RCP additionally identified Resident #24 was edentulous with interventions that included monitor/document/report to the medical doctor signs and symptoms of oral/dental problems needing attention and teeth missing, loose, broken, eroded, or decayed. The physician's order dated 6/4/2024 directed dental, optometry, audiology, and podiatry consults and treat as needed. A Registered Dental Hygienist (RDH) note dated 6/7/2024 identified Resident #24 was evaluated for a dental prophylaxis examination, and his/her next annual exam was set for 6/7/2025. A Social Services note dated 2/21/2025 identified Resident #24's care plan meeting was held and Resident #24's last dental visit occurred on 6/7/2024.A Social Services note dated 8/26/2025 identified Resident #24's care plan meeting was held, and Resident #24's responsible party agreed to referrals for dental, podiatry, and optometry.Review of the clinical record from 6/7/2025 through 4/14/2026 was unable to provide documentation to reflect that Resident #24 received the annual dental examination due on 6/7/2025 or at any time thereafter. 2. Resident #55 had diagnoses that included dysphagia and dementia.The physician's order dated 11/15/2024 directed dental, optometry, audiology, and podiatry consults and treat as needed.The RCP dated 11/15/2024 identified Resident #55 had a self-care deficit with interventions that included to provide the assistance of one with personal hygiene and eating. The quarterly MDS assessment dated [DATE] identified Resident #55 had a BIMS score of three (3) indicative severe cognitive impairment, required maximal assistance with oral hygiene, and moderate assistance with eating. A Registered Dental Hygienist (RDH) note dated 1/20/2025 identified Resident #55 was evaluated for a dental prophylaxis examination, had upper and lower dentures, and exhibited light plaque and calculus buildup. The RDH set a recall for the resident's next annual exam for 4/10/2025.Review of the clinical record from 4/10/2025 through 4/14/2026 was unable to provide documentation to reflect that Resident #55 received the annual dental examination due on 4/10/2025 or at any time thereafter. 3. Resident #56 had diagnoses that included dysphagia, parkinsonism, and obstructive sleep apnea.The physician's order dated 8/30/2024 directed dental, optometry, audiology, and podiatry consults and treat as needed.The RCP dated 11/15/2024 identified Resident #56 had a self-care deficit. Interventions included personal hygiene and eating with an assist of 1, oral care daily and as needed: setup to brush teeth, clean gums with toothette, rinse mouth with wash, observe for broken/chip denture/teeth, bleeding, pain or mouth sores and report to the nurse, and coordinate arrangements for dental care, transportation as needed as ordered.The quarterly MDS assessment dated [DATE] identified Resident #56 had a BIMS score of 4 indicative of severe cognitive impairment, required maximal assistance with oral hygiene, and moderate assistance with eating. A Registered Dental Hygienist (RDH) note dated 1/20/2025 identified Resident #56 was evaluated for a dental prophylaxis examination, had upper and lower dentures, and exhibited light plaque and calculus buildup. The RDH set a recall for the resident's next annual exam for 4/10/2025.A signed consent form dated 9/08/2025, completed by Resident #56's responsible party identified he/she authorized for Resident #56 to be enrolled in the facility's dental, optometry, audiology, and podiatry programs.Review of the clinical record from 4/10/2025 through 4/14/2026 was unable to provide documentation to reflect that Resident #56 received the annual dental examination due on 4/10/2025 or at any time thereafter. 4. Resident #118 had diagnoses that included malignant neoplasm of tongue, dementia, and chronic systolic heart failure.The quarterly MDS assessment dated [DATE] identified Resident #118 had a BIMS score of three (3) indicative of severe cognitive impairment, required moderate assistance with oral hygiene, and set-up assistance with eating. The RCP dated 5/2/2024 identified Resident #118 had a self-care deficit with interventions that included morning and nighttime assistance with oral care. The physician's order dated 5/14/2024 directed dental, optometry, audiology, and podiatry consults and treat as needed.A Doctor of Dental Surgery (DDS) note dated 5/17/2024 identified Resident #118 was evaluated for an initial examination and found to have heavy plaque and calculus buildup, severe inflamed and swollen gums with bleeding, and chronic periodontitis. The DDS set a recall for the resident's next examination for 12/15/2024.A signed consent form dated 3/17/2025, completed by Resident #118's responsible party identified he/she authorized for Resident #118 to be enrolled in the facility's dental, optometry, audiology, and podiatry programs.Review of the clinical record from 12/15/2024 through 4/14/2026 was unable to provide documentation to reflect that Resident #118 received the annual dental examination due on 12/15/2024 or at any time thereafter.Interview with the Director of Nursing Services (DNS) on 4/14/2026 at 9:05 AM identified she was responsible for ensuring residents requiring dental, ophthalmology, and podiatry services were scheduled for appointments. The DNS indicated she relied on Social Work and Resident Care Conferences as the only mechanisms for identifying and tracking residents in need of follow-up for dental services. The DNS was unable to explain why the residents requiring dental services were not scheduled for follow-up appointments. The DNS identified Resident #24, Resident #55, Resident #56, and Resident #118 should have been scheduled for their dental exams.Interview with the Administrator (formerly the facility's Social Worker) on 4/14/2026 at 9:47 AM identified she is notified by nursing when a resident required dental services. The Administrator indicated that potential dental needs were also discussed during Care Conference meetings. The Administrator was unable to explain why residents were not receiving scheduled dental follow-up visits. The Administrator identified that follow-up visits should have been scheduled. Review of the facility Dental Care and Services Policy identified in part that residents will be assisted with obtaining routine and emergency dental services. Routine dental services are an annual inspection of the oral cavity for signs of disease, detailed x-rays, corrections of broken teeth, denture fittings and adjustments, fillings and limited procedures.

Based on observation of the kitchen, policy review and staff interview, the facility failed to ensure that opened food items in the dry storage were labeled and items requiring refrigeration were stored appropriately. Findings include: On 4/7/2026 at 10:12 AM, a tour of the dry storage area of the kitchen was conducted with the Director of Dietary. An observation identified two open jars of peanut butter that were both about 2/3 empty. Both jars were noted to have peanut butter around the outside rim of the jars. There was no open or use-by date on the jar other than the manufacturer's expiration date of 2/21/2028. The Director of Dietary indicated peanut butter would be good for six months after opening and indicates she/he did not know when the jars had been opened. An open jar of grape jelly was also observed to be 1/3 used. There was no open or use-by date on the jar. The jar also identified the jelly should be refrigerated after opening. The Director of Dietary indicated that the jelly should have been refrigerated and that it could last up to six months if properly stored. The Director of Dietary further indicated that open food items should have been labeled with the date they were opened.A review of facility policy for Date Marking given on site identified that food items would be date-marked with the name of the product and the date of production or opening.

Based on observation of the kitchen, policy review and interview, the facility failed to maintain the outdoor garbage area in a sanitary condition. Findings include: On 4/7/2026 at 10:45 AM, a tour of the outdoor garbage storage area was conducted with the Director of Dietary.An observation identified 6 mattresses, a large plastic pipe, and a large metal pipe behind the garbage compactor. The Director of Dietary indicated she was not sure of the plan for disposing of the mattresses and the pipes. An interview with the Director of Maintenance indicated he did not know how long the items had been there since he was recently employed by the facility. The Director of Maintenance further indicated the facility was looking into obtaining a large dumpster for the items.The trash compactor was further observed to have food waste on the lower edge of the compactor. There were multiple, red-colored food items in the shape of cubes, a leftover sandwich, pieces of lettuce, and carrots. There were also straws, plastic cups, and lids, a black food container, and multiple blue gloves on the ground next to the trash compactor. The Director of Dietary indicated she was not sure whether the garbage was from the kitchen or from housekeeping.On 4/7/2026, at 10:55 AM, an observation was conducted with the Director of Dietary and Housekeeper #1 which identified she/he appropriately using the trash compactor with the lift mechanism. An interview with the Director of Dietary indicated that the kitchen does not have garbage cans that can be attached to the trash compactor's lift mechanism and when dietary staff lifts the garbage cans up, the bags may break and kitchen trash may fall outside the compactor.A review of the facilities standard operating procedure for Trash Disposal and Compactor Sanitation given onsite identified that the compactor area must remain free of debris.

Based on clinical record reviews, observations, facility documentation, reviewed of the facility infection surveillance, facility policy and interviews, the facility failed to ensure environmental rounds were conducted by nursing and department heads monthly, and for 2 of 4 residents reviewed for infection control practices, the facility failed to wear appropriate Personal Protective Equipment (PPE) and practice hand hygiene between glove changes (Resident #2) and failed to ensure a sterile single use tracheostomy suction equipment was discarded appropriately for (Resident #125). The findings included:1.The facility's infection control environmental round documentation for the years 2024 and 2025, identified that quarterly environmental rounds were not completed by the nursing department or department heads in 2024. The quarterly environmental rounds were not completed by the nursing department or department heads for the months of February, April, May, June, August, September, October, November, or December 2025. Interview with the Assistant Director of Nurses and Licensed Practical Nurse (LPN ) #1 (Infection Preventionist) on 4/10/26 at 10:50 AM identified they were unable to locate the environmental rounds worksheets prior to February 2026. LPN #1 identified he was new to the role, and on 1/20/26 he received training on environmental rounds. LPN #1 indicated in February 2026 he implemented monthly environmental rounds. Interview with LPN #1 on 4/10/26 at 12:42 PM identified he was unable to locate any environmental round worksheets for 2024. LPN #1 further identified he was unable to locate the the environmental rounds worksheets for February, April, May, June, August, September, October, November, and December 2025. Review of the facility Environmental Rounds Best Practice policy, directed in part, that environmental rounds will be conducted by the IP/designee monthly from nursing and should also include maintenance, dietary, & housekeeping representatives. Environmental rounds should be reviewed monthly in QAPI/infection control meetings (or weekly if done with risk) with the IDT team and quarterly in with Med Staff team for any reoccurring issues and resolutions. 2.Resident #2's diagnoses included dementia and diabetes mellitus. A physician's order dated 2/28/2026 directed to cleanse the left lateral great toe with normal saline followed by application of Iodosorb and a border gauze dressing daily. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #2 had severe cognitive impairment and had a pressure ulcer wound. The care plan dated 3/20/26 indicated Resident #2 was at risk for and had actual pressure ulcers. Interventions included providing wound care as ordered and indicated the resident requires enhanced barrier precautions due to wounds. An observation of LPN #5 performing wound care to Resident #2 's left foot identified the following: After preparing the over the bed table and supplies needed, LPN #5 completed hand hygiene donned gloves(one type of personal protective equipment-PPE), explained the procedure to the resident. LPN #5 then leaned into and started to remove the old dressing but was stopped by the surveyor as LPN # 5 did not have a gown to protect her clothing and the resident appropriately as required for Enhanced Barrier Precautions. When asked what the Enhanced Barrier precautions sign outside the door meant LPN #5 indicated she needed to wear a gown. After removing gloves and conducting hand hygiene LPN #5 donned a gown and proceeded to provide wound care as ordered. After removing the old dressing LPN #5 removed the used gloves, opened the top of a bottle of saline then applied a new pair of gloves then was stopped by the surveyor and reminded to complete hand hygiene after glove removal and prior to application of a new pair of gloves. LPN #5 completed hand hygiene then applied a new pair of gloves. Wound care was completed as ordered. An interview on 4/10/2026 at 12:30 PM with the Infection Preventionist (LPN #1) indicated a gown and gloves should have been worn for direct wound care with Resident #2 due to the need for enhanced barrier precautions to protect the resident from potential exposure to infective organisms that may be brought in due to having an open wound. LPN #1 further indicated hand hygiene needed to be conducted after the removal of gloves, before donning a new pair of gloves. The facility policy labeled Enhanced Barrier Precautions directed staff to wear a gown and gloves while performing high contact care activities including wound care with all residents at high risk for acquiring or spreading a Multidrug Resistant Organism (MDRO). The facility policy labeled hand hygiene given onsite indicated hand hygiene must be completed after removing gloves. 3.Resident #125's diagnoses included Multiple Sclerosis (MS) and laryngeal cancer with tracheostomy placement. The annual MDS assessment dated [DATE] identified Resident #125 as cognitively intact and noted a tracheostomy. The MDS assessment further indicated the resident did not require suctioning. A review of physician's orders and of the Treatment Administration Record (TAR) for February and March 2026 did not identify an order for suctioning. A care plan last reviewed on 3/19/2026 identified Resident #125 had a tracheostomy related to laryngeal cancer. Interventions included assisting with coughing as needed and suctioning as needed. An observation during screening on 4/7/2026 at 1:55 PM identified a suction machine and suction tubing set up in the resident's room. The tubing and suction canister were undated. The suction canister contained 100ml of clear fluid. At the end of the suction tubing was a suction catheter hanging from the canister and dangling down towards and touching the bed's headboard. On 4/8/2026 at 11:00 AM, an observation and interview with licensed Practical Nurse (LPN#3) identified the undated suction canister and tubing, along with the suction catheter still hanging down towards and touching the headboard. LPN#3 indicated Resident #125 was unable to suction her/himself and the resident rarely needed suction. LPN#3 did not recall the last time Resident #125 required tracheal suctioning. LPN#3 indicated suction catheters are one-time use, and that the canister and tubing should have been changed every two weeks. On 4/8/2026 at 1:44 PM, an interview with the Infection Control Nurse (LPN#1) identified tracheal suction catheters are single-use and should be discarded after use. Additionally, suction catheters should not have been left hanging since a new, unopened catheter should be used when a resident requires suction. A review of the facility policy for Suction Unit given onsite identified when suction is needed, a disposable sterile suction catheter would be needed, and sterile technique should be used.

Based on employee record review, facility documentation, and staff interview for 2 of 5 staff members reviewed for education ( Nurse Aide (NA) #3 and NA#5), the facility failed to ensure nurse aides documentation for 12 hours in-service training yearly; and for 2 of 5 staff members reviewed for education (NA#3 and NA#5), the facility failed to ensure staff received mandatory dementia training for 2025. The findings included: On 4/13/2026 at 10:10 AM, an interview and record review with the Staff Development Nurse (LPN#1) identified an in-service tracker for January 2025 and February 2025 which noted the following : NA#3 received 2.5 hours of training in January and 2 hours of training in February 2025. NA#5 received 1.5 hours of training in January and 30 minutes of training in February 2025. The facility was unable to produce a tracking system for the remainder of 2025. For 2024, there was no tracking system available. There were multiple individual in-service sign-in sheets for 2024 and 2025 without specific time lengths indicated on the in-service sheets.A further review of the facilities' education records with LPN#1 identified NA#3 and NA#5 received dementia training in 2024; however, the facility was unable to produce documentation that indicated that NA#3 and NA#4 had received dementia training for 2025.LPN#1 indicated that he recently took over the role of Staff Development Nurse and was in the process of creating a system for tracking education and in-services. LPN#1 indicated he could not speak to the process of prior staff development nurses other than the records reviewed.Although requested, the facility did not provide a facility policy for staff training and in-services.

Based on clinical record review, facility policy and staff interviews for 1of 1 resident (Resident # 15) reviewed for Advanced Directives, the facility failed to ensure a resident who was a new admission had advanced directive choices offered, and the responsible party's decision documented on the facility forms. The findings include: Resident #15 was admitted to the facility on [DATE]. The resident's diagnosis includes Alzheimer's disease. A physician 's order dated 2/17/2026 at 5:32 PM directed Resident #15's advanced directives would be Do Not Resuscitate (DNR), Do Not Intubate (DNI) and Registered Nurse may pronounce death when occurs( without any directives from the responsible party). An Advanced Practice Registered Nurse (APRN) note dated 2/18/2026 indicated Resident #15's code status was reviewed over the phone with the resident's responsible party and indicated to continue with Do Not Resuscitate, DNI and Do Not Hospitalize (DNH) with a goal of keeping Resident #15 comfortable. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 had moderate cognitive loss. The care plan revised on 6/17/2026 ( dated as initiated on 3/07/23 from a previous admission) and indicated Resident #15's responsible party requested do not resuscitate ( DNR), do not intubate ( DNI), do not hospitalize ( DNH) and Registered Nurse(RN) may pronounce resident upon death with interventions including to discuss advanced directives with the responsible party and to verify presence of a physician's order for DNR and to review the DNR status quarterly and as needed. An interview and clinical record review with charge nurse Licensed Practical Nurse ( LPN#3) on 4/08/2026 at 10:01 AM identified no advanced directives form for Resident #15 in the clinical record despite the physician order for DNR, DNI and RN may pronounce. LPN # 3 further indicated the red transparent folder in the front of the chart is where the advanced directive forms are placed to be able to find them quickly. 0n 4/13/2026 12:22 PM an interview and clinical record review with the Registered Nurse (RN) supervisor, RN #1, indicated the advanced directive form was in medical records, now placed in the chart and was dated 4/09/2024 along with a signed form that had been faxed by the responsible party on 4/11/2024 ( prior to Resident #15's current admission). An interview and clinical record review with the Director of Nursing Services ( DNS) on 4/13/2026 at 1:09 PM indicated a new admission should have advanced directive forms completed by the resident or their responsible party. The DNS additionally indicated even if a resident had previously been in the facility if the resident was out of the facility for 30 days or more upon return to the facility the resident would be considered a new admission following all the policies and procedures required for a new admission. The DNS indicated advanced directive forms for Resident #15 would be obtained. After inquiry, a Resident Health Care Advanced Directives Instructions Form was completed on 4/14/2026 with verbal consent from the responsible party signed by the RN supervisor, RN #1, cosigned by the DNS, and an electronic signature of the attending physician Medical Doctor (MD) 2 (60 days after admission).

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #130 and #131) reviewed for beneficiary notices, the facility to provide Medicare denial notices to the residents upon being discharged from Medicare Part A with benefit days remaining. The findings include:1.Resident #130 was admitted to the facility on [DATE] with Medicare Part A as a payor source and was discharged home on [DATE] with benefit days remaining. Although requested, a Notice of Medicare Non-Coverage ( NOMNC) for CMS-10123 (a notice that explains your right to appeal the Medicare Part A denial and how to ask for an immediate appeal) was not provided to Resident #130 as required. Interview with the Administrator (formerly the facility's Social Worker) on 4/9/26 at 9:49 AM identified Minimum Data Set (MDS) coordinator and business office manager are responsible for providing the NOMNC notices. Interview and clinical record review with LPN #6 (MDS Coordinator) on 4/9/26 at 9:53 AM identified she is responsible for providing Medicare Part A residents with NOMNC notices two days prior to discharge. LPN #6 indicated that Resident #130 expressed a desire to discharge earlier and a note dated 10/19/25 indicated the notices could have been issued at that time, with the last covered day identified as 10/21/25. LPN #6 stated the NOMNC and Advanced Beneficiary Notice of Non-coverage (SNF ABN) could have been provided on 10/19/25, allowing two days' notice prior to discharge. LPN #6 identified there was no signed NOMNC or ABN on file for the last covered day of 10/21/25. LPN #6 stated she was not in the role at that time but, if she had been, she would have issued the NOMNC and ABN to Resident #130 on 10/19/25 and ensured signed copies were retained in the record.Interview with LPN #7 (facility's former MDS Coordinator) on 4/9/26 at 11:19 AM identified she was responsible for the MDS department from August 2025 through November 2025, when LPN #6 assumed the role. LPN #7 stated she did not issue ABN or NOMNC notifications and was unsure whether these were issued by Social Services or the Business Office. Interview with the Business Office Manager on 4/9/26 at 11:37 AM identified she has worked at the facility for five years. She stated the MDS nurse is responsible for providing NOMNC and ABN notifications to residents or resident representatives when a Medicare Part A stay is ending. The Business Office Manager stated she does not routinely issue NOMNC notices and only occasionally provides an ABN if she notices the MDS nurse has not completed it. 2. Resident #131 was admitted on [DATE] with Medicare Part A as a payor source and was discharged home on [DATE] with benefit days remaining. Although requested, a Notice of Medicare Non-Coverage ( NOMNC) for CMS-10123 (a notice that explains your right to appeal the Medicare Part A denial and how to ask for an immediate appeal) was not provided to Resident #131 as required. Interview with LPN #6 (MDS Coordinator) on 4/9/26 at 9:57 AM identified Resident #131 had a planned discharge home with hospice services to begin after discharge. LPN #6 stated Resident #131 should have received NOMNC and ABN notifications because the facility was planning the discharge and the resident was receiving services under Medicare Part A. LPN #6 identified here was no signed NOMNC or ABN on file for Resident #131, although she stated the notices should have been provided 48 hours prior to discharge. Interview with LPN #7 (facility's former MDS Coordinator) on 4/9/26 at 11:19 AM identified she was responsible for the MDS department from August 2025 through November 2025, when LPN #6 assumed the role. LPN #7 stated she did not issue ABN or NOMNC notifications and was unsure whether these were issued by Social Services or the Business Office. Interview with RN #6 (Regional Nurse) on 4/9/26 at 11:49 AM identified Residents #130 and #131 were not provided with NOMNC notices. RN #6 stated the NOMNC notices should have been issued to both residents.Review of the facility Notice of Medicare Non-Coverage (NOMNC) and SNF Advanced Beneficiary Notice (ABN) Policy identified to ensure staff are issuing the NOMNC and ABN notifications accurately. NOMNC and ABN are issued when residents utilize their Medicare or Managed care benefits and are no longer needing skilled nursing care or therapy services. Issuance of notice - NOMNC and ABN if applicable must be issued no later than 2 days prior to skilled services ending. Complete notice at Medicare meeting when determining the last covered day. The notice should be issued promptly to ensure that we remain in compliance. Completing the NOMNC with resident's name, resident medical number, and if resident is unable to sign the facility must contact the resident's representative and all attempts to contact the residents' representative must be documented on the notice and in the electronic medical record. Completing the ABN notice when a resident is being discharged from skilled services but are staying in the facility and not being discharged home.

Based on review of the clinical record, facility documents, facility policy and interviews for 1 of 3 residents reviewed for abuse ( Resident #98), the facility failed to ensure staff reported bruising when noticed while providing care. The findings include:Resident #98's diagnosis included cerebral infarction and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #98 was severely cognitive impaired. The care plan dated 3/19/2026 indicated Resident #98 exhibited behaviors of verbal/physical aggression and picking at skin which result in repeated bruising and skin tears. Interventions included speaking softly and clearly, allowing time for the resident to communicate and to encourage participation in activity as able. A Situation Background Assessment Recommendation ( SBAR) summary for providers note dated 3/06/2026 at 10:45 PM indicated bruising was noted to the left inner upper arm and left lateral lower extremity. The bruise was without noted immediate cause. The primary care provider and police were notified with laboratory work ordered. The facility investigation into the bruising of unknown origin on 3/6/26 identified although the bruising was noted and reported by the second shift NA, (NA#1) who cared for Resident #98. Additionally, the investigation noted Resident # 98 was noted with discoloration to left lateral arm that measured 23 Centimeter ( CM) by 11 CM . The left leg discoloration measured 23 CM by 7 CM. However , both left lateral arms and legs were noted with no signs and symptoms of pain.An interview with the 7-3 PM NA, (NA#12), indicated she/he noticed the bruising on Resident #98's left upper arm and left outer leg on 3/6/26 and did not report it to anyone as s/he thought it had already been reported due to the color of the skin areas. An interview with NA#12 on 4/14/2026 at 11:11 AM indicated s/he had noticed the skin bruising while providing morning care when pulling down the resident's Geri sleeves on the arm( protective skin sleeves) at which time she/he noticed the bruising from the upper arm going down toward the wrist and when s/he turned Resident #98 the Geri leg sleeve started to roll down revealing the leg bruising. NA#12 further indicated s/he believed the bruising had already been reported and was called to serve breakfast trays at the time she/he completed care for Resident #98. NA #12 also indicated the last time s/he worked with Resident #98 was 3-4 days prior and no bruising was noted. An interview with the DNS on 4/14/2026 12:00 PM indicated NA #12 should have reported the bruising when she noticed it and no education or in- servicing had been completed by the facility after the incident. The facility policy labeled Abuse prohibition and Quality Assurance/Reporting reasonable suspicion of Crime-Elder Justice Act indicated in part an injury of unknown origin is one that the source of the injury was not observed by anyone, could not be explained by the resident. Everyone who has knowledge of apparent abuse or neglect of a resident is required to report this to their immediate supervisor and the administrator will be informed immediately of an incident of alleged or expected abuse.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #80 and #127) reviewed for hospitalization, the facility failed to ensure bed hold notifications were given at the time of transfer and the ombudsman was notified of the transfers. The findings include:1.Resident #80 was admitted to the facility in November 2025 with diagnoses that included heart failure and major depression. The Resident Care Plan care dated 11/20/25 identified Resident #80 had coronary artery disease with interventions that directed to administer hypertension medications as prescribed. The admission [NAME] Data Set (MDS) dated [DATE] identified Resident #80 had severely impaired cognition. a.A nurse's note dated 2/22/26 at 8:13 AM identified Resident #80 presented at shift change with signs of deteriorating respiratory status. Assessment showed an oxygen saturation of 74% on 2 liters of oxygen via nasal cannula. Resident #80 was warm to the touch, with temporal temperatures ranging from 98.4 degrees Fahrenheit (F) to 99.6 degrees F, heart rate was 134 beats per minute, apical pulse by auscultation was 142 beats per minute with an irregular rhythm. The physician was notified and ordered to transfer Resident #80 to the emergency room. Review of the census report identified Resident #80 was admitted to the hospital on [DATE] and returned to the facility on 2/26/26. Review of the clinical record failed to reflect that written notice, which specifies the duration of the bed-hold policy, had been provided to the Resident #80 or his/her resident representative when the resident was transferred to the hospital on 2/22/26. b.A nurse's note dated 3/4/26 at 2:20 AM identified Resident #80 had an elevated white blood cell count per the laboratory results, which was reported to the APRN. The APRN ordered to transfer Resident #80 to the emergency room for further evaluation and question of possible pneumonia. Review of the census report identified Resident #80 was admitted to the hospital on [DATE] and returned to the facility on 3/10/26. Review of the clinical record failed to reflect that written notice, which specifies the duration of the bed-hold policy, had been provided to the Resident #80 or his/her resident representative when the resident was transferred to the hospital on 3/4/26. Interview with Registered Nurse (RN) #1 (7:00 AM–3:00 PM shift supervisor) identified when a resident transfers to the hospital she prints a transfer/discharge packet that includes the face sheet, diagnosis list, medication list, and the SBAR (change of condition form). RN #1 stated she does not complete the bed hold notification. Interview with the Director of Nursing (DNS) on 4/9/26 at 1:40 PM identified when a resident is transferred to the hospital, the nurse sends the face sheet, transfer/discharge form, medication list with last administration times, recent APRN note, signed DNR form, and the completed bed hold notification form. The DNS indicated the completed bed hold notification is sent with resident's paperwork to the hospital. Interview with RN #6 (corporate nurse) on 4/9/26 at 2:16 PM identified when a resident is transferred to the hospital the nurse is responsible for completing the bed hold notification and providing it to the resident at the time of the transfer. RN #6 indicated the social worker is responsible for providing notifications to the Ombudsman. RN #6 confirmed the Ombudsman was not notified of Resident #80's two hospital transfers. Interview with the Administrator on 4/9/26 at 2:25 PM identified she was responsible as the former social worker for completing and providing the bed hold notification. The Administrator indicated she would also contact the resident's representative regarding the bed hold notification, document the call on the form, and scan it into the clinical record. The Administrator identified the bed hold notifications were not provided to Resident #80 on 2/22/26 and 3/4/26 and she could not explain why they were not completed. The Administrator indicated she was also responsible as the former social worker for Ombudsman notification. The Administrator identified Resident #80's transfers on 2/22/26 and 3/4/26 were not included in the Ombudsman notifications. The Administrator indicated she was transitioning from the social worker role to the administrator role at that time and must have missed Ombudsman notifications. Interview with RN #5 (11 PM-7 AM shift supervisor) on 4/9/26 at 3:39 PM identified when a resident transfers to the hospital she prints a transfer/discharge packet that includes the face sheet, diagnosis list, medication list, and the SBAR (change of condition form). RN #5 stated she does not complete the bed hold notification. Review of the facility Transfer and Discharge Policy identified the purpose is to maintain compliance with state and federal and local regulations regarding the transfer and/or discharge of residents from the facility, while ensuring safe and appropriate placement. The facility will notify the resident and the resident's representative of the transfer or discharge in writing in a language and manner they understand, and the facility must send a copy of the notice to a representative of the state long term care ombudsman. The notice will be made by the facility The facility will ensure that the transfer or discharge is documented in the residents' medical record and appropriate information is communicated to the receiving health care institution or provider. Documents will include the basis for the transfer, comprehensive care plan goals, advanced directive information, discharge summary, and any other documentation to ensure a safe and effective transition of care. Review of the facility Bed Holds and Returns Policy identified prior to transfers the resident and the residents' representatives will be informed in writing of the bed hold and return policy. Prior to transfer, written information will be given to the resident and the resident representative that explains in detail the rights and limitations of the resident regarding bed-holds, the reserve bed payment policy, the facility per diem rate required to hold the bed, and the details of the transfer. 2. Resident #127's diagnosis included acute kidney failure. The RCP dated 2/2/26 identified Resident #127 need for discharge planning due to the desire to discharge back to his/her home in the community. Interventions included to discuss the discharge planning process. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #127 had intact cognition. Review of the Skilled Nursing Facility (SNF/NF) census identified Resident #127 was transferred to the hospital on 3/14/26 at 8:45 AM due to pneumonia and change of condition. An interview and clinical record review with the DNS on 4/14/2026 at 1:47 PM was unable to provide evidence that the resident/responsible party had been provided bed hold information at the time of Resident #127's transfer to the hospital and no evidence the State Ombudsman had been notified of Resident #127's transfer to the hospital. Review of the facility Bed Holds and Returns Policy identified prior to transfers the resident and the residents' representatives will be informed in writing of the bed hold and return policy. Prior to transfer, written information will be given to the resident and the resident representative that explains in detail the rights and limitations of the resident regarding bed-holds, the reserve bed payment policy a, the facility per diem rate required to hold the bed, and the details of the transfer.

Based on clinical record review, facility policy and staff interviews for 1of 1 resident (Resident # 5) reviewed for communication, the facility failed to ensure a care plan was developed for a resident with hearing loss. The findings include: Resident #5's diagnosis included schizoaffective disorder. A hearing consultation conducted by a hearing aid specialist on 1/17/2026 indicated Resident #5 had severe and moderate hearing loss. A plan was developed for medical clearance and a hearing aid evaluation. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #5 was cognitively intact and the resident's ability to hear was adequate. A consultation for a hearing test dated 3/26/2026 indicated findings were conclusive of decreased hearing bilaterally. Additionally, noted new hearing aids are needed and ordered through insurance with a plan for the resident to return in one month to pick up hearing aids. An interview on 4/13/2026 at 10:14 AM inter with NA #2, #3 and #11 who work on the unit regularly indicated seeing Resident #5 cupping his/her ear if located in the hall trying to hear and she/he does this especially when taking a shower. NA #2 indicated someone had said Resident # 5 was getting hearing aids soon. NA #11 indicated Resident #5 was not on his/her assignment but talks with him/her on the unit in the last 6 months or more and s/he had asked me to repeat what I had said. An interview and clinical record review on 4/13/2026 at 10:42 AM with LPN #6 (MDS nurse) indicated although s/he completes the short-term residents' MDS's s/he had spent time at Resident #5's birthday party here at the facility late January 2026 and noted Resident #5 was using a hearing device around his /her neck that kept squeaking. LPN#6 also noticed Resident # 5 adjusting the device so s/he could carry on a conversation without difficulty. An interview and clinical record review with LPN #11 on 4/13/2026 at 10:53 AM who completed Resident #5's 3/16/2026 quarterly MDS assessment indicated to be able to code the MDS section regarding hearing, s/he talks to the resident, staff and reviews the clinical record. LPN# 11 further indicated she/he had spoken with Resident #5 at her/his birthday in late January2026 and the resident had no problem hearing and did not use a device. LPN #11 indicated not knowing how s/he could have missed the hearing consultations in the clinical record and once the hearing aids are obtained further updates would be made. After inquiry, Resident #5's care plan was updated on 4/13/2026 to include Resident #5 was at risk for a communication deficit related to hearing loss. Interventions were added to include speaking slowly and clearly and adjusting tone as necessary and anticipating needs. The facility policy labeled Care Plans, Comprehensive Person-Centered indicated the care plan would include identified problem areas to aid and reduce decline in functional status and are revised as information about residents and their condition changes.

Based on clinical record review, review of facility policy and staff interviews for 1 of 3 residents (Resident # 70) reviewed for pressure ulcers, the facility failed to ensure staff completed a weekly skin evaluation as per facility policy for a resident at risk for pressure ulcers. The findings include: Resident #70's diagnoses included muscle weakness and cognitive impairment.A nursing admission assessment dated [DATE] identified Resident #70 was alert and oriented to self, place, and time, used a walker for ambulation, and had no skin issues.A nursing skin check evaluation dated 1/30/2026 identified Resident #70 had intact skin. A Braden pressure ulcer risk evaluation identified Resident #70 was at risk for pressure ulcers.A care plan dated 1/30/2026 indicated Resident #70 was at risk for skin breakdown related to decreased mobility; interventions included inspecting skin weekly.A physician's order dated 2/2/2026 directed to check the skin weekly on Mondays on shower days.The Treatment Administration Record (TAR) dated 2/2/2026 identified that a skin check was signed off/completed; the record did not identify if the skin was noted to be intact. A further review of the medical record failed to identify a nursing skin check evaluation on 2/2/2026. A Braden Scale ( measure resident at risk for pressure development) on 2/7/26 identified the resident score 19 indicating the resident was at risk for pressure development.A nursing skin check evaluation dated 2/9/2026 (10 days after the admission skin check) identified a new stage 2 pressure ulcer to the coccyx. The stage 2 pressure area on coccyx measured 1.5 Centimeter ( CM) by 1.5 cm by 2.0 cm. A physician's orders directed to cleanse with Normal Saline and apply a foam dressing. The skin check did not identify skin breakdown on the resident's heels.A wound specialist's note dated 2/9/2026 identified the coccyx wound as a moisture-associated non-pressure wound. The wound specialist's note further identified a deep tissue injury to the left heel. A review of the clinical record on 4/10/26 identified on 2/1/2026, Resident #70's room was changed, resulting in the shower day changing from Monday to Saturday. The Treatment Administration Record (TAR) and the physician's order were not updated to reflect the new shower day. Subsequently, on 2/2/2026, Resident #70's weekly skin check may have been missed. On 4/10/2026 at 11:48 AM, an interview with the wound nurse (LPN#10) identified that staff must complete weekly skin checks on a resident's shower day, and she/he explained this as the possible reason for the missed evaluation.A review of the facility policy for Prevention of Pressure Ulcers identified that the facility should ensure that assessments were timely and appropriate, and that changes in condition were recognized and evaluated.

Based on clinical record review, resident interview, review of facility policy and staff interviews for 1 of 4 residents reviewed for nutrition (Resident #42), the facility failed to ensure a resident with a history of heart failure was educated on and offered a low-sodium diet. The findings include: Resident #42's diagnoses included intellectual disabilities, primary hypertension, hypertensive heart disease with heart failure, and Congestive Heart failure (CHF).A nursing admission assessment dated [DATE] identified Resident #42 was oriented to self, place, and time and did not have any nutritional or fluid needs. The assessment further indicated Resident #42 did not have any edema.A diet order dated 4/14/2025 directed a regular diet with low lactose.An admission nutrition assessment dated [DATE] identified the resident's weight was 169.7 pounds (lbs.). Nutritional goals included consuming greater than 75% of meals and maintaining a stable weight.A quarterly nutrition assessment dated [DATE] indicated Resident #42 had weight fluctuations likely secondly to CHF/fluid. Interventions included a continuous plan of care.A quarterly nutrition assessment dated [DATE] indicated Resident # 42's weight was 200.2 pounds and noted nutrition-related diagnoses, including heart disease and CHF. Nutritional goals included maintaining a stable weight. Interventions included providing diet as ordered, obtaining weights as ordered, and diet teaching/support as needed.A quarterly nutritional assessment dated [DATE] indicated Resident #42 continued with lower extremity edema with compression stockings and noted weight changes may be fluid related. The note further identified that the resident's hydrochlorothiazide (a diuretic medication) had been increased. Interventions included verifying weight gain and reviewing weight gain with the resident.A comprehensive nutritional assessment dated [DATE] indicated Resident #42's weight was 212lb's. The assessment indicated the nutrition-related diagnosis included heart failure, diabetes mellitus, and hypertension. The assessment further indicated that the resident had nutritional risk related to obesity and Left Lower Leg Edema (LLE) edema. Nutrition goals included maintaining a stable weight. Interventions included providing a regular diet, obtaining weights as ordered, continuing to monitor nutritional parameters, and providing education on weight management by a registered dietician.A further review of the clinical record failed to identify resident education on diet related to edema, CHF, or sodium intake. Additionally, the medical record did not identify if Resident #42 had been offered or had refused a low-sodium diet as part of their CHF management.On 4/7/2026 at 2:24 PM, Resident #42 was observed with lower extremity edema. Resident #42 indicated she/he believed her/his swelling was due to her/his blood pressure. Resident #42 further indicated that her/his food was too salty and she/he had not had a conversation with the dietician about decreasing salt intake.On 4/9/2026 at 2:46 PM, an interview with Dietician #1 and Dietician #2 indicated on admission, Resident #42's diet was not restricted because the resident had been admitted with poor appetite. Additionally, Dieticians #1 and #2 indicated that if a resident has a diagnosis of CHF, the resident will not necessarily have a low-sodium diet and it would depend on conversations with the resident, if the resident would be willing to be on a more restricted diet. Both also indicated resident's rights would be a consideration when planning care. Dietician #2 further indicated that she would typically converse about a low-sodium diet with residents but could not recall the conversation with Resident #42 but would refer to her note on 1/2/2026.A review of the facility policy for Management of Congestive Heart Failure identified nursing measures to be implemented including educating the resident on diet recommendations and CHF management.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 4 residents (Resident #8) reviewed for respiratory care, the facility failed to ensure the BIPAP (Bilevel positive airway pressure is a machine that uses air pressure to keep breathing airways open) tubing, filter, and mask were changed in accordance with the manufacturer's recommendations. The findings include: Resident #8 had diagnoses that included respiratory failure, sleep apnea, and emphysema.The quarterly MDS dated [DATE] identified Resident #8 had intact cognition and required extensive assistance with personal hygiene and dressing.The Resident Care Plan (RCP) dated 1/5/26 identified Resident #8 requires assistance with activities of daily living. Interventions included assistance of 1 person for bed mobility and personal hygiene and assistance with 2 with a mechanical lift for transfers.The physician's orders dated 3/1/2026 directed to administer BIPAP 8/20 cmH20 (centimeters of water) at bedtime and for naps every shift and daily cleaning of the BIPAP: disassemble residents circuit (exhalation valve and mask) place pieces in a basin of lukewarm soapy water, wash all parts of the circuit with a soft cloth, rinse under running water, then hang the tubing to dry on every day on the day shift for infection control. Additionally, wash BIPAP headgear with warm water and soap, hang to dry, and replace monthly on the 11th on the day shift and as needed.Observation on 4/7/26 at 10:09 AM identified Resident #8 had a BIPAP machine on top of the nightstand with the BIPAP mask without the benefit of being bagged, and the mask and tubing were not dated. In addition, there was a gallon jug of distilled water on the floor next to bed dated 5/10/25 that was almost empty.Interview with Licensed Practical Nurse (LPN) #10 on 4/7/26 at 10:25 AM indicated that the BIPAP masks must be bagged when not in use, and both the mask and tubing should be dated when changed. LPN #10 identified Resident #8's mask, tubing, and water chamber were not dated, and the mask was not bagged. LPN #10 indicated she did not know when the equipment was last changed or cleaned.Interview with the Director of Nurses (DNS) on 4/14/2026 at 10:50 AM indicated that BIPAP masks should be stored in a bag when not in use and changed weekly. The DNS further indicated masks, and tubing should be dated when changed. The DNS was unable to identify when Resident #8's mask and tubing should be changed, when the BiPAP equipment should be cleaned, or who is responsible for changing the mask and tubing, cleaning the equipment, and replacing the humidifier chamber.Interview with Oxygen Technician #1 on 4/14/26 10:57 AM indicated BIPAP face masks should be changed at least every 3 to 6 months; depending on usage, while the tubing should be changed monthly by the facility's nurses. Technician #1 indicated he changes the filters in the machine monthly.Interview with Registered Nurse (RN) #1 (7:00 AM to 3:00 PM supervisor) on 4/14/26 at 11:00 AM indicated that the Oxygen Technician #1 is responsible for changing the BIPAP face masks, tubing, filters, and water chambers. RN #1 indicated nursing only changes the tubing if there is a hole or leak in it. Review of the facility Care and Instructions for BIPAP and CPAP Units policy identified if you are using disposable tubing change the tubing monthly. Nasal and full-face masks need to be cleaned daily using warm water and mild soap. Let air dry before being used. Headgear for mask should be hand washed with warm water and a mild soap once per month or sooner if needed. Let air dry before using. Inspect mask frequently and replace it as needed. If your equipment has a humidifier clean the chamber every morning using warm water and mild soap. Let air dry. Fill chamber to the fill line with sterile or distilled water every night before use. BIPAP filters will be cleaned by oxygen technician's company. The Manufacture Guide for BIPAP dated 2026 identified the replacement guidelines are to replace the mask, cushions, nasal pillows monthly; replace the mask frame and tubing every 3 months and replace the headgear/straps and humidifier water tub every 6 months.

Based on facility documentation review, facility policy reviews, and interviews for 4 of 6 employees reviewed, the facility failed to ensure staff were provided with the necessary education and competency assessments related to Intravenous Therapy (IV). The findings include:Review of the facility IV Education and Competencies for the years 2024 and 2025 identified the following:Registered Nurse (RN) #5 lacked an IV certificate, education, or competencies for both 2024 and 2025.Nurse Aide (NA) #3 had no IV education documented for 2025.Nurse Aide (NA) #4 had no IV education documented for 2025.Nurse Aide (NA) #5 had no IV education documented for 2025.Interview with LPN #1 (Staff Educator) on 4/8/26 at 12:18 PM identified he was responsible for staff education and competency. LPN #1 identified he was aware that some employees had not completed intravenous (IV) education. LPN #1 stated that NA #3, NA #5, and NA #4 did not have IV education in 2025. LPN #1 identified RN #5, the night supervisor, had no IV certification, education, or competencies on file. LPN #1 indicated that he/she had reached out to staff, including RN #5, multiple times to complete the IV training. LPN #1 stated that IV education and competency should have been completed by both nurse aides and licensed staff upon hire and annually thereafter.The facility was unable to produce documentation of IV education or competency validation for facility staff listed. Although requested an IV education and competency policy was not provided.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident who was at high risk for falls and sustained multiple falls with major injuries (fractures) had adequate supervision and adequate fall interventions to maintain safety. The findings include: Resident #1 had diagnoses that included falls, right femur fracture, generalized muscle weakness, need for assistance with personal care, type 2 diabetes mellitus, difficulty walking, generalized muscle weakness, cognitive communication deficit, and unspecified lack of coordination. A Fall Risk Evaluation dated 4/22/2025 by LPN #5 identified Resident #1 was a moderate fall risk. The physician's orders dated 4/23/2025 directed to provide the assistance of one at wheelchair level with ADLs and toileting. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately impaired (Brief Interview for Mental Status (BIMS) score of 9), was occasionally incontinent of bowel and bladder, and required moderate assistance with bed mobility, transfers, ambulation, and personal hygiene. The Resident Care Plan (RCP) dated 5/4/2025 identified Resident #1 was at risk for falls related to recent falls at home with a right hip fracture, new to environment, pain, use of diuretic medication, diagnosis of diabetes, and prescribed hypoglycemic medication. Interventions directed to orient to new environment, PT/OT as indicated, appropriate footwear when transferring and/or ambulating, bed in low position (if unable to self-transfer), fall assessment per facility policy, call bell within reach, provide with moderate assistance of one, ambulation and transfers using rolling walker, staff to offer resident assistance to bathroom as needed, and remove walker and wheelchair from bedside while resident is in bed. a. A nurse's note dated 5/4/2025 at 11:53 P.M. by RN #1 identified she was called to Resident #1's room by staff at the change of shift. RN #1 identified upon entering the room Resident #1 was noted to be sitting on the floor in between the beds, with h/her back up against the low bed with h/her legs outstretched. RN #1 indicated when Resident #1 was asked what happened h/she stated h/she was trying to get into the chair (pointing at wheelchair) and fell onto h/her buttocks. Review of Resident #1's right ribs X-ray report dated 5/7/2025 at 1:51 P.M. identified acute appearing right lateral 9 and 10 rib fractures with displacement (broken bones are not in alignment) and mild soft tissue swelling. A nurse's note dated 5/7/2025 at 2:38 P.M. by RN #4 identified Resident #1 fell a few days prior and initially did not complain of pain but currently had pain to the right flank. RN #4 indicated APRN #1 was updated and Resident #1's right unilateral X-ray resulted with acute right rib fractures. Review of a physiatry progress note dated 5/7/2025 at 3:00 P.M. by Physician Assistant (PA) #1 identified Resident #1 was complaining of more intense pain to h/her right posterior rib cage and while sitting up in the wheelchair Resident #1 was uncomfortable. PA #1 identified Resident #1 felt the pain was worse than it was two days ago. The APRN note dated 5/7/2025 at 4:00 P.M. by APRN #1 identified Resident #1 had a fall on 5/4/2025 with no injuries noted at that time, a recent X-ray showed right rib fractures of ribs 9 and 10 with mild soft swelling. APRN #1 indicated Resident #1's right rib fractures are related to h/her most recent fall. Review of the facility's accident and incident report dated 5/7/2025 at 6:28 P.M. identified on 5/4/2025 at 11:05 P.M. Resident #1 sustained a fall, h/she was observed on the floor with back up against the side of h/her bed initially no injury was noted. Resident #1 later developed pain to the flank area and an X-ray was obtained. The X-ray indicated Resident #1 had fractures of ribs 9 and 10 on h/her right side. The facility's summary dated 5/12/2025 identified that on 5/4/2025 Resident #1 had recent assistance with care (prior to the change of shift), h/she was not able to say why h/she was getting up but stated h/she was getting into the wheelchair. Resident #1 was evaluated by therapy services and h/her care plan was updated to change the height of the bed from low position to a position that was most comfortable for safe rise and return to bed. Interview with NA #1 on 6/10/2025 at 12:44 P.M. identified she was assigned to Resident #1 on 5/4/2025 during the 3 PM to 11 PM shift. NA #1 indicated on 5/4/2025 during her shift she conducted rounds every 2 hours. NA #1 indicated that prior to the end of her shift, she and LPN #1 toileted Resident #1 and prior to leaving her shift, she last saw Resident #1 lying in bed. Interview with LPN #1 on 6/10/2025 at 12:55 P.M. identified on 5/4/2025 at approximately 10:45 P.M. she assisted Resident #1 to the bathroom and then back into bed. LPN #1 indicated that when she left the room Resident #1 was in bed resting and at the change of shift NA #2 found Resident #1 on the floor. Interview with the DNS on 6/10/2025 at 1:17 P.M. identified on 5/4/2025 RN #1 reported Resident #1 was found on the floor in h/her room at approximately 11:05 P.M., RN #1 assessed Resident #1 and noted no injuries, and Resident #1 had no complaints of pain or discomfort. The DNS identified an accident and incident report was completed on 5/4/2025 with a classification of an E because Resident #1 had no injuries. The DNS identified on 5/7/2025 Resident #1 complained of pain in h/her right flank area and a new order was obtained for a unilateral X-ray which resulted positive for fractures of the right 9th and 10th ribs. The DNS identified prior to the fall on 5/4/2025, Resident #1 was identified as at risk for falls, a care plan was in place with interventions, and following the fall on 5/4/2025 the care plan was updated with a new intervention directing to remove wheelchair and walker when Resident #1 was in bed. The DNS identified based on the investigation, Resident #1 got out of bed without calling for assistance and fell. b. A nurse's note dated 5/8/2025 at 12:03 P.M. by RN #4 identified Resident #1 was observed on the floor in the rehab room following a witnessed fall and Resident #1 complained of 3 out of 10 right wrist pain. Resident #1 was scheduled for an orthopedic appointment for the right femur fracture so she applied ice to the right wrist, reported to the orthopedic office, and requested they assess Resident #1's right wrist. Resident # 1 returned from the appointment with a splint applied to the right wrist and confirmed fractures of the distal radius and ulna sustained from the fall at the facility that morning. Review of the facility accident and incident report dated 5/9/2025 at 11:21 A.M. identified on 5/8/2025 at 8:30 A.M. Resident #1 was performing tasks with occupational therapy and tipped to h/her right side, extending h/her right arm which struck the floor and sustained a fracture to h/her right wrist. The facility summary dated 5/12/2025 identified the orthopedic doctor recommended the therapy plan be adjusted to wheelchair level to prevent further falls. A recommendation was made to initiate speech therapy for cognitive loss, a bone density test was scheduled, a medication reconciliation was completed, staff were to encourage participation in activities and to have an increased presence outside of Resident #1 ' s room due to forgetfulness and impulsiveness. Interview with OT #2 on 6/10/2025 at 3:50 P.M. identified on 5/4/2025 Resident #1 was in the gym doing tasks of picking up cones that were of various height that were above h/her waist level, at waist level, and at knee level. OT #1 identified when Resident #1 went to pick up a cone on a step in the gym, h/she fell over with h/her arms extended. c. The revised Resident Care Plan (RCP) dated 5/9/2025 included Resident #1 was at risk for falls related to use of cardiac medications, right wrist fractures, and rib fractures right side. Interventions included provide moderate assistance of one with ambulation and transfers using rolling walker, anticipate increased need for toileting (diuretic), assist with toileting at start of night shift, bed in low position, encourage resident to be within view of staff while awake, and monitor blood sugars as ordered. The RCP failed to identify a toileting schedule despite identifying Resident #1 was at risk for falls and identifying an increased need for toileting due to the use of a diuretic (medication that promotes the removal of excess water and salt from the body through increased urination.) A nurse's note dated 5/13/2025 at 3:05 A.M. by RN #2 identified Resident #1 was found at the bedside on h/her knees and Resident #1 was unsure how the fall occurred but Resident #1 was eager to get into h/her wheelchair. RN #2 identified Resident #1 reported severe pain to the left knee and right ribs. RN #2 identified that redness was noted to the right torso area, MD #1 was notified and Resident #1 was transferred to the emergency department (ED) for further evaluation. Review of the facility accident and incident report dated 5/15/2025 at 5:41 P.M. identified on 5/13/2025 at 2:40 A.M. Resident #1 was found on h/her knees at the bedside. Resident #1 reported severe pain in the left knee and right ribs, with redness present to the right torso area. Resident #1 was last cared for at 1:45 A.M. MD #1 was notified, and a new order was obtained to transfer Resident #1 to the ED for evaluation. Resident #1 had a recent diagnosis of displaced right rib fractures #9 and #10 and remained in the hospital with diagnoses of a non-displaced fracture of right rib #7 and displaced fractures of right ribs #8, #9 and #10. The report indicated Resident #1 would be placed on every 15-minute checks and referred to psych services. The facility summary identified while in the hospital Resident #1 had X-rays and CT scans, the CT scan indicated right sided minimally displaced right rib fractures of #7-10 with small pleural effusion. Review of the hospital Discharge summary dated [DATE] identified Resident #1 was presented as a trauma after an unwitnessed fall; Resident #1 was found on the ground next to h/her wheelchair complaining of right-sided rib pain. Resident #1 was diagnosed with right-sided pleural effusion, hospital acquired delirium, and acute minimally displaced right posterior lateral 7th through 10th rib fractures. A physician's order dated 5/16/2025 directed every 15-minute checks for safety, high fall and fracture risk on every shift. A nurse's note dated 5/16/2025 at 2:41 P.M. by RN #4 identified Resident #1 returned from the hospital, had several falls in the facility, and was very impulsive. RN #4 identified Resident #1 had multiple images obtained which showed additional right rib fractures of #7 and #8 and Resident #1 appeared to be suffering from hospital acquired delirium and impulsivity and would be monitored closely on every 15-minute checks. RN #4 identified Resident #1 was very impulsive although h/she was redirected and transfers self in and out of bed to wheelchair alone. RN #4 identified that since arrival, Resident #1 was getting up from bed multiple times, redirected, and was on every 15-minute checks to try and limit falls. Interview with NA #3 on 6/10/2025 at 1:26 P.M. identified on 5/13/2025 at approximately 1:45 A.M. she checked on Resident #1 who was lying asleep in bed. NA #3 indicated Resident #1 was clean and dry, she repositioned Resident #1, put the bed in a low position, placed the call bell near Resident #1, and left the room. NA #3 identified that Resident #1 was at risk for falls and had previously fallen at the facility. NA #3 indicated that NA #12 was sitting outside of Resident #1's room doing her charting, so she went to complete her rounds. NA #3 identified approximately an hour later she was told that Resident #1 was on the floor in h/her room. NA #3 indicated that Resident #1 complained of pain in h/her right side and was sent to the hospital for evaluation. Interview with NA #12 on 6/13/2025 at 7:38 A.M. identified that when she worked the 11 P.M. to 7 A.M. shift she would sit outside of Resident #1's room when not caring for other residents because Resident #1 was a high fall risk. NA #12 identified Resident #1 would often not call for assistance and would get up alone. NA #12 indicated she was sitting outside of Resident #1's room in the hallway on 5/13/2025 and at approximately 2:00 A.M. she heard Resident #1 making noise in the room. NA #12 indicated she took Resident #1 to the bathroom and she assisted Resident #1 back into bed then at approximately 2:35 A.M. she heard a loud yell from Resident #1's room and found Resident #1 on the floor kneeling on one knee by h/her bed. Interview with the DNS on 6/13/2025 at 12:34 P.M. identified that on 5/13/2025 at approximately 2:30 A.M. NA #12 heard yelling from Resident #1's room and when she entered the room, she observed Resident #1 was kneeling on h/her left knee next to the bed. The DNS indicated that NA #12 called for help, LPN #3 and RN #2 went to the room, Resident #1 complained of left knee pain, and Resident #1 was transferred to the ED. The DNS identified during the hospitalization Resident #1 had a CT scan that identified Resident #1 had right rib fractures of #7, #8, #9, and #10. The DNS indicated Resident #1 had right rib fractures of #9 and #10 from a previous fall on 5/4/2025. The DNS identified on 5/16/2025 Resident #1 was placed on 15-minute checks to prevent further falls. Although attempted interviews with APRN #1 and RN #2 were not obtained. d.The Resident Care Plan (RCP) dated 5/16/2025 identified Resident #1 was at risk for falls and included interventions to encourage resident to be within view of staff while awake, refer to speech therapy for cognition, provide cues and reminders, every 15-minute checks for safety, and flat call bell. Physician's orders dated 5/17/2025 directed to provide assist of one at wheelchair level for ADLs, with ambulation provide assist of one handheld assist and gait belt, provide assist of one for bed mobility, every 15-minute checks for safety due to high fall risk and fracture risk on every shift. A nurse's note dated 5/17/2025 at 9:23 P.M. by RN #1 identified LPN #4 called her to the unit for a witnessed fall. RN #1 indicated upon arrival Resident #1 was sitting in the wheelchair and had a long scratch to the back of the left arm and an area that looked to be bruising. RN #1 identified Resident #1 was educated on asking for assistance and h/she verbalized understanding. RN #1 indicated Resident #1 was brought to the nurse's station for safety and provided a snack. Review of the facility's accident and incident report dated 5/17/2025 identified Resident #1 had a fall witnessed by NA #5 who observed Resident #1 walking unassisted from the doorway when h/she lost h/her balance and stumbled into the wheelchair in the hallway. RN #1 identified Resident #1 was noted with a 6-inch scratch to the left arm with probable bruising. RN #1 identified MD #1 directed to monitor vital signs every shift for 72 hours and maintain every 15-minute checks. Review of NA #5's written statement dated 5/17/2025 identified she witnessed Resident #1 step into h/her bedroom doorway without clothes or brief on with a urinal in h/her hand. NA #5 indicated as she walked towards Resident #1 h/she spun around, fell on the floor, on h/her bottom, bumping h/her back against the wheelchair that was in the hallway outside the bedroom door. Review of the RCP dated 5/21/2025 identified Resident #1 was at risk for functional incontinence related to external factors i.e. inability to get to the toilet in time independently and frequently incontinent with interventions that directed to ensure adequate lighting, ensure pathway to toileting area, monitor for skin breakdown, absorbent product as appropriate, pain evaluation and control, and utilize adaptive equipment if appropriate. The RCP failed to identify a toileting schedule despite identifying frequent incontinence and inability for Resident #1 to make it to the toilet in time. Interview with NA #4 on 6/10/2025 at 1:41 P.M. identified on 5/17/2025 she was assigned to care for Resident #1 during the 3 PM to 11 PM shift. NA #4 identified she was aware Resident #1 was a fall risk and Resident #1 was on 15-minute checks. NA #4 indicated at approximately 8:45 P.M. she toileted Resident #1 and assisted Resident #1 back into bed and when she walked past the room again, observed LPN #4 and NA #5 standing next to Resident #1 in the hallway. Resident #1 then self-transferred h/herself back into the wheelchair. NA #4 indicated they brought Resident #1 to the nurse's station so they could monitor h/her for the rest of the shift. Interview with RN #1 on 6/13/2025 at 8:17 A.M. identified on 5/17/2025 she was called to the unit by LPN #4 who reported that she and NA #5 witnessed Resident #1 fall in the hallway landing on h/her buttocks. RN #1 indicated when she arrived on the unit Resident #1 was already sitting in a wheelchair in the hallway outside of h/her room and identified LPN #4 and NA #5 reported that Resident #1 would not wait for them to assist h/her off the floor. RN #1 identified that NA #5 reported when Resident #1 was standing in the doorway with an empty urinal in hand. RN #1 indicated she assessed Resident #1 from head to toe for injuries, noted a scratch on Resident #1's arm, and Resident #1 denied pain or discomfort. RN #1 identified that Resident #1 had been on 15-minute checks since h/her readmission and that Resident #1 had been toileted approximately 15 minutes prior to the fall. RN #1 identified she added a new intervention to empty the urinal as needed and implemented a care plan for functional incontinence. Although attempted, an interview with NA #5 was not obtained. e. Physician's orders dated 5/17/2025 directed to provide assist of one at wheelchair level for ADLs, provide assist of one handheld assist and gait belt with ambulation, provide the assist of one for bed mobility, and every 15-minute checks for safety due to high fall risk/fracture risk on every shift. Review of the initial psychotherapy evaluation dated 5/19/2025 completed by APRN #2 identified she was asked to conduct a cognitive screen for Resident #1. APRN #2 indicated Resident #1 identified feeling confused at times and needing increased care. APRN #2 identified Resident #1 had fair short term and long-term memory and was forgetful. APRN #2 identified she used the short form Brief Cognitive Assessment Tool (BCAT) to evaluate Resident #1 in which h/she scored in the dementia range a seven (7) out of twenty one (21). The 5-day MDS dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 9), was occasionally incontinent of bowel and bladder, and required moderate assistance with bed mobility, transfers, ambulation, and personal hygiene. The Resident Care Plan (RCP) dated 5/23/2025 identified Resident #1 at risk for falls related to recent falls at home with a right hip fracture, new to environment, pain, use of diuretic medication, diagnosis of diabetes, prescribed hypoglycemic medication, use of cardiac medications, fracture of right wrist, and rib fractures right side. Interventions included staff to offer resident assistance to bathroom as needed, anticipate increased need for toileting (diuretic), assist with toileting at start of night shift, bed in low position, encourage resident to be within view of staff while awake, refer to speech therapy for cognition, and flat call bell. The RCP failed to identify a toileting schedule despite identifying Resident #1 was at risk for falls and identifying an increased need for toileting due to the use of a diuretic. A nurse's note dated 5/24/2025 at 10:14 P.M. by LPN #8 identified Resident #1 was seen ambulating without staff, despite encouraging to ask for assistance. LPN #8 indicated that Resident #1's safety was maintained, and Resident #1's 15-minute checks maintained. A nurse's note dated 5/25/2025 10:16 P.M. written by LPN #8 identified Resident #1 was seen several times in the bathroom throughout the shift, despite encouragement, multiple attempts to re-educate to ask for help, and with the call light in reach. LPN #8 indicated Resident #1's 15-minute checks were maintained. Review of the clinical record identified no toileting schedule was initiated despite documentation of Resident #1 being seen several times in the bathroom. A nurse's note dated 5/28/2025 at 1:48 P.M. by RN #4 identified she was notified by the physiatrist (Physician Assistant #1) that Resident #1 presented with a new onset of pain and discomfort of the left femur without known injury. RN #4 identified Resident #1 was rubbing h/her femur and reported pain with standing. RN #4 indicated Resident #1 denied injury or falls. RN #4 identified APRN #1 was notified, and an order was obtained for an X-ray of the left femur to rule out injury or abnormalities. A physician's order dated 5/28/2025 directed to obtain an X-ray of left femur due to a new onset of pain and discomfort. Review of Resident #1's left femur X-ray report dated 5/28/2025 at 2:21 P.M. identified an acute left greater trochanter fracture (palpable bony projection located on the upper femur a bone in the upper thigh) with mild displacement (broken bones are not in alignment). A nurse's note dated 5/28/2025 at 7:16 P.M. by the Director of Nursing (DNS) identified that the RN supervisor reported the bedside X-ray indicated Resident #1 has a fracture of the left greater trochanter. The DNS indicated APRN #1 was in to assess Resident #1 and h/she was lying in bed and appeared in no apparent distress. The DNS identified Resident #1 endorsed pain in the left thigh and described the pain as mild to moderate. The DNS indicated Resident #1's legs were even, no shortening visible, no internal or external rotation of leg, Resident #1 was able to raise both legs independently and bend both knees without difficulty. The DNS indicated that the orthopedic was called, the injury was reported, and a new appointment was scheduled for the following morning. The DNS identified Resident #1 was not able to state if h/she had a fall overnight but Resident #1 has been on 15-minute checks with no events noted in the last few days. The APRN note dated 5/28/2025 at 9:45 P.M. by APRN #1 identified Resident #1 stated the distal part of the femur was painful on palpation. APRN #1 identified Resident #1 had a history of multiple falls with fractures but denied having fallen. APRN #1 identified Resident #1 had a history of confusion, forgetfulness, and at times, impulsiveness. APRN #1 identified an X-ray of the left hip was ordered to rule out fracture the results show Resident #1 has an acute greater trochanter fracture with mild displacement. APRN #1 identified that an emergent orthopedic appointment was made. Review of the facility accident and incident report dated 5/28/2025 identified the classification as a class B reportable event for an injury of unknown origin. On the morning of 5/28/2025, Resident #1 complained of left leg pain, a bedside X-ray was ordered and resulted with a fracture of left greater trochanter. The report indicated the facility was uncertain if the fracture was related to a previous fall. The facility summary dated 6/3/2025 identified on 5/28/2025, Resident #1 complained of left leg pain and was seen by the physiatry physician assistant. An in-house bedside x-ray was obtained on 5/28/2025 and indicated that Resident #1 had a left greater trochanter fracture with mild displacement. Resident #1 was transferred to the ED for evaluation and a CT scan performed on 5/29/2025 indicated the left greater trochanter fracture appeared unchanged from the CT scan on 5/13/2025. On 5/13/2025 Resident #1 was observed on the floor, complained of left knee pain and right flank pain and was sent to the ED for evaluation. The hospital report indicated Resident #1 had right rib fractures but no further fractures were identified. Resident #1 had been on every 15-minute checks with no indication of a recent fall. A review of Resident #1's previous falls was completed with the most obvious possibility being related to the fall on 5/13/2025 when Resident #1 fell on h/her left knee. A nurse's note dated 5/28/2025 at 10:02 P.M. by LPN #8 identified despite encouragement and education to ring for assistance, Resident #1 transferred independently or attempted to transfer several times throughout this shift and Resident #1 became verbally aggressive with staff when redirected back to bed. LPN #8 identified after the call light was put back in reach Resident #1 was seen dropping the call light off the bed. LPN #8 identified 15-minute checks were maintained with no further issues. Review of the hospital Discharge summary dated [DATE] identified Resident #1 presented to the hospital with left hip pain, after a possible fall. The ED documentation identified an MRI preliminary report showed a left greater trochanter fracture was noted again. Resident #1 was found to have a non-displaced fracture of the greater trochanter of the left femur. Interview with NA #8 on 6/13/2025 at 8:10 A.M. identified she was assigned to care for Resident #1 on 5/27/2025 and 5/28/2025 during the 7 A.M. to 3:00 P.M. shifts. NA #8 identified Resident #1 was a fall risk, would not call for help and often got out of bed without assistance. NA #8 identified Resident #1 always wanted to go to the bathroom. Interview with NA #9 on 6/13/2025 at 10:48 A.M. identified that despite 15-minute checks, Resident #1 would get out of bed without calling for help. NA #9 identified Resident #1 was so fast that she would do the 15-minute checks, take Resident #1 to the bathroom, remind Resident #1 to use the call bell, and still find Resident #1 out of bed. NA #9 identified there was no way to ensure Resident #1 did not get up alone and fall unless Resident #1 was on one to one monitoring. Interview with the DNS on 6/13/2025 at 12:34 P.M. identified Resident #1 was at risk for falls and had multiple falls with and without injury from 4/23/2025 to 5/17/2025. The DNS identified Resident #1 had an RCP in place that identified h/she was at risk for falls with multiple interventions to prevent falls. The DNS identified that on 5/16/2025 Resident #1 was placed on 15-minute checks due to multiple falls, and on 5/17/2025 despite the 15-minute checks, Resident #1 had a witnessed fall. The DNS identified on 5/28/2025 Resident #1 complained of new onset pain in h/her left leg, the APRN #1 was notified, and an X-ray order was obtained. The DNS indicated she spoke with the hospitalist who identified Resident #1 had a CT scan on 5/29/2025 and the results identified a left greater trochanter fracture which appeared unchanged from the CT scan done on 5/13/2025. The DNS indicated Resident #1's hospital Discharge summary dated [DATE] did not mention a left greater trochanter fracture seen on the CT scan nor did the hospital treat the fracture. The DNS identified on 5/29/2025, when it was confirmed Resident #1 fractured the left greater trochanter, she initiated an investigation for an injury of unknown origin. The DNS indicated based on her investigation, Resident #1 did not have any falls, incidents, or events during the period of 5/18/2025 to 5/28/2025 that could have caused the left greater trochanter fracture, and she attributes Resident #1's fracture of the left greater trochanter to Resident #1's fall on 5/13/2025. The DNS indicated that although there was not a physician's order directing to provide one-to-one monitoring for Resident #1, she would place Resident #1 on one-to-one monitoring when she had the staff. The DNS identified that despite Resident #1 being identified as at risk for falls with impaired cognition, bowel and bladder functional incontinence, frequently observed by staff ambulating to the bathroom without calling for assistance, and staff reports of Resident #1 always wanting to go to the bathroom, Resident #1 was not on a toileting schedule. Although attempted, an interview with APRN #1 was not obtained. Review of the fall and fall risk policy dated March 2018 directed, in part the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and if falling recurs despite initial interventions, staff will implement additional or different interventions, and if the resident continues to fall staff will re-evaluate the situation and whether it is appropriate to continue or change interventions.

Based on clinical record reviews, review of facility documentation, policy review, and interviews for one resident (Resident #1) who was at risk for the development of a pressure ulcer and was dependent on staff for personal care and repositioning, the facility failed to provide incontinent care in accordance with the plan of care for over a six (6) hour time period to ensure the resident did not develop of a pressure ulcer. The findings include: Resident #1's [DIAGNOSES REDACTED]. The admission skin assessment, Braden scale for predicting pressure sore risk, dated 12/27/19 indicated Resident #1 was at mild risk for developing pressure sores. The admission care plan initiated on 12/27/19 identified urinary incontinence and a self-care performance deficit. Interventions directed assistance with toileting as needed and per care plan, toilet, check and change upon rising, before and after meals, at bedtime, and as needed with routine care, apply barrier cream after each incontinent episode, and to observe for any new areas of skin breakdown noted during bath or daily care. The weekly skin checks dated 12/27/19 and 1/3/2020 indicated Resident #1 was at risk for developing a pressure wound and the resident had no identified [MEDICAL CONDITION] at the times of the assessments. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was not able to make decisions regarding tasks of daily life, required limited one (1) person assistance with turning and repositioning while in the bed and personal hygiene, extensive two (2) person assistance for transfers in and out of the bed and chair, extensive one (1) person assistance for toileting, was non-ambulatory, utilized a wheelchair for mobility, was always incontinent of bowel and bladder, was at risk for developing pressure ulcers, had pressure reducing device, and was on a turning and positioning program and had no ulcers, wounds or skin problems. The nurse aide care card indicated Resident #1 was incontinent of bowel and bladder and directed to toilet, check and change upon rising, before or after meals, at bedtime and as needed. The nurse's note dated 1/8/20 at 10:42 PM identified while providing incontinent care Resident #1 was noted to have a Stage II wound that measured 2.0 centimeters (cm) by 0.5cm with 100% granulation to the wound bed, there were no signs or symptoms of infection noted, and subsequent to physician notification new orders were obtained. A physician's orders [REDACTED]. The Reportable Event Form and investigation dated 1/8/20 at 10:45 PM indicated the 3-11PM nurse aide who was assigned to Resident #1 gave a statement indicating she had not provided care to Resident #1 from the start of the shift at 4:00 PM until 10:00 PM, six (6) hours later. In a written statement the 3-11PM nurse aide, Nurse Aide (NA) #1, identified she was unfamiliar with Resident #1 and asked the charge nurse for direction after supper and again after 8:00 PM, to which the charge nurse told her not to put Resident #1 back to bed because the resident would be climbing back out of bed within five (5) minutes. The statement indicated at 10:00 PM NA #1 again asked the charge nurse about Resident #1 and the charge nurse told her to toilet the resident and put Resident #1 back in the wheelchair. The statement identified when NA #1 was proceeding to provide care after she removed the incontinent brief she realized Resident #1 had a skin tear on the buttock so she called the nurse. The wound physician's evaluation and management summary dated 1/14/20 indicated Resident #1 had a Stage II pressure wound on the buttocks for greater than six (6) days duration. The evaluation identified the wound measured 3cm x 1cm, with moderate serous exudate and the treatment plan was to apply Alginate calcium, cover with a dry clean dressing daily for thirty (30) days and the recommendations included to offload the wound and position per facility protocol. In an interview with the 7AM-3PM nurse aide, NA #2, on 2/14/20 at 11:00 AM, she recalled providing care to Resident #1 on 1/8/20, had noted the resident's buttocks being a little red and stated she applied cream to Resident #1's buttocks. NA #2 stated she could not recall Resident #1 with an open skin area and if the resident did have an open area she would have reported the finding to the charge nurse. Interview with NA #1 on 2/14/20 at 11:10 AM she identified that she did not know the residents on the unit and the charge nurse informed her not to remove Resident #1 from the nurse's station. NA #1 stated she did not provide care to Resident #1 from 4:00 PM through 10:00 PM, six (6) hours had lapsed. NA #1 indicated she usually received direction about the residents at report and from the resident care cards. NA #1 stated she did not check Resident #1's care card on 1/8/20 however she did ask the charge nurse for direction. Interview with the 7AM-3PM charge nurse, Registered Nurse (RN) #2, on 2/14/20 at 11:45AM identified she cared for Resident #1 and examined the resident's buttocks between 1:00-2:00 PM on 1/8/20. RN #2 stated she did not note an open area or any pinkish area to Resident #1's buttocks at the time she examined the resident. In an interview with the wound physician, MD #1, on 2/14/20 at 1:30 PM he indicated with the combination of not moving, incontinence and a low blood supply, it was not unusual for a resident to develop a pressure ulcer in a very short period of time. MD #1 stated it was not unusual to also see the development of a deep tissue injury within as short as an hour's time. Review of the Abuse Prohibition and Quality Assurance/Reporting reasonable suspicion of Crime policy defined neglect as failure to provide the necessary treatment, rehabilitation, care, attention, food, clothing, shelter, supervision or medical services by a caregiver and directed that when a charge of resident abuse, neglect or misappropriation of property is substantiated prompt disciplinary action/suspension/termination will be implemented. Interview with the Director of Nursing (DON) on 2/14/20 at 3:15 PM she indicated that NA #1 failed to provide care to Resident #1 for greater than six (6) hours during the 3-11 shift on 1/8/20. Subsequent to the facility's investigation, LPN #1 and NA #1 were terminated for failure to ensure the resident received care in accordance to the care plan, to toilet, check and change upon rising, before and after meals, at bedtime, and as needed with routine care. Attempts to interview LPN #1 were unsuccessful.

Based on clinical record review, facility documentation, and interviews, for one of three residents at who were at risk for elopement (Resident #1), the facility failed to ensure audible door alarms were responded to by staff to prevent an elopement, resulting in a finding of Immediate Jeopardy (IJ). The facility implemented immediate action to remediate the Immediate Jeopardy, which was verified during the onsite visit, resulting in a finding of IJ past non-compliance. The findings include: Resident #1 was admitted on [DATE] and had diagnoses that included [CONDITION(S)], [CONDITION(S)] and a [CONDITION(S)]. An admission Minimum Data Set, dated dated dated [DATE] identified that the resident had severe cognitive impairment, wandered one to three days of the week, was independent with mobility, and required extensive assistance with activities of daily living. Review of physicians order's dated 8/29/19 directed to apply a roam alert (alarm band) to the right ankle, to check placement every shift and check function daily on the 3:00 PM to 11:00 PM shift. Review of a care plan dated 8/30/19 identified that the resident was an elopement risk because he/she actively exit seeks, and verbalizes the desire to leave, with interventions that included a roam alert to the right ankle, and to use audible alarm system to alert staff to exit seeking behavior. Review of a behavioral health note dated 9/11/19 identified that nursing had reported the resident to be confused, and exit seeking, but the resident was re-directable, with a recommendation made to continue to use [MEDICATION(S)] 100 milligrams (mg) as needed for anxiety and/or anger. Review of a behavioral health note dated 9/25/19 identified that the resident was delusional and nursing had reported that the resident was exit seeking stating I want to go home with recommendations to obtain a complete blood count and to start trazadone 25 mg every 8 hours as needed for 14 days. Review of a physician's order dated 9/25/19 identified that the resident required supervision during ambulation to prevent loss of balance and/or falls. Review of the nurse's notes from 9/9/19 through 10/20/19 identified that the resident needed frequent redirection for wandering around facility, would use a wheelchair for rest periods, and had exhibited exit seeking behavior on 9/28/19, 10/1/19, 10/8/19. Review of a reportable event and investigation dated 10/22/19 identified that the resident was last seen at 7:15 PM self-propelling in his/her wheelchair on the South Transitional Care Unit (TCU). Around 7:25 PM staff reported that an alarm had been sounding, but they were uncertain where it was coming from. The nursing supervisor was heading towards South TCU when she heard the alarm sounding, but before she reached the nurses station the alarm had stopped. She questioned the nurse sitting at the station where the alarm was coming from and he told her the alarm panel was saying the alarm was on South West. The nurse stated where is that? The supervisor explained that the alarm was coming from the South TCU door. The supervisor asked the staff on the unit if any of them had entered or exited through the doors, since staff uses those doors at times and they all denied exiting or entering. At that time she saw LPN #1 wheeling Resident #1 up the hallway and was told that another resident's family member had brought Resident #1 into the building from the outside. The family member identified that she had seen Resident #1 in the breakdown lane of Route 5, starting to slide out of his/her wheelchair. A [NAME]-by stopped and helped him/her to sit the resident back up, and the family member wheeled the resident back into the facility. Observation on 11/12/19 at 10:30 AM of Route 5 (a U.S. highway) with the Director of Nurse (DON) identified a two lane road with a heavy traffic pattern and no sidewalks. The DON identified that at the time of the elopement (somewhere between 7:15 PM and 7:30 PM) it was dark outside. The resident was found by the family member approximately 20 feet beyond the facility driveway to the left, on Route 5 in the breakdown lane, sliding down in his/her wheelchair. Observation and interview of the of the South TCU door with the Director of Nurses (DON) and maintenance director on 11/12/19 at 10:30 AM identified that the South TCU door was not roam alert equipped. The door had a delayed egress, and once the door is pushed the alarm sounds and continues to sound. If the door is pushed for 15 seconds, it can be opened allowing exit from the facility to the side parking lot of the building. The alarm will continue to sound until a code is entered into the keypad to disarm the alarm. Interview with Licensed Practical Nurse (LPN #1) on 11/12/19 at 11:00 AM identified that on 10/22/19 she was working on the Center nurses station which is adjacent the South TCU nursing unit. She identified that she had seen the resident at 7:15 PM self-propelling in his/her wheelchair at the South TCU nurse's station. She identified that shortly after seeing Resident #1 at the nurse's station she heard an alarm sounding, she thought it might be the kitchen door alarm, she checked the alarm box located at the Center nurse's station and noted the kitchen door was not alarming. She stated that she did not respond to the alarm because she didn't think it was on her unit, and figured wherever the alarm was coming from, staff on that unit would respond to the alarm. Interview with Nurse Aide (NA) #1 on 11/12/19 at 10:00 AM identified that she was working on South TCU on 10/22/19, she stated that she was returning to the unit and heard an alarm, but she didn't know where it was coming from, so she continued to do her work, and did not respond to the alarm. NA#1 further stated that she was never given direction on what to do when an alarm is sounding, and furthermore did not know that there was an alarm box at the nurse's station that would identify which door was alarming. Interview with Registered Nurse (RN) #1 on 11/12/19 at 12:27 PM identified that he was the charge nurse on 10/22/19 on the North TCU nursing unit, which shares a nurse's station with the South TCU nursing unit. He stated that he heard the alarm start sounding, and at that time instead of investigating where the alarm was coming from, he went to answer a call light. When RN #1 returned to the nurse's station the alarm was still sounding. RN #1 further explained that when he looked at the alarm panel on the unit, the alarm for the door on South West was alarming, and he thought that door was located on another unit, so he did not respond, but then the alarm had stopped. The nursing supervisor (RN#2) then approached the nurse's station and asked what was that alarm? , RN #1 told her he did not know, but explained that the alarm panel identified it was the door on the South West unit that was alarming. RN #2 informed him that the alarm panel for the South TCU unit was mislabeled with the old unit name, (South West) and it was in fact the South TCU door that had been alarming. Additionally, although he was informed that it was the door on the next unit that was alarming, he still did not go to the door and investigate because the alarm had already shut off. Interview with RN#2 on 11/12/19 at 12:56 AM identified that she was the nursing supervisor on 10/22/19, she had just finished sending a resident to the hospital, and when she was approaching the TCU North and South unit she heard an alarm sounding, but before she reached the nurses station the alarm had shut off. She stated that she asked RN #1 where the alarm was coming from, he stated that he did not know, but stated that the alarm panel identified that it was the South West unit door that had been alarming. She then explained to RN #1 that the alarm panels were labeled with the old unit names and the South West door was currently the South TCU door. RN #2 identified that she did not respond to the door to investigate because she thought it may have been a staff member entering or exiting, as staff often use that door to enter and exit the building. She then questioned the staff on the unit if they used that door, and they all denied using the door. About a minute later (approxiamtely 7:30 PM) LPN #1 came up the hallway with Resident #1 stating that a family member had found him/her outside. She conducted an assessment of Resident #1 and no injuries were identified. She then notified the DON. RN#2 stated that as soon as she found out that it had been the South TCU door alarming she should have gone to the door, and exited the building to ensure that a resident had not exited, but stated at that time she assumed it was a staff member that had exited and not a resident. Interviews with RN #1, RN #2, LPN#1, and NA#1, identified that they failed to respond to or investigate the sounding alarm, and furthermore all denied entering the code into the keypad to disarm the door and silence the alarm. In addition, RN #1, RN #2, LPN#1, and NA#1 failed to ensure that all residents were accounted for when the door alarm sounded. Review of disciplinary action forms for RN#1, RN#2, LPN#1, and NA#1 identified final written warnings were issued for not responding to an alarming door. Interview with the DON on 11/12/19 at 12:30 PM identified that the elopement of Resident #1 had taken place between 7:15 and 7:30 PM on 10/22/19. She further identified that although the door alarm response is not included in their elopement policy, it is the responsibility of all staff in the facility to immediately respond to door alarms, whether or not the door alarm is on their unit. The DON stated that the staff is educated about alarm response and alarm boxes at the nurse's station on orientation. The DON identified that the unit's names had changed over 3 years ago, but the alarm panels were never corrected to reflect the new unit names. The DON identified that RN #1, RN #2, LPN#1, and NA#1 all failed to respond to the South TCU door alarm (which was determined to be the point of exit for Resident #1), and the time that elapsed allowed Resident #1 exit the building, make it through the parking lot, up the driveway, and onto the breakdowm lane of the highway. She further identified that when RN #2 identified that it was the South TCU door that was alarming she should have immediately responded to the door and gone outside to investigate to ensure a resident had not exited, even if the alarm had stopped. Furthermore it was determined that although all staff denied entering the code into the keypad to stop the door alarm, it was determined through testing of the South TCU door that the only way to stop the alarm was to enter the code into the keypad. The DON determined that an unknown staff member entered the code to stop the alarm. The DON identified that she arrived at the facility on 10/22/19 very shortly after the resident was returned, and immediately started educating staff on alarm response, changed the label on the alarm boxes to reflect the proper unit, held elopement drills with different scenarios, exit doors were checked for proper function, an audit was done on roam alert residents, staff were told they could no longer use side doors as an entrance/exit, and key pad codes were changed. Review of the wandering/unsafe resident policy identified that the facility will strive to prevent unsafe wandering of residents.

Based on a review of clinical records, facility documentation, interviews, and policies, for two of two residents who were identified to have a full code status and were reviewed for cardiopulmonary resuscitation (Residents #1 and #2), the facility failed to initiate CPR immediately once an unresponsive/pulseless resident was identified, and/or failed to follow procedures for CPR in accordance with facility policy, and/or failed to utilize the Automated External Defibrillator (AED) device in accordance with facility policies, which resulted in a finding of Immediate Jeopardy (IJ). The facility implemented immediate action to remediate the Immediate Jeopardy, which was verified during the onsite visit, resulting in IJ past non-compliance. The findings include: 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A minimum (MDS) data set [DATE] identified that the resident had moderately impaired cognition, required extensive assistance with activities, had shortness of breath both on exertion, and lying flat, and required oxygen therapy. Review of a physician's orders [REDACTED]. Review of a resident care plan dated [DATE] identified that the resident requested to his/her full code status be honored. Review of a facility reportable event, investigation, and a nurse's note written by the Director of Nurses (DON) dated [DATE] identified that the resident was found unresponsive sitting upright with the meal in front of him/her with emesis coming from his/her mouth and nose. The nurse (LPN #1) told the Nurse Aides (NA) to clean the resident up and went to inform the supervisor that the resident was a full code. The nursing supervisor then placed a call to the DON who instructed the nurses to initiate CPR. Review of a code blue worksheet dated [DATE] identified that Resident #1 was found unresponsive at 6:32 PM, the emergency cart and the chart arrived at the resident at 6:35 PM, CPR was initiated at 6:37 PM (5 minutes after the resident was determined to be unresponsive), 911 was called at 6:38 PM (6 minutes after the resident was found unresponsive), and emergency services arrived at 6:47 PM. Review of an ambulance run sheet dated [DATE] identified that the call for [MEDICAL CONDITION] was received at 6:43 PM (5 minutes after the facility documented that they called 911, and/or 11 minutes after the resident was found to be unresponsive), emergency services arrived at the scene at 6:47 PM, and continued CPR. The resident was then presumed deceased by emergency services at 7:12 PM. a) Interview with Licensed Practical Nurse (LPN#) 1 on [DATE] at 12:30 PM identified that she had last seen the resident around 5:50 PM and he/she was alert with no distress. LPN #1 re-entered Resident #1's room around 6:32 PM to administer medication, and found the resident unresponsive sitting upright in bed, with emesis on his/her face, with no respirations or pulse. LPN#1 then went to check the resident's code status and identified that the resident was a full code. LPN #1 then ran to the supervisor's office to inform the supervisor that the resident was deceased and had a full code status. LPN#1 stated that once she informed the nursing supervisor of the resident's condition and code status, the nursing supervisor then called the Director of Nursing at home, who then directed the nursing supervisor and LPN#1 to start CPR on Resident #1. LPN #1 stated once the DON instructed them to initiate CPR, she and the nursing supervisor ran to the unit, grabbed the code cart, instructed LPN #1 to call 911, and started CPR on the resident. LPN #1 identified that she did not use the AED device during resuscitation efforts because she did not think to do so. LPN#1 further identified that although she had a current CPR certification, she could not explain why when the resident was found to be pulseless and verified that the resident was a full code status, she did not call a code blue, start CPR and/or call 911. Interview with Registered Nurse (RN) #1 on [DATE] at 2:30 PM identified that she was the ,[DATE] PM shift nursing supervisor on [DATE]. RN #1 identified that she was in the supervisor's office when LPN #1 came in the office and stated that Resident #1 was deceased . RN #1 then asked LPN #1 what the resident's code status was, LPN #1 stated that the resident was a full code. RN#1 then asked LPN #1 what she had done, and LPN#1 stated that she didn't provide any assistance to the resident because s/he was dead. RN #1 stated that although she thought to herself that compressions should be started, she was confused, because LPN #1 seemed so calm, so she decided to call the Director of Nurses (DON) for further direction. The DON directed LPN #1 and RN #1 to immediately start CPR and call 911. RN #1 stated that she hung up the phone with the DON, got the crash cart, told LPN #2 to call 911, and started compressions on Resident #1. RN #1 identified that she did not utilize the AED device because she did not think of it at the time. Further interview with RN#1 identified that although she was CPR certified, she did not act immediately when given the information about Resident #1 because she was confused, and was not sure why LPN#1 had done nothing to assist Resident #1 when she found him/her pulseless with a full code status. Interview with the DON on [DATE] at 11:00 AM identified that she received a call from RN #1 at 6:38 PM on [DATE] and was informed that Resident #1 was found pulseless and had a full code status. The DON instructed LPN #1 and RN #1 to immediately start CPR and to call 911. The DON further identified that once LPN #1 found Resident #1 pulseless she should have called out for help, called a code blue, verified the resident full code status, began CPR immediately and have staff call 911. The DON stated that she was unsure why LPN #1 and RN #1 did not act immediately when the resident was found unresponsive and pulseless, but it seemed that they were confused because the resident was already deceased , and because of this, were unsure whether to start CPR or not. Interview with the Medical Director on [DATE] at 2:00 PM identified that when a resident has a full code status and is found unresponsive and pulseless, CPR must be started immediately, without any delay. Review of the CPR policy identified that upon identification that a resident is unresponsive, the person making the identification will immediately check for a pulse and respirations, and immediately call out for help; loudly calling Code Blue with the room number, staff will respond with the medical record and the emergency cart. The chart will be checked for the code status, if a full code CPR will be started immediately, the AED will be activated, 911 will be called and CPR will continue until the emergency services arrive. The facility immediately implemented corrective measures on [DATE] that included the suspension of both LPN #1 and RN #1 that evening. Immediate staff education was initiated regarding the facilities CPR protocol, and code blue drills began [DATE] into [DATE] and continued with each on-coming shift. On-coming staff received the education before being allowed to work and the education is ongoing. Education included the use of the AED. The facility conducted an inventory of each resident's code status and documented the code status on the resident roster for easy access. All staff were required to be CPR certified were verified as having a current CPR certification. In addition, the facility initiated audits to monitor complaince with education and facility policies and incorporated into the facility's Quality Assurance plan. b) Review of the clinical record identified that the DON had written a nurse's note to describe the events that occurred with Resident #1 as told to her by LPN #1 and RN #1. The clinical record failed to identify a nurse's note was written to describe the resident's condition once found by LPN#1, the clinical record further failed to detail the initiation of CPR and/or the notation of activity during CPR, and/or the pronouncement of death. Interview with the DON on [DATE] at 2:30 PM identified that the nurse and/or supervisor should have written a nurse's note in regards to Resident #1's condition once found unresponsive and documented the initiation of CPR, including a detailed timeline of the events up to and including the termination of CPR and pronouncement of death by emergency services. The DON identified that both LPN #1 and RN #1 were suspended that evening, pending the investigation, and further identified that she should have had the nurse's write the nurses note before leaving the facility. Review of the CPR policy and charting and documentation policy identified that when there is a change in condition, it will be documented in the medical record, and further identified that the code blue worksheets will be completed to notate the timeline and activity of CPR and will be transcribed into the medical record upon resolution of the event. 2) Resident #2 had a [DIAGNOSES REDACTED]. A 14 day minimum (MDS) data set [DATE] identified that the resident was cognitively intact, and required extensive assistance with activities of daily living. A care plan dated [DATE] identified that the resident's wish to be a full code will be honored. Review of a nurse's note dated [DATE] at 1:50 AM identified that the resident was found sitting on the floor beside the bed holding onto the bed frame. The resident was alert and responsive, and had full range of motion to all extremities. Neurological signs were within normal limits, and the resident had shortness of breath. A skin tear was noted to the left upper extremity. Review of an SBAR communication form dated [DATE] identified a blood pressure of ,[DATE], a pulse of 90, and an oxygen saturaration on 97%. The resident was placed back into bed with the Hoyer lift and suddenly became unresponsive with no pulse, no breathing, with his/her pupils fixed and dilated. 911 was called, CPR was initiated immediately and continued until paramedics arrived. Resident #2 was pronounced deceased by the paramedics at 2:55 AM. Interview with LPN #3 on [DATE] at 10:00 AM identified that she had last seen the resident around 12:00 AM and the resident was alert and had no complaints. LPN #2 further stated that she heard someone saying help me so she responded to Resident #2's room and found the resident on his/her knees next to the bed. The resident was alert, had no complaints at the time, and was short of breath, per his/her baseline. Oxygen saturations were normal. The nursing supervisor (RN #4) came to the room and assessed the resident, once the assessment was complete, he/she was Hoyer lifted back to bed, and when they removed the Hoyer pad from underneath the resident, he/she became unresponsive with no pulse or breathing. LPN #3 stayed with the resident while the supervisor verified that he/she was a full code, CPR was started immediately and 911 was called. LPN #3 stated that CPR was continued until emergency services arrived and took over. LPN #3 further identified that although CPR was started immediately, the AED was not utilized. LPN #3 was unsure why she didn't use it during the resuscitation efforts. Interview with RN #4 on [DATE] at 10:40 AM identified that she had responded to the room because of a fall. When she entered the room the resident was in no distress, an assessment was completed, and his vital signs were normal. The resident was Hoyer lifted back to bed once the assessment was completed. When the hoyer pad was removed from under the resident, the resident became unresponsive, with no pulse and no respirations. LPN #3 stayed with the resident, she verified that the resident was a full code, a code blue was called, CPR was started immediately and 911 was called. RN #4 identified that although CPR was started immediately, they did not utilize the AED because she wasn't aware that the facility had one at the time. Interview with MD #1 on [DATE] at 2:00 PM identified that although his expectation is for the facility to follow the CPR policy and use the AED, the immediate initiation of CPR was sufficient. Interview with the DON on [DATE] at 1:00 PM identified that the AED had been in the facility since (YEAR) and the AED should be used during a code according to facility policy. She further identified that she was unable to find any documentation that the staff had been in-serviced on the arrival of the AED, but identified that when the facility offers CPR classes the AED is reviewed. Review of the CPR policy identified that once a resident is found unresponsive and without a pulse and it is determined that the resident is a full code, CPR will be initiated and the AED will be activated.

Based on review of the clinical record, review of facility documentation, review of facility policies and procedures and interviews for one of three sampled resident (Resident #1) reviewed for falls, the facility failed to ensure the resident had adequate supervision to prevent a fall. The findings include: Resident # 1was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission fall risk assessment dated [DATE] identified resident was a moderate risk for falls. The admission MDS assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and required extensive assistance of one staff member for transfers and ambulation, total dependence for locomotion on unit, balance not steady, and only able to stabilize with staff assistance during transitions and walking. The Resident Care Plan (RCP) dated 2/27/19 identified Resident #1 was at risk for falls secondary to history of falls prior to admission, generalized weakness, difficulty ambulating related to recent hospitalization with interventions directed to have staff assistance with transfers and ambulation, encourage to wear non-skid socks when out of bed, and educate the resident to request for assistance prior to ambulation. Review of the reportable event form dated 3/1/19 at approximately 5:35am, NA #3 walked Resident #1 to the scale to obtain his weight and passed NA #4 who advised NA #3 that resident uses a wheelchair to obtain the weight. NA #3 told the resident to not move and went back to room to obtain wheelchair. NA #3 heard the resident fall and then observed resident in hallway lying flat on his back. Resident #1 was noted with bleeding to back of head with 3cm laceration. Review of the nurse's note dated 3/1/19 at 07:00 AM identified that the resident was noted lying on his back on the floor in hallway, bleeding to the back of head, area was cleansed and a 3cm laceration was noted. Further review identified that the resident's neurological assessment was normal and the resident was able to move all extremities. The MD was updated and Resident #1 was sent to the hospital for an evaluation. Review of the CAT scan dated 3/1/19 indicated no acute traumatic injury. Review of the hospital record on 3/1/19 identified that the resident sustained [REDACTED]. Resident #1 was discharged back to the facility on [DATE]. The facility 1:1 employee education dated 3/1/19 provided to NA #3 identified assist of one residents must have hands on contact of staff when ambulating. Interview with NA #3 on 3/13/19 at 11:01 am identified he/she was walking the resident to the scale and saw NA#4 who told her the resident gets weighed with a wheelchair. NA #3 identified that although he/she received report from the nurse that the resident was to ambulate with walker and assist of one he/she thought NA #4 knew the resident better so he/she left the resident in the hallway to get the wheelchair from the resident's room and told the resident not to move. NA#3 identified he/she was in the resident's room when he/she heard Resident #1 fall in the hallway. NA #3 further identified he/she thought the other NA was in the hallway with the resident and should not have left he resident alone in the hallway. Interview with the ADNS on 3/14/19 at 12:30 identified he/she reported to NA#3 that Resident #1 was to ambulate with an assistance of one. Further interview with the ADNS identified that NA #3 should not have left the resident standing alone in the hallway, but should have gotten a chair for the resident to sit on when he/she left the resident. Review of facilities safety and supervision policy identfied that care team will analyze information obtained from assessments and observations to identify risks for individual residents and the care team will target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive devices.

Based on clinical record review, observation and interview for 1 of 3 sampled residents (Resident #92) reviewed for pressure ulcers, the facility failed to ensure interventions were implemented to prevent the development of a pressure ulcer. The findings include: Resident #92's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified severely impaired cognition, required total assistance of two staff members for bed mobility and transfers and did not ambulate. The assessment further identified the resident was at risk for the development of pressure ulcers but did not have any unhealed pressure ulcers at the time. The care plan dated 3/31/17 identified a potential for impairment to skin integrity related to fragile skin interventions included to apply gerisleeves and keep skin clean and dry. The nurse's note dated 4/1/17 identified during evening care the nurse aide observed an area of discoloration to the left outer heel. The area was intact and measured at 2.0 cm by 1.5 cm. A review of the weekly wound pressure ulcer documentation identified the initial presentation/stage was identified as deep tissue injury (DTI) and on 4/17/17 the pressure ulcer stage is identified as unstageable and measured 2.0cm by 3.1 cm with a depth of 0.1 and contained slough with moderate drainage. Review of the care plan and the treatment kardex for the month of April 2017 identified an intervention dated 4/1/17 for skin prep to the left outer heel every shift and to float heels on pillows. It further identified an intervention dated 4/26/17 for blue heel boots to be applied at all times for protection. Interview and review of the clinical record on 5/17/17 at 2:45 PM with the DNS identified interventions related to turning and repositioning every two hours and/or floating the heels were not implemented prior to the development of the pressure ulcer on 4/1/17. The DNS identified the care plan interventions were based on the Braden scale dated 8/15/16 which identified a score of 16 representing a mild risk of pressure ulcer development. The DNS further identified Resident #92 had a tendency to dig her/his heels into the mattress, would make restless movements in the bed and could not explain how a resident who required the assistance of two staff members for bedmobility would have been able to relieve pressure to the heels without the use of a pillow and/ or heel floats. The policy regarding the prevention of pressure ulcers identified interventions and preventative measures include: change position at least every two hours or more frequently if needed,when repositioning, reduce friction and shear by lifting, and protect bony prominences as needed.

Based on clinical record review, facility documentation and interviews for one of three sampled residents (Resident #1) reviewed for abuse, the facility failed to protect the resident from an alleged sexual abuse by a staff member. The findings include: Resident #1' s [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] identified that Resident #1 had intact cognition, required extensive assist of two for bed mobility, assist of one for toilet use and personal hygiene and used a wheelchair for mobility. The Resident Care Plan (RCP) dated 12/14/16 identified discomfort related to right above knee amputation. Interventions directed to maintain dignity and privacy during care. The nurse ' s note dated 1/3/17 at 1:23PM identified that R#1 alleges he/she was touched inappropriately by a staff member last evening. The resident was assessed with [REDACTED]. Police, administrative staff and family were notified. R#1 was interviewed by the nursing supervisor and social worker and sent to the emergency room for evaluation after physician notification. The Reportable Event Form dated 1/3/17 identified R#1 reported to LPN#1 that he/she was touched inappropriately by a staff member (NA#1) the previous evening. Facility investigation included interviews with R#1, residents assigned to NA#1 and staff interviews. After physician notification R#1 was sent to the emergency room for evaluation and returned to facility with negative findings. The investigation identified the facility was notified on 1/5/17 by the police department that NA#1 stated while repositioning R#1 in bed, his finger had penetrated the vagina on several occasions. The facility investigation further identified NA#1 was suspended pending investigation, the incident was substantiated and NA#1 terminated. Facility investigation identified R#1 received psychosocial support and staff was educated on the abuse policy. In an interview on 1/11/17 at 3:40PM, NA#2 identified he/she is frequently assigned to work along with NA#1 on the 3-11 shift. NA#2 identified on the evening of 1/2/17 during the last rounds of providing care to residents, he/she witnessed NA#1 place R#1 on a bed pan and then he/she left the room. NA#2 stated she remained in close proximity to the room while NA#1 was providing care to R#1, the door was open and privacy curtains were drawn. NA#2 further identified he/she did not hear anything while the resident was receiving care, NA#1 did not report anything and for the remainder of the shift R#1 did not report any incident to her or the nurse. In an interview on 1/12/17 at 8:50AM, NA#1 identified R#1 was assigned to him/her since the residents on 12/14/16 and stated that he/she is assist of two persons for transfer and bed positioning. NA#1 identified on the evening of 1/2/17 NA#2 assisted him with transferring R#1 back to bed, left the room and then NA#1 placed the resident on a bed pan. NA#1 stated he provided care to the resident and then repositioned the resident without assistance. NA#1 acknowledged he/she was aware the plan of care directs two staff for bed positioning but he believed the resident was strong enough to facilitate the positioning with one person. NA#1 identified he/she positioned his/her right hand under the right above knee stump and his left hand around the resident's back to boost him/her and during the momentum of repositioning, his/her right hand slipped and touched the vaginal area. NA#1 identified he/she repositioned R#1 three times on 1/2/17 and on previous occasions and that the resident never complained about him providing care. NA#1 stated he/she was notified by the DNS on 1/3/17 of the resident's allegation and subsequently terminated on 1/6/17. In an interview on 1/12/17 at 10:45AM, the Administrator identified the facility was not aware of any concerns of NA#1 providing care and that the incident is still being investigated by the police department. Review of facility policy on abuse prohibition indicated in part that sexual abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault and that there is a zero tolerance for any form of abuse of a resident.

Based on clinical record reviews, observations, review of facility documentation and interviews for one of three sampled residents (Resident #45) who were reviewed for falls, the facility failed to ensure safety measures were implemented prior to responding to a fire alarm drill to prevent a fall that resulted with an injury and/or for one of three sampled residents (Resident #159) who was identified to be at risk for elopement on admission, the facility failed to provide the appropriate supervision to ensure the resident did not leave the facility grounds and/or for one of six sampled residents reviewed for accidents (R#159) the facility failed to implement the plan of care after an incident of noncompliance with smoking. The findings include: 1. Resident #45's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #45 had severe cognitive impairments, required two person total care with bed mobility and transfers in and out of the bed and chair, was non-ambulatory and had functional limitation in range of motion on both sides of the upper and lower extremities. The Resident Care Plan (RCP) dated 2/25/16 identified the resident was at risk for falls and was unaware of safety needs. Interventions directed to keep the bed in the low position, a scoop mattress, to utilize bed and chair alarms, body pillows on each side when in bed and floor pads on each side of the bed. A physician's orders [REDACTED]. Review of the nurse aide care card directed body pillows on each side of the resident when in bed and low bed with mats on the floor when in bed. The Reportable Event Form dated 4/15/16 at 11:15 AM identified Resident #45 was found face down on the floor in the room. The investigation identified the 7-3 PM nurse aide, NA #1, had completed morning care with the intention of transferring the resident out of bed when the fire alarm sounded. In response to the alarm NA #1 left the resident positioned in bed on his/her back, did not place the body pillows alongside the resident, left the resident and closed the door. Once the fire alarm all clear was announced as staff proceeded to open the residents' doors, a housekeeper found Resident #45 lying face down between the two beds and immediately reported the finding to the nursing staff. After the 7-3 PM Nursing Supervisor, Registered Nurse (RN) #1, assessed the resident and the physician was notified Resident #45 was transferred to the hospital for evaluation at 11:45 AM. The nurse ' s note dated 4/15/16 at 10:42 PM identified Resident#45 returned to the facility with a [DIAGNOSES REDACTED]. Interview with the 7-3PM charge nurse, Licensed Practical Nurse (LPN) #1, on 6/7/16 at 11:20 AM identified after a fire drill on 4/15/16 Resident #45 was found on the floor between the two beds by a housekeeper. LPN #1 notified RN #1 and assisted with assessment of the resident. LPN #1 identified that there were no floor mats in place on each side of the bed when the resident was found. In an interview on 6/6/16 at 12:00 PM, NA #1 identified she was assigned to Resident #45 on 4/15/16. NA #1 stated she was in the process of preparing the resident to be transferred out of bed when the fire alarm sounded. NA#1 identified she lowered the bed and left the resident lying on his/her back, did not place the body pillows alongside the resident and could not recall if tab alarms were on. NA #1 stated after the fire drill concluded she was notified that Resident #45 had fallen out of bed. NA #1 identified two floor mats were to be utilized however prior to the incident only one floor mat was available. NA #1 stated she was not aware the body pillows were used as a preventive measure for falls. Subsequent to the incident, NA #1 indicated she received education on resident safety during an emergency or fire drill. In an interview on 6/7/16 at 2:30 PM, the Director of Nursing (DON) identified the expectation was for staff to ensure the safety of a resident during a fire alarm and to follow the care plan for the resident. 2. Resident #159 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Resident Care Plan dated 9/1/15 identified the resident had impaired thought processes with difficulty to redirect at times and preferred unstructured activities. Interventions directed a code alert to right ankle, resident prefers to go outdoors for short intervals with staff to water plants and to take on supervised walks. The Standards of Care meeting note dated 9/6/15 identified on 8/22/15 the elopement risk assessment was conducted and identified Resident #159 was an elopement risk and a wanderguard was in place. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #159 had poor decision making cognitive skills and required cues and/or supervision, was independent with activities of daily living, and exhibited no behavioral symptoms. A physician's orders [REDACTED]. The nurse ' s note dated 12/3/15 at 3:52 PM identified Resident #159 was seen outside at 10:20 AM walking away from the facility, the resident was returned to the facility with staff, the resident was compliant and no injuries were noted during a body audit. The Reportable Event Form dated 12/3/15 identified between 10:15 AM to 10:30AM Resident #159 went outside of the facility and walked down Route 5 to the cemetery, two (2) properties over from the facility. The report indicated the resident was picked up by facility staff. The facility ' s investigation identified the speech therapist had let the resident outside to tend to the flowers in the front of the building. The speech therapist did not notify staff that the resident was outside without supervision and she did not keep Resident #159 in her line of sight. Licensed Practical Nurse (LPN) #2 and the former Director of Rehabilitation had identified Resident #159 was seen walking off the facility premises, staff was notified and a Dr. Hunt was announced to alert staff of a missing resident. LPN #2 drove in the direction that Resident #159 was last seen and located the resident in the cemetery. Resident #159 was compliant upon return to the facility, the physician was notified, a body audit was done with negative findings. Facility staff were re-educated that all residents should be in direct vision when allowed outside and the resident care plan was revised, the resident is only allowed outside supervised. Observations on 6/6/16 at 1:00 PM identified a cemetery in direct view and adjacent to the facility. Walking access to the cemetery from the facility was via a busy main road without a side walk, the cemetery is approximately an eighth of a mile from the facility. In an interview on 6/6/16 at 10:40 AM, Resident #159 identified that he/she wanted to go to the cemetery and pray because it was the anniversary of the death a family member. Resident #159 identified he/she routinely asks to go outside to tend to the flowers and was aware that he/she should not leave the facility premises without permission. Resident #159 identified the code alert on his/her right ankle and demonstrated the alarm system when he/she walked to the front door. In an interview on 6/6/16 at 1:50 PM, the Receptionist identified a folder titled elopement risk which contained information and a picture of residents who are identified as elopement risks. The Receptionist identified prior to the incident on 12/3/15 recreation staff would be with Resident #159 when he/she went outside and had not been informed to watch the resident when outside. In an interview on 6/7/16 at 8:40 AM, the speech therapist identified she provided speech therapy daily to Resident #159 and the resident routinely went outside to tend to the flowers. The speech therapist stated on 12/3/15 she allowed Resident #159 to go outside, had reset the code alert at the front entrance and proceeded to continue with her duties. The speech therapist identified she was aware the resident was an elopement risk however she was not aware the resident should not be left alone. The speech therapist was could not recall if anyone else was outside at that time and/or if she had told the receptionist the resident was outside. The speech therapist identified she received education after the incident about elopement risk residents. In an interview on 6/7/16 at 9:25 M, LPN #2 identified on 12/3/15 at approximately 10:00 AM she saw Resident #159 outside walking towards the end of the driveway, she assumed he/she would turn back but noted that he/she continued to walk off the facility perimeter. LPN #2 identified the resident was appropriately dressed for the weather. After notifying the resident's charge nurse, LPN #2 drove in the direction of where the resident was last seen and found him/her in the cemetery near the facility. In an interview on 6/7/16 at 2:30 PM, the Director of Nursing (DON) identified the plan of care intervention stated outside with supervision, this was interpreted as distant supervision and all nursing staff knew to keep an eye on the resident. The DON stated subsequent to the incident all staff received in-services on the facility ' s elopement policy, the LOA policy and education that elopement risk residents can only be outdoors with direct supervision. a. Resident # 159's [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] identified the resident as cognitively impaired and required extensive assistance with activities of daily living. A care plan dated 11/06/15 identified that the resident was found cigarettes in his/her pocket with additional interventions that included may do room checks if a suspicion of smoking exist. A Social Service note dated 11/06/15 at 11:24 AM written by SW# 1 identified that the resident was found with a full pack of cigarettes in his back pocket. The resident was educated on the facility's non-smoking policy, which included the resident could not have any smoking materials on his/her person or in his/her room. The cigarettes were taken from the resident and kept in SW#1's office to be picked up by the resident's family. Resident was also informed that room checks will be performed each time the resident leaves the facility. Resident in agreement. A nurse's note dated 5/04/16 at 9:00 PM written by LPN #5 identified that the resident was found in the bathroom with a strong odor of smoke. The resident denies smoking, basic room search was performed by supervisor with no cigarettes found. Resident placed on every fifteen minute checks. Interview with the DNS on 6/09/16 at 8:30 AM and review of the clinical record failed to reflect that room searches were conducted once the resident returned from leave of absence (LOA) after the episode of non-compliance with the smoking policy on 11/06/15. Interview with LPN # 5 on 6/09/16 at 10:30 AM (charge nurse on 5/04/16) identified that he/she had been informed by a staff member that he/she had smelled smoke in the resident's bathroom. Upon entering the bathroom, there may have been a slight odor of smoke, no visible smoke and the resident denied smoking. A room search was conducted and no smoking materials were found. Interview with RN#2 ( the 3-11 supervisor on 5/04/16) identified that he/she and LPN# 5 went to R#159's room after another staff member informed him/her that he/she had smelled smoke in R#159's bathroom. Upon entering the bathroom, he/she did not recall smelling smoke, but there may have been a slight odor, no visible smoke, and the resident denied smoking, a room search was conducted and no smoking material were found. Interview with SW#1 on 6/09/16 at 10:00 AM identified that he/she had been notified that the resident had cigarettes on 11/06/15. SW#1 indicated he/she had a conversation with the resident about the smoking policy and had informed the resident that a room search would be conducted after each LOA. SW#1 indicated he/she further identified that he/she could not remember who directed her to put this intervention into place. Interview with the DNS on 6/09/16 identified that he/she was not aware that the intervention of room checks was noted in the clinical record and could not find any documentation that the room checks were done after the resident's LOA's. The DNS indicated he/she remembered being called about the incident on 5/04/16, was informed the resident smelled of smoke and was not aware a smell of smoke was coming from the bathroom. Furthermore on 6/08/16 the care plan was revised to do room checks only if the resident smells of smoke, because the room checks could agitate the resident. Review of the resident's LOA log from 5/23/15 through the present identified that the resident went LOA at least twice weekly. Review of the facility smoking policy identified that it is a non-smoking facility and no residents will be allowed to possess smoking materials.