Every finding on record at Pierce Memorial Baptist Home, Inc.

Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from neglect and failed to ensure the resident was not left on a commode without staff returning time, and care was provided timely. The findings include: Resident #1's diagnoses included Parkinson's Disease, sciatica, and dysarthria and anarthria (motor disorders impairing lips, tongue, vocal cords or diaphragm causing slurred, slow or difficult to understand speech). The Resident Care Plan (RCP) dated 3/15/2026 identified limited physical mobility and ADL assistance related to balance and coordination deficits. Interventions directed encourage to participate to fullest extent possible, transfer with [NAME] Hall [NAME] device with assistance of two (2), and resident was non-ambulatory. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment, required assistance with ADLs (activities of daily living), required substantial/maximal assistance with bed mobility, bathing, dressing, toilet hygiene, was non-ambulatory, and transferred with two (2) staff and standing rotary turning device. The facility reportable event (RE) dated 6/9/2026 at 11:15 PM identified Resident #1 had an unwitnessed fall in his/her room. Assessment identified a bump to right forehead with some decolorization and complained of pain to left arm. Resident had been assisted to commode around 8 PM by two (2) nurse aides (NAs). The NA on the 11 PM to 7 AM shift responded to resident's call bell and found Resident #1 on the floor. Resident #1 stated he/she fell reaching for his/her call bell and stated that he/she was left on the commode for hours. Review of the RE summary report dated 6/11/2026 indicated Resident #1 was assisted to commode between 8 and 8:30 PM by two (2) NAs. A NA on the 11 PM to 7 AM shift responded to Resident #1's call light around 11:15 (at the start of her shift, approximately 2 hours and 45 minutes after NA #1 left Resident #1 on the commode), and alerted the nurse that the resident was on the floor. Resident #1 stated he/she fell reaching for her call bell after staff left him/her on the commode for hours. The facility determined Resident #1 was left on the commode without access to the call bell (not in reach) and he/she sustained a fall. Resident #1 was transferred to the hospital, returned with no new orders, and imaging was negative. Interview and record review on 6/17/2026 at 10:40 AM with NA #1 identified on 6/9/2026, Resident #1 was on his assignment. Between 8 to 8:30 PM (approximately 2 hours and 45 minutes before Resident #1 was found on the floor), he and NA #2 assisted Resident #1 to the commode. NA #1 did rounds around 9:45 PM and stated he was distracted and forgot to go back to assist Resident #1 off the commode. In addition, NA #1 stated he forgot to go back and provide bedtime personal care and last care rounds for Resident #1. NA #1 further indicated that rounds should be done throughout the shift, and he forgot to give Resident #1 the call bell when he left him/her on the commode. Later during the shift, NA #2 had asked him if he needed help with anything, and he responded, no. NA #1 stated he should not have left Resident #1 on the commode without returning to assist Resident #1 off the commode and he should have left the call bell in reach. On 6/17/2026 at 11:25 AM interview and statement review with NA #2 identified on 6/9/2026 around 8 to 8:30 AM she assisted NA #1 to transfer Resident #1 onto the commode. When they left the room the door was closed for privacy and AC was on. Resident #1 was dressed in clothes from the day (not in bedtime clothes), and Resident #1 indicated he/she wanted to change into a johnny after using the commode. NA #2 stated she left NA #1 with Resident #1 and later asked NA #1 if he needed help (indicating she meant if he needed help to transfer Resident #1 off the commode). NA #2 stated he was all set and she assumed another team member helped NA #1 assist Resident #1 off the commode. NA #2 stated NAs are supposed to check residents every two (2) hours or as needed, if she sees a resident's door is closed (with AC on), she stops and checks on the resident. Interview and observation with Resident #1 on 6/17/2026 at 9:06 AM identified Resident #1's voice was very quiet, and speech was slow. Resident #1 stated on 6/9/2026 staff assisted him/her onto the commode before bedtime, and left the call bell attached to the recliner chair out of reach, and attempts to reach the bell were unsuccessful. After waiting for a long time (hours), he/she attempted to reach the call bell again, and when tried to stand up, he/she fell to the floor. Resident #1 stated he/she got a bump on the head and was sent to the hospital and had scans done. Resident #1 stated he/she did not know why NA #1 or NA #2, who had helped him/her onto the commode. Resident #1 stated NA #1 was assigned to provide care for him/her and had no excuse to forget him/her. Resident #1 stated he/she was upset, and was observed to be weepy during the interview. Record review identified on 6/10/2026 DNS a follow up visit with Resident #1 and family member identified Resident #1 stated when he/she was left on the commode, I tried to call out but door was closed for privacy and the AC (air conditioner) was also on. Resident #1 stated, they forgot me, it was after 11 PM when NA #3 came in to help. Resident stated he/she was left on the commode for about three (3) hours. Interview and record review on 6/17/2026 at 1:33 PM with DNS indicated on 6/9/2026 Resident #1 was assisted by NA #1 and NA #2 onto the commode around 8 to 8:30 PM and the call bell was not placed within reach, the door was closed and the AC was on. Resident #1 attempted to reach for the call bell, fell and NA #3 (11-7 NA) found Resident #1 on floor still in his/her day clothes at 11:15 PM (approximately 2 hours and 45 minutes after NA #1 left him/her on the commode).The DNS further indicated NAs should perform resident care rounds at least every two (2) hours or more often as needed and NA #1 should have ensured the call bell was in reach, and revisited a resident who was left on a commode. Further, bedtime care should have provided and NA #1 should have completed last rounds on all residents on his assignment, including Resident #1. Review of facility Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property directed in part; it is the policy of this facility that each resident will be free from Abuse. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility Certified Nursing Assistant Job Description directed in part; the Certified Nursing Assistant is responsible for the direct care of resident needs for activities of daily living and maintains an environment which is safe, pleasant and therapeutic.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the call bell was in reach, failed to ensure staff performed resident rounds and personal care timely. The findings include: Resident #1's diagnoses included Parkinson's Disease, sciatica, and dysarthria and anarthria (motor disorders impairing lips, tongue, vocal cords or diaphragm causing slurred, slow or difficult to understand speech). The Resident Care Plan (RCP) dated 3/15/2026 identified limited physical mobility and ADL assistance related to balance and coordination deficits. Interventions directed encourage to participate to fullest extent possible, transfer with [NAME] Hall [NAME] device with assistance of two (2), and resident was non-ambulatory. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen, indicative of no cognitive impairment, required assistance with ADLs (activities of daily living), required substantial/maximal assistance with bed mobility, bathing, dressing, toilet hygiene, was non-ambulatory, and transferred with two (2) staff and standing rotary turning device. The facility reportable event (RE) dated 6/9/2026 at 11:15 PM identified Resident #1 had an unwitnessed fall in his/her room. Assessment identified a bump to right forehead with some decolorization and complained of pain to left arm. Resident had been assisted to commode around 8 PM by two (2) nurse aides (NAs). The NA on the 11 PM to 7 AM shift responded to resident's call bell and found Resident #1 on the floor. Resident #1 stated he/she fell reaching for his/her call bell and stated that he/she was left on the commode for hours. Review of the RE summary report dated 6/11/2026 indicated Resident #1 was assisted to commode between 8 and 8:30 PM by two (2) NAs. A NA on the 11 PM to 7 AM shift responded to Resident #1's call light around 11:15 (at the start of her shift, approximately 2 hours and 45 minutes after NA #1 left Resident #1 on the commode), and alerted the nurse that the resident was on the floor. Resident #1 stated he/she fell reaching for her call bell after staff left him/her on the commode for hours. The facility determined Resident #1 was left on the commode without access to the call bell (not in reach) and he/she sustained a fall. Resident #1 was transferred to the hospital, returned with no new orders, and imaging was negative. Interview and record review on 6/17/2026 at 10:40 AM with NA #1 identified on 6/9/2026, Resident #1 was on his assignment. Between 8 to 8:30 PM (approximately 2 hours and 45 minutes before Resident #1 was found on the floor), he and NA #2 assisted Resident #1 to the commode. NA #1 did rounds around 9:45 PM and stated he was distracted and forgot to go back to assist Resident #1 off the commode. In addition, NA #1 stated he forgot to go back and provide bedtime personal care and last care rounds for Resident #1. NA #1 further indicated that rounds should be done throughout the shift, and he forgot to give Resident #1 the call bell when he left him/her on the commode. Later during the shift, NA #2 had asked him if he needed help with anything, and he responded, no. NA #1 stated he should not have left Resident #1 on the commode without returning to assist Resident #1 off the commode and he should have left the call bell in reach. Interview and record review on 6/17/2026 at 1:33 PM with DNS indicated on 6/9/2026 Resident #1 was assisted by NA #1 and NA #2 onto the commode around 8 to 8:30 PM and the call bell was not placed within reach, the door was closed and the AC was on. The DNS indicated NA #1 should not have left Resident #1 on the commode without returning to check on him/her, should have left the call bell in reach, should have provided evening care, and should have completed rounds at least every two (2) hours. Review of facility Certified Nursing Assistant Job Description directed in part; the Certified Nursing Assistant is responsible for the direct care of resident needs for activities of daily living and maintains an environment which is safe, pleasant and therapeutic.

Based on clinical record review, review of facility documentation, review of facility policy, and staff interviews, for two of six sampled residents (Resident #17 and Resident #24) reviewed for accidents, the facility failed to ensure that staff utilized a gait belt during assisted ambulation in accordance with the facility's policy, which resulted in a fall with injury, and failed to ensure that a resident who required staff assistance for transfers did not sustain a skin tear during a staff-assisted transfer. The findings include: Resident #24 had diagnoses that included anemia, osteoarthritis, weakness, and difficulty walking.The fall risk assessment dated [DATE] identified Resident #24 received a total score of 3, a score of 3 indicates a low fall risk.The Resident Care Plan (RCP) dated 2/12/26 identified Resident #24 had limited physical mobility related to weakness. The care plan interventions directed staff to transfer the resident with assistance of one and to ambulate the resident with assistance of one using a gait belt and walker.The admission MDS assessment dated [DATE] identified Resident #24 had intact cognition, required extensive assistance for toileting, personal hygiene, dressing, transfers, and ambulation. It further identified the resident utilized both a rolling walker and a wheelchair for mobility and had no documented history of falls.The nurses' aide care card, updated on 3/11/26 identified Resident #24 was alert and oriented but could be forgetful, and required assistance of one with a rolling walker for transfers and ambulation.The facility reportable event report dated 3/12/26 at 3:20 PM identified Resident #24 experienced a fall while ambulating in the hallway. The facility's investigation identified NA #1 had not utilized a gait belt while assisting the resident during ambulation. An intervention put in place following the fall consisted of re-educating NA #1 regarding the purpose of using the gait belt and competency in proper gait belt application.LPN #1's nurse's note dated 3/12/26 at 8:12 PM identified Resident #24 was walking in the hallway with NA #1 using a rolling walker when the resident lost balance and fell to the floor. The RN completed an assessment and noted a skin tear to the resident's left forearm. Resident #24 denied hitting his/her head. Range of motion was intact to all extremities, and the resident reported left elbow pain rated 7 out of 10 on a 0-to-10 pain scale.The physician's orders dated 3/12/26 directed staff to transfer Resident #24 to the hospital for evaluation following the fall.The two view left elbow X ray (an imaging diagnostic test) dated 3/12/26 at 5:23 PM completed at the hospital identified Resident #24 presented after a fall with left elbow pain and limited range of motion. The radiology findings identified posterior elbow soft tissue swelling and a nondisplaced fracture of the left olecranon.The nurse's notes dated 3/12/26 at 11:19 PM identified Resident #24 returned from the hospital with a sling to the left arm. The nurse assessed the resident's hand and fingers, performed range of motion checks and documented that the left hand and fingers were warm to the touch. Resident #24's neurological checks were within normal limits.The physician's orders dated 3/13/26 directed staff to ensure proper positioning of the left arm sling every shift, to ensure the hard splint was properly positioned to the left arm and/or elbow, to monitor circulation, motion, and sensation of the left upper extremity, and to maintain non weight bearing status to the left upper extremity.The revised Resident Care Plan (RCP) dated 3/16/26 identified Resident #24 had limited physical mobility related to weakness. The care plan interventions directed staff to transfer the resident with assistance of one from the bed to the wheelchair, and wheelchair to toilet, remove resident from the ambulation list at this time, and resident is non-ambulatory with nursing staff at this time. Interview with LPN #1 on 3/25/26 at 10:00 AM identified NA #1 was assisting Resident #24 with ambulation in the hallway when the resident lost his/her balance and fell to the floor. LPN #1 also identified that the nursing supervisor was called to assess the resident following the fall and Resident #24 was directed to be sent to the hospital for further evaluation. She identified that NA #1 acknowledged she had not applied a gait belt to Resident #24 and reported that she had forgotten to apply the gait belt. She further identified that the facility's policy required the use of a gait belt during transfers and/or ambulation whenever a resident required assistance.Interview with OTA #1 on 3/25/26 at 10:10 AM identified that all staff should use a gait belt for all transfers and/or ambulation unless a resident is independent with transfers and ambulation. He identified that the purpose of a gait belt is to allow staff to maintain a secure grasp on the resident in case the resident loses balance. He identified that Resident #24 required assistance of one for transfers and ambulation, and that staff should have been using a gait belt whenever assisting the resident. He further identified that NA #1 may have been able to maintain control of Resident #24 if a gait belt had been used at the time of the fall, and could have assisted the resident to the floor, thereby preventing a major injury. In addition, he identified that Resident #24 was removed from the ambulation list following the fall and could only ambulate with physical therapy.Interview with the DNS on 3/25/26 at 10:33 AM identified that all staff are required to use a gait belt during transfers and/or ambulation for any resident who requires assistance. She identified that the gait belt is used to maintain the staff's grasp in the event the resident loses balance and to help prevent a major injury if a fall occurs. She further identified that NA #1 was recently hired but had been trained and deemed competent in the use of the gait belt during orientation. She further identified that NA #1 had not used a gait belt while assisting Resident #24 with ambulation, which resulted in a fall and left elbow fracture. Additionally, the DNS noted that NA #1 received reeducation and competency validation regarding proper gait belt use following the incident.Attempts to interview NA #1 were unsuccessful during the survey period.The facility's policy for Gait Belt Use and Ambulation identified that staff are required to use a gait belt with residents who cannot independently ambulate and/or transfers, and a gait belt is used to support, guide the resident and to avoid using the resident's clothing or limbs to support their weight. Resident #17 had diagnoses that included type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease.The annual MDS assessment dated [DATE] identified Resident #17 had severe cognitive impairment, required extensive assistance for toileting, personal hygiene, dressing, and transfers, was non-ambulatory and utilized a rolling walker and wheelchair for mobility.The nursing aide care card identified that Resident #17 required the assistance of one staff member with a rolling walker for transfers. The Accident and Incident (A&I) report dated 11/20/25 at 7:45 PM identified that Resident #17 was transferred by NA #2 and NA #8 and was noted to have a skin tear to his/her left lower leg that measured 2.5 cm in length by 1.5 cm in width following the transfer. The facility's investigation identified Resident #17 did not have a skin tear prior to the transfer. Statements obtained from NA #2 and NA #8 identified that Resident #17 was giving them a hard time during the transfer. NA #2 identified that she attempted to talk to the resident, but nothing helped, and NA #8 identified that they could have waited for Resident #17 to calm down.LPN #2's nurse's note dated 11/20/25 at 9:54 PM identified that NA#2 and NA #8 transferred Resident #17, after which the resident was noted to have a skin tear on the left lateral lower leg. The skin tear measured 2.5 cm in length by 1.5 cm in width. The nursing supervisor, physician, and family were notified of the incident.The Resident Care Plan (RCP) dated 11/20/25 identified Resident #17 had a skin tear to the left lateral lower leg. Care plan interventions directed staff to use protective sleeves to the leg, identify the potential causative factor and resolve when possible, and encourage good nutrition and hydration to promote healthier skin.The Occupational Therapy (OT) screening dated 11/24/25 identified Resident #17 was seen for an OT screen related to sustaining a skin tear while being transferred. The OT screen identified that Resident #17 had not had a change in his/her functional mobility. The plan was to request the maintenance department to place a cushion liner on the right side of the bed frame, where Resident #17 had been pressing his/her left leg against the metal frame.The physician's initial wound consultation dated 11/25/25 at 10:56 AM identified the skin tear to the left lower extremity was evaluated. The skin tear measured 2 cm in length by 0.7 cm in width by 0.1 cm in depth, with a small amount of serosanguineous drainage. The treatment plan directed to cleanse the wound with normal saline, apply silver hydrogel to the base of the wound, and cover it with a dry, clean dressing daily and as needed when soiled or dislodged.The weekly wound physician's progress notes from 12/2/25 through 12/23/25 identified Resident #17 had a skin tear to the left lower leg. Documentation reflected that the wound physician continued to monitor the condition and provided an ongoing treatment plan for the skin tear throughout this period.The nurse's notes dated 12/30/25 at 10:35 AM identified that Resident #17's skin tear to the left lower leg was documented as healed.Interview with LPN #2 on 3/26/26 at 11:00 AM identified that NA #2 had reported a skin tear that had occurred during Resident #17's transfer. She identified that NA #2 had reported Resident #17 did not have a skin tear prior to the transfer and that the skin tear to the left lower leg had been obtained after the resident was transferred from the wheelchair to the bed. She identified that Resident #17 required assistance of one staff member for transfers. She further identified that she could not recall whether Resident #17 had been agitated at the time of the transfer. She also identified that Resident #17 had not been using a leg rest on his/her wheelchair because he/she could self propel while in the wheelchair.Interview with the DNS on 3/26/26 at 1:30 PM identified that Resident #17's skin tear had been noted after the resident was transferred from the wheelchair to the bed. She reviewed the witness statements obtained from NA #2 and NA #8, which identified that the resident had been agitated and that staff should have waited prior to transferring the resident; however, she identified that Resident #17 had been agitated during the transfer. She further identified that Resident #17 should have been free from any type of accident while care was being provided by her staff.Attempts to interview NA #2 and NA #8 were unsuccessful during the survey period.The facility's policy for Accidents and Supervision identified that the facility would maintain the resident environment free of accident hazards to the greatest extent possible and ensure that each resident received adequate supervision and appropriate assistive devices to prevent accidents.

Based on observations, review of the clinical record, review of facility policy and interviews for one sampled resident (Resident #45) reviewed for respiratory care, the facility failed to ensure a physician's order was in place directing the use of oxygen therapy and failed to ensure a comprehensive care plan was developed to address how to provide care for the resident utilizing continuous oxygen therapy. The findings include:Resident #45's diagnoses included mild intermittent asthma, type 2 diabetes, dementia, and anxiety. The annual MDS assessment dated [DATE] identified Resident #45 had moderately impaired cognition, required moderate assistance with personal hygiene, and required supervision with ambulation utilizing a walker. The assessment further identified that the resident was not receiving oxygen therapy. Observation on 3/23/26 at 1:19 PM identified a posted sign on the outside of the doorframe with the written warning. caution, oxygen in use no smoking or open flame. Upon entering the room, Resident #45 was sitting on the side of the bed wearing a nasal cannula connected to the oxygen concentrator at 3 liters/minute (LPM). Resident #45 identified he/she uses oxygen at all times except when he/she goes to the bathroom. Review of the physician's orders for the time period of December 16, 2025, through March 23, 2026, failed to identify an order for continuous or as needed use of oxygen therapy. Review of Resident #45's care plan dated 2/12/26 failed to identify the use of oxygen therapy or interventions that might include: monitor resident for respiratory distress and report to the provider as needed, oxygen settings as directed by the physician's order, to promote lung expansion and improve air exchange by positioning with proper body alignment. Interview with LPN #3 on 3/24/26 at 11:50 AM Resident #45 should have an order for oxygen use, and it is the responsibility of the nurse who obtains the order from the provider to ensure the order is transcribed into the computer. Review of the clinical record with LPN #3 failed to identify an order for oxygen therapy. Interview and review of the clinical record with the Charge Nurse (LPN #3) on 3/24/26 at 11:49 AM identified that all residents receiving oxygen therapy should have a physician's order directing the use of oxygen indicating how many liters of oxygen needed specific to the resident. LPN #3 identified Resident #45 utilizes oxygen therapy and should have an order for oxygen usage as the resident started on oxygen over a month ago when he/she had pneumonia. LPN #3 failed to identify a physician's order or a care plan regarding the use of oxygen therapy for Resident #45. Review of the nurse aide care card also failed to identify that the resident utilized oxygen and/or how to provide care for the resident in regard to the continuous oxygen therapy.Interview with the Administrator and the Infection Preventionist Nurse (RN #4) on 3/24/25 at 1:30 PM identified that the ADNS, who is also the MDS Coordinator, was on vacation but is responsible for revising and updating the care plan. RN #4 identified Resident #45 utilizes oxygen therapy and should have had a care plan for the use of oxygen with interventions. They identified that the facility has a library of care plans which include oxygen usage and they would have to review the care plans to see what interventions needed to be included in the care plan for this resident. Following surveyor's inquiry on 3/24/26, oxygen therapy related to ineffective gas exchange was added to the resident care plan. Interview with the DNS on 3/25/26 at 2:04 PM identified Resident #45 utilized continuous oxygen and should have had an order directing the use of oxygen in the clinical records and an individualized care plan in place regarding the use of oxygen. The DNS further identified the care plan should include specific interventions related to the resident. Review of the Oxygen Administration policy identified oxygen is administered under orders of a physician, except in the case of an emergency. The policy further identifies the residents' care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: the type of oxygen delivery system; when to administer, such as continuous or intermittent and/or when to discontinue; equipment setting for the prescribed flow rates, monitoring oxygen saturation levels and monitoring for complications associated with the use of oxygen.Review of the Comprehensive Care Plan policy identified that the facility is to develop a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental psychological needs that are identified in the resident's comprehensive assessment. The policy further identifies that the comprehensive care plan will describe at a minimum the following the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, psychological well-being and will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, facility policy and interviews for 1 of 2 sampled medication rooms, the facility failed to store medications appropriately. The findings include:Observation on 3/26/26 at 2:30PM with LPN#4 of Level 1 Medication room identified 2 boxes of Mucus Relief ER with an expiration date of 12/20/25. Interview on 3/26/26 at 2:35PM with LPN#4 identified that the nurses and the person that stocks the medications check the medication room for expired medication. Interview on 3/27/26 at 2:02PM with the DNS identified that expired medication should not be stored in the medication room. The nurses or the person who stocks it are responsible for going through the medications regularly as well as the pharmacy consultant going through everything once a month. Review of Consultant Pharmacy Summary for February 1st- February 28th, 2026, identified there were isolated issues observed of expired medications that were removed from the carts on Unit 2 and given to the nurse. Review of the medication storage policy directed the medication carts and all medication rooms routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.

Based on review of the clinical record, review of facility documentation and interviews for one of two sampled residents (Resident #36) with an allegation of mistreatment, the facility failed to ensure social service visits were documented and readily accessible in the medical record. The findings include: Resident #36's diagnoses included chronic systolic congestive heart failure, depression, anxiety and adult failure to thrive.The quarterly MDS assessment dated [DATE] identified Resident #36 had intact cognition, no identified behaviors, required maximal assistance with toileting hygiene, lower body dressing, was dependent on staff for transfers, and always incontinent of bladder and frequently incontinent of bowel functioning. The care plan dated 1/29/26 identified Resident #36 had limited physical mobility related to a history of stroke and left hip fracture with an intervention dated 2/3/26 to ensure special care when turning resident due to chronic right knee pain. The accident and incident report dated 2/2/26 at 8:15 PM identified Resident #36 reported NA #5 was rude and rough with him/her and that the she doesn't like her job. The resident further noted he/she had chronic right knee pain, and NA #5 had just rolled him/her over like it was a job. Review of the Service Recovery/Grievance/Concern form with a date of occurrence of 2/2/26 identified Resident #36 reported a nurse aide was rough with care and the DNS and social service spoke with the resident who is alert and oriented to time, person and place. The outcome/resolution identified that the nurse aide was relieved of his/her duties. In addition, an attached note to the grievance dated 2/3/26 written by the DNS identified she saw the resident after breakfast with SW #1, to speak with Resident #36 regarding what happened last evening. The note further identified resident had no pain today, and no alterations in skin integrity, and the resident indicated he/she thought they would be fine now knowing that nurse aide would not be taking care of him/her. Review of social services progress notes for the period of February 1, 2026, through February 28, 2026, failed to identify written documentation regarding the alleged allegation of rough care occurring on 2/2/26. Interview with SW #1 on 3/24/26 at 2:45 PM identified that she was aware of the incident between Resident #36 and a staff member which occurred on 2/2/26 and saw the resident. SW #1 identified that she would have written a note after her visit with the resident and it is usually included in the investigation. SW #1 thoroughly reviewed the folder provided by the facility to the surveyor and identified that her documentation was not included and would have to check her records.Interview with SW #1 on 3/25/26 at 8:50 AM identified she was unable to locate her note written after her visit with the resident. Interview with the DNS on 3/25/26 at 8:40 PM identified she reviewed the records and was unable to identify a note from social services as there should have been a note documented from the social worker regarding the allegation in the resident's record. The DNS identified Resident #36 was offered a psychiatric consult which the resident declined at the time as the nurse aide would no longer care for the resident. Review of the Documentation in Medical Record policy identified each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of the Abuse/Indignity/Mistreatment/Neglect policy and procedure identified under the follow-up care section that the Social Services Department will be notified to provide counseling and support to the residents (and family as indicated). Follow-up care, including counseling and support, will be documented in medical records.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedure and interviews for one of five sampled residents (Resident #17), reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was offered to the resident. The findings include: Resident #17 was admitted to the facility in November/2024 with diagnoses that included type 2 diabetes, dementia and cognitive communication deficit. The quarterly MDS assessment dated [DATE] identified Resident #17 had severely impaired cognition. The assessment further identified Resident #17 had not received the pneumococcal vaccine with the reason indicated that the vaccine was offered and decline. Resident #17's Pneumococcal Vaccination history under the immunization tab identified the resident had received the PPSV 23 (pneumococcal vaccine) on 10/4/2012 and had received the Prevnar 13 vaccine (PCV 13) on 4/6/2026 prior to his/her admission to the facility. The record also identified Resident #17 was not eligible for the pneumococcal vaccine (PCV 20) with a reason of no consent obtained dated 11/2024. The immunization records for Resident #17 on 3/25/26 at 11:15 AM with the Infection Preventionist (RN #4) failed to identify any documentation that the pneumococcal vaccine (PCV 20) was offered to the resident on admission or thereafter. Interview with RN #4 on 3/25/26 at 11:15 AM identified it is the responsibility of the IP nurse to ensure the resident vaccination status is assessed and the appropriate vaccine offered to the resident on admission and thereafter. RN #4 identified Resident #17 was eligible to receive the PCV 20 pneumococcal vaccine on admission but checked off ineligible because she was unable to get a hold of the resident's responsible party to offer the PCV20 vaccine to obtain the consent. RN #4 further identified she had not tried to obtain the consent for the pneumococcal vaccine since admission, even though she had contacted Resident #17's responsible party a few times to obtain the influenza and covid-19 vaccine and could have obtained consent for the pneumococcal at that time. RN #4 identified she should have tried again to obtain a consent. Subsequent to surveyor's inquiry consent from the responsible party was obtained on 3/26/26 and the resident was given the PCV 20 pneumococcal vaccine. Review of the Immunizations Pneumococcal vaccine PVC 20 (Prevnar 20) policy identified each resident's pneumococcal immunization status will be determined upon admission and will be documented in the resident's medical record. The policy further identifies that all resident with undocumented, unknown, or not up to date pneumococcal vaccination status will be offered the vaccine. Informed consent in the form of a discussion regarding the risks and benefits of vaccination will occur prior to vaccination (this may be with the resident's authorized representative when appropriate and signed consent or declination of the vaccine will be obtained at this time.

Based on review of clinical records, review of facility policy/procedures and interviews for two of three sampled residents (Residents #2 and #4) reviewed for Preadmission Screening and Resident Review (PASRR) and hospitalization, the facility failed to ensure the comprehensive MDS assessments accurately reflected a positive Level II PASRR screening and the resident's correct admission date. The findings include:Resident #2's diagnoses included alcoholic cirrhosis of the liver, type 1 diabetes mellitus, dementia, and neoplasm of digestive organ. The quarterly MDS assessment dated [DATE] identified Resident #2 had severe cognitive impairment, and required extensive assistance for toileting, dressing, personal hygiene, and transfers. The nurse's notes dated 10/11/25 identified Resident #2 was observed expressing suicidal ideation and expressed an intent to harm himself/herself by stabbing himself/herself. The room was checked for sharp objects, while staff remained with the resident. When informed of the plan to be sent to the hospital for evaluation, the resident became non verbal and unresponsive, with a flat affect and minimal eye contact. The resident was transferred to the hospital for further evaluation. The electronic clinical record identified Resident #2 was out of the facility from 10/12/25 to 10/27/25. The nurse's note dated 10/28/25 identified Resident #2 returned to the facility from the hospital via ambulance at 3:30 PM. Resident #2 was readmitted to the facility with diagnoses of urosepsis and atrial fibrillation. The entry MDS assessment identified the resident returned to the facility on [DATE], when Resident #2 actually returned to the facility on [DATE]. The date of 10/29/25 was incorrect. Interview with the DNS on 3/26/26 at 10:35 AM identified the MDS nurse was unavailable for interview. She identified that she was not very knowledgeable about MDS coding; however, she would expect the coding to be accurate. She identified that Resident #2 was readmitted to the facility on [DATE] from the hospital. Subsequent to the surveyor's inquiry, the MDS entry date was corrected and submitted. The facility's MDS 3.0 Policy and Procedures identified that an entry tracking record would be created on the date of admission or readmission. Resident #4's diagnoses included anxiety, depression, and psychotic disorder with delusions. The PASRR level II outcome determination dated 2/20/2023 identified Resident #4 had a positive level II PASRR. The annual MDS assessments dated 2/19/25 and 2/16/26 identified Resident #4 had intact cognition and under the Preadmission Screening and Resident Review (PASRR) section, a response of no to the question that asks if the resident was currently considered by the level II PASRR process to have a serious mental illness and or intellectual disability or a related condition. The response of no was incorrect because the resident had a positive level II assessment. Interview with the Social Worker (SW #1) on 3/25/26 at 1:25 PM identified that the comprehensive MDS assessments should be coded to reflect Resident #4 had a positive level II PASRR assessment. She noted that the MDS Coordinator is responsible for completing that section of the MDS. She further identified that the MDS Coordinator at times asks her about residents' PASRR status, she noted that the PASRR assessments are located in the physical clinical record or uploaded to the electronic clinical record and if necessary, the assessment can be pulled off the PASRR portal. The MDS Coordinator was not available to be interviewed due to a planned leave of absence. Interview with the DNS on 3/25/26 at 2:04 PM identified the ADNS is responsible for completing the MDS assessment but is currently away on vacation. The DNS identified that if the resident has a positive level II PASRR it should be reflected on the MDS. The MDS 3.0 policy and procedure identified that according to federal regulations, the facility conducts an initial and periodical, comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the state. The policy and procedures further identified persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who was dependent on staff for transfers with a mechanical lift, the facility failed to ensure the resident's rights to refuse treatment were honored when the resident refused the transfer and to be showered several times. The findings include: Resident #1's diagnoses included chronic osteomyelitis, anxiety, and abnormal gait and mobility. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was oriented to person, place, time, and situation, was dependent on staff for toileting, personal hygiene, bathing, bed mobility, and transfers. The Resident Care Plan dated 4/17/25 identified Resident #1 had limited physical mobility and was at risk for falls. Interventions directed to use a mechanical lift with two (2) staff for all transfers, physical and occupational therapy referrals as needed, and call bell in reach at all times. The nurse's note dated 5/29/25 at 8:59 PM identified the 3PM-11PM Nursing Supervisor was called to Resident #1's room to interview Resident #1. The note indicated Resident #1 stated on 5/28/25 one (1) of two (2) nurse aides was pulling on my leg to get it into the Hoyer lift, I told them I did not want a shower, and they put me in the Hoyer lift anyway. One (1) of the nurse aides was pulling on my leg to get it into the Hoyer, I told her to stop she was hurting me, my right leg was dangling down, I said that it is the leg they operated on it hurts. They gave me a shower and when they brought me back the shower chair fell back, I thought I was going to fall I yelled stop it. A third staff member came in the room to help after she heard me yelling. The Facility Reported Incident form dated 5/29/25 identified Resident #1 had alleged on 5/28/25 during a transfer with the mechanical lift, NA #2 caused pain to Resident #1's right leg when bending the leg to fit it into the Hoyer lift and the nurse aide continued with the transfer even after Resident #1 told the nurse aide to stop the transfer. Interview with Resident #1 on 6/11/25 at 11:45 AM identified on 5/28/25 he/she initially agreed to the transfer with the Hoyer lift for the purpose of showering. Resident #1 identified he/she began to refuse the transfer and shower after the nurse aides were having difficulty with the transfer and causing pain to his/her right leg. Resident #1 explained that despite his/her repeated requests to stop the transfer, the nurse aide continued with the process. Interview with the 3-11PM nurse aide, Nurse Aide (NA) #1, on 6/11/25 at 12:05 PM identified she was in training. NA #1 identified on 5/28/25 during the transfer process when Resident #1 was in pain from the process and began to refuse the transfer, NA #2 continued with the transfer. Interview with NA #2 on 6/11/25 at 12:45 PM identified on 5/28/25 Resident #1 did not refuse to take a shower. Interview with the Director of Nursing (DON) on 6/11/25 at 1:45 PM identified it was a violation of the resident's rights to proceed with the transfer and shower and the nurse aides should have stopped the transfer immediately when Resident #1 refused. The DON stated NA #2 was terminated for failure to comply with the Resident's [NAME] of Rights. Review of the facility Residents' [NAME] of Rights identified in part, the resident had the right to request, refuse, and/or discontinue treatment.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff for transfers via a mechanical lift, the facility failed to ensure the lift pad was the correct size to properly transfer the resident out of the bed for a shower. The findings include: Resident #1's diagnoses included chronic osteomyelitis, anxiety, and abnormal gait and mobility. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was oriented to person, place, time, and situation, was dependent on staff for toileting, personal hygiene, bathing, bed mobility, and transfers. The Resident Care Plan dated 4/17/25 identified Resident #1 had limited physical mobility and was at risk for falls. Interventions directed to use a mechanical lift with two (2) staff for all transfers, physical and occupational therapy referrals as needed, and call bell in reach at all times. The nurse's note dated 5/28/25 at 10:38 PM identified Resident #1's right leg was outstretched during a transfer into the mechanical lift and bumped his/her right knee and had some initial redness at the area. The nurse's note dated 5/29/25 at 8:59 PM identified the 3PM-11PM Nursing Supervisor was called to Resident #1's room to interview Resident #1. The note indicated Resident #1 stated on 5/28/25 one (1) of two (2) nurse aides was pulling on my leg to get it into the Hoyer lift, I told them I did not want a shower, and they put me in the Hoyer lift anyway. One of the nurse aides was pulling on my leg to get it into the Hoyer, I told her to stop she was hurting me, my right leg was dangling down, I said that it is the leg they operated on it hurts. They gave me a shower and when they brought me back the shower chair fell back, I thought I was going to fall I yelled stop it. A third staff member came into the room to help after she heard me yelling. The Facility Reported Incident form dated 5/29/25 identified Resident #1 had alleged on 5/28/25 during a transfer with the mechanical lift, NA #2 caused pain to the resident's right leg when bending the leg to fit it into the Hoyer lift. Review of the clinical record including the care card failed to reflect documentation of the specific sling size to use for Resident #1. Interview with Resident #1 on 6/11/25 at 11:45 AM identified on 5/28/25 he/she initially agreed to the transfer with the Hoyer lift for the purpose of showering. Resident #1 identified he/she began to refuse the transfer and shower after the nurse aides were having difficulty with the transfer and causing pain to his/her right leg. Resident #1 explained upon return from the shower, during the transfer back to bed, he/she identified the the Hoyer broke down and collapsed and I went down. Resident #1 identified another staff member came into the room and helped the aides get me back into bed. Resident #1 indicated this was the first time the nurse aides had transferred him/her. Interview with NA #1 on 6/11/25 at 12:05 PM identified on 5/28/25 she was being trained by NA #2. NA #1 indicated Resident #1 began to refuse the transfer when he/she was experiencing pain while NA #2 was attempting to get Resident #1's right leg into the Hoyer lift. NA #1 identified she recognized the hoyer pad NA #2 was using was too small for Resident #1 and questioned NA #2. NA #1 explained NA #2 left the room to get another pad and returned with the same size pad and proceeded with the transfer, Resident #1 continued to refuse the transfer, and NA #2 was having difficulty getting Resident #1 positioned on the pad causing discomfort to Resident #1. NA #1 identified she asked Resident #1 if he/she would agree to the transfer if she took over and Resident #1 agreed. NA #1 explained she took over the transfer and when performing the transfer NA #2 began to move the shower chair prematurely causing Resident #1 to hit his/her leg on the bedside table. NA #1 indicated during the transfer back to bed, one (1) of the latches of the Hoyer pad slipped off the lift and Resident #1 began to fall backwards, she caught Resident #1 and broke the fall. NA #1 identified the charge nurse heard Resident #1 yell, she entered the room and assisted with getting Resident #1 back into bed. Interview with NA #2 on 6/11/25 at 12:45 PM identified she had not transferred Resident #1 before and she was using the correct pad for Resident #1 because she had seen other nurse aides use that pad. NA #2 indicated a latch came off the Hoyer lift during the process of transferring Resident #1 back to bed and the charge nurse entered the room to assist with getting Resident #1 back to bed. Interview with the Director of Nursing (DON) on 6/11/25 at 1:45 PM identified on 5/28/25 NA #2 was training NA #1 and NA #2 used a large size sling pad when an extra-large sling pad should have been used for Resident #1. The DON explained the hoyer pad was placed improperly under Resident #1 causing the right leg to not be supported correctly, the leg did not fit properly into the sling causing pain. The DON identified NA #2 should have stopped the transfer and differed to a nurse for direction. Review of the facility policy Mechanical Lift use identified in part, residents will be transferred by trained and qualified caregivers and to use the proper size sling recommended for use of the lift.

Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff for transfers via a mechanical lift, the facility failed to ensure staff were trained on the proper use of mechanical lift transfers which ultimately caused staff to improperly transfer a resident. The findings include: Resident #1's diagnoses included chronic osteomyelitis, anxiety, and abnormal gait and mobility. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, was oriented to person, place, time, and situation, was dependent on staff for toileting, personal hygiene, bathing, bed mobility, and transfers. The Resident Care Plan dated 4/17/25 identified Resident #1 had limited physical mobility and was at risk for falls. Interventions directed use of a mechanical lift with two (2) staff for all transfers, Physical and Occupational Therapy referrals as needed, and call bell in reach at all times. The nurse's note dated 5/29/25 at 8:59 PM identified the 3PM-11PM Nursing Supervisor was called to Resident #1's room to interview Resident #1. The note indicated Resident #1 stated on 5/28/25 one (1) of two (2) nurse aides was pulling on my leg to get it into the Hoyer lift, I told them I did not want a shower, and they put me in the Hoyer lift anyway. One of the nurse aides was pulling on my leg to get it into the Hoyer, I told her to stop she was hurting me, my right leg was dangling down, I said that it is the leg they operated on it hurts. They gave me a shower and when they brought me back the shower chair fell back, I thought I was going to fall I yelled stop it. A third staff member came into the room to help after she heard me yelling. Interview with Resident #1 on 6/11/25 at 11:45 AM identified on 5/28/25 he/she initially agreed to the transfer with the Hoyer lift for the purpose of showering. Resident #1 identified he/she began to refuse the transfer and shower after the nurse aides were having difficulty with the transfer and causing pain to his/her right leg. Resident #1 explained upon return from the shower, during the transfer back to bed, he/she identified the the Hoyer broke down and collapsed and I went down. Resident #1 identified another staff member came into the room and helped the aides get me back into bed. Resident #1 indicated this was the first time the nurse aides had transferred him/her. Interview with NA #1 on 6/11/25 at 12:05 PM identified on 5/28/25 she was being trained by NA #2. NA #1 indicated Resident #1 began to refuse the transfer when he/she was experiencing pain while NA #2 was attempting to get Resident #1's right leg into the Hoyer lift. NA #1 identified she recognized the hoyer pad NA #2 was using was too small for Resident #1 and questioned NA #2. NA #1 explained NA #2 left the room to get another pad and returned with the same size pad and proceeded with the transfer, Resident #1 continued to refuse the transfer, and NA #2 was having difficulty getting the resident positioned on the pad causing discomfort to Resident #1. NA #1 identified she asked Resident #1 if he/she would agree to the transfer if she took over and Resident #1 agreed. NA #1 explained she took over the transfer and when performing the transfer NA #2 began to move the shower chair prematurely causing Resident #1 to hit his/her leg on the bedside table. NA #1 indicated during the transfer back to bed, one (1) of the latches of the Hoyer pad slipped off the lift and Resident #1 began to fall backwards, she caught Resident #1 and broke the fall. NA #1 identified the charge nurse heard Resident #1 yell, she entered the room and assisted with getting Resident #1 back into bed. Interview with NA #2 on 6/11/25 at 12:45 PM identified she had not transferred Resident #1 before and she was using the correct pad for Resident #1 because she had seen other nurse aides use that pad. NA #2 indicated a latch came off the Hoyer lift during the process of transferring Resident #1 back to bed and the charge nurse entered the room to assist with getting Resident #1 back to bed. Interview with the Director of Nursing (DON) on 6/11/25 at 1:45 PM identified on 5/28/25 NA #2 was training NA #1 and NA #2 used a large size sling pad when an extra-large sling pad should have been used for Resident #1. The DON explained the hoyer pad was placed improperly under Resident #1 causing the right leg to not be supported correctly, the leg did not fit properly into the sling causing pain. The DON identified NA #1 should not have taken over the transfer process since NA #1 was in training. NA #2 should have stopped the transfer and differed to a nurse for direction. The DON explained that the facility does not have a formal training protocol for mechanical lift transfers, the expectation was that nurse aides train each other and the facility has no documentation to support any training regarding mechanical lift transfers. Review of the facility policy Mechanical Lift use identified in part, residents will be transferred by trained and qualified caregivers and to use the proper size sling recommended for use of the lift.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who was reviewed for an allegation of physical abuse by a staff member and had a known history of making accusatory statements against staff, the facility failed to ensure two (2) staff members were present during care in accordance with the resident care plan. The findings include: Resident #2 's diagnoses included transient ischemic attacks, mood disorder, and a psychotic disorder with delusions. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented, had difficulty focusing attention, disorganized thinking, delusions and hallucinations, and required moderate staff assistance for toileting, bathing, dressing, ambulation, and maximum assistance for transfers. The Resident Care Plan dated 6/3/24 identified Resident #2 had a self-care deficit. Interventions directed assistance from two (2) staff members for all care due to the resident's history of accusatory behaviors. The nurse aide care card identified assistance of two (2) staff at all times with care. The nurse's note dated 7/20/24 at 2:33 PM identified Resident #2 was in no distress from reported incident, nurse aide was removed from providing care, the physician, family, and Director of Nursing (DON) were informed of incident, and statements from the resident and staff were obtained. The Facility Reported Incident form dated 7/20/24 at 3:27 PM identified Resident #2 reported to the 7AM-3PM charge nurse, Licensed Practical Nurse (LPN) #1, that the 7AM-3PM nurse aide, Nurse Aide (NA) #2, was bossy and rough and stated she shoved me down onto the toilet causing me to almost fall. LPN #1 reported the allegation to the 7AM-3PM supervisor, Registered Nurse (RN) #1. RN #1 conducted a skin assessment, and no findings were documented. She also removed NA #2 from care and notified the Director of Nursing and physician. The social service note dated 7/22/24 identified Social Worker (SW) #1 spoke with Resident #2 following the alleged incident and Resident #2 reported that NA #2 had to have things her way or the highway and that NA #2 rubbed Resident #2 the wrong way. Resident #2 was not in any distress during the conversation. In an interview with the 7AM-3PM nurse aide, (NA) #1, on 5/5/25 at 2:30 PM, NA #1 identified that on 7/20/24 she was assisting NA #2 with the care of several residents. NA #1 explained after they provided care to one (1) resident, they were proceeding down the hall to provide care to Resident #2 when she had to respond to a call bell for another resident. NA #2 indicated she was delayed in that room, once finished with care, she proceeded to Resident #2's room and witnessed NA #1 in the process of assisting Resident #2 into the chair. NA #1 identified NA #2 had already provided morning hygiene and care had been provided bedside according to NA #1. NA #1 indicated while she was making Resident #2's bed the resident said something like, I am glad you are here, she (NA #2) has been rough with me all morning. NA #1 identified she was not in the room when NA #2 provided Resident #2 with care. Interview with the Director of Nursing (DON) on 5/5/25 at 2:50 PM identified the facility was not able to substantiate an allegation of abuse, however the facility identified poor customer service and the failure for NA #2 to follow the policy when NA #2 provided care to Resident #2 alone which was in direct contradiction to the resident's care plan which required two (2) staff members to be present for care due to the resident's history of accusatory behaviors. Review of the facility policy Comprehensive Care Plan identified, in part, staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out the interventions, initially and when changes were made. Although attempted, an interview with RN #1, LPN #1, and NA #2 were unsuccessful.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed ensure timely notification to the provider when a resident had an identified change of condition. The findings include: Resident #1's diagnoses included dementia, aortic valve stenosis. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicative of moderate cognitive impairment and required partial/moderate assistance ADLs. The Resident Care Plan (RCP) dated 3/3/2025 identified the resident had an ADL self-performance deficit related to arthritic pain. Interventions directed assist of one with ADL. Physician order dated 2/4/2025 directed Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 108 (90) base two (2) puffs inhale orally every six (60 hours as needed for bronchodilator use as needed for shortness of breath or wheezing. Nursing note dated 3/20/2025 at 1:37 AM (written by LPN #1) identified Resident #1 had an audible wheeze, an as needed (prn) inhaler was administered with effect, temperature was 99.7, and lung sounds were bilateral faint crackles. Acetaminophen was administered, the head of the bed was raised, fluids were encouraged. Record review failed to identify the RN supervisor and the physician or APRN were notified of the change in condition identified per the nursing note dated 3/20/2025 at 1:37 AM. Interview, clinical record and facility documentation review on 3/25/2025 at 12:09 PM with LPN #1 identified she notified the 11 PM to 7 AM supervisor (RN #3) regarding Resident #1's status identified on 3/20/2025. LPN #1 further stated she wrote a fax note to update the provider that Resident #1 seemed congested and had wheezing to alert the provider in the morning of resident's status. Interview, clinical record and facility documentation review on 3/25/2025 at 1:22 PM with RN #3/supervisor identified although LPN #1 had notified her that Resident #1 had respiratory issues, crackles (lung sounds), afebrile (no temperature), and she was on the unit about 3 AM, RN #3 stated she did not notify the physician or APRN. RN #3 stated she passed the information along in morning report at 7 AM to the on-coming supervisor. RN #3 stated she should have notified the on-call provider (physician or APRN). Interview failed to identity why RN #3 did not notify the on-call provider. Interview, clinical record and facility documentation review on 3/25/2025 at 1:56 PM with APRN #1 identified that she was not aware or notified of Resident #1's change of condition on the 11 PM to 7 AM shift on 3/20/2025. Further, APRN #1 stated review of the on-call records failed to identify the on-call services was notified. APRN #1 stated a change in condition such as a low-grade temperature and adventitious lungs sounds (abnormal sounds) should be called to the on-call service provider instead of a fax note for review when the provider next visited the facility. APRN #1 stated if she was notified, she would probably have ordered labs and a chest x-ray. Interview, clinical record and facility documentation review on 3/25/2025 at 2:24 PM with the DNS identified when LPN #1 identified a change in condition and she notified RN #3, the provider (physician/APRN) should have been called to notify of the change in condition. Review of the facility Change in Condition Policy directed in part, when a resident has a change in condition the physician/NP (Nurse Practitioners) will be notified of the change.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure an RN assessment was completed timely when a resident had an identified change of condition. The findings include: Resident #1's diagnoses included dementia, aortic valve stenosis. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicative of moderate cognitive impairment and required partial/moderate assistance ADLs. The Resident Care Plan (RCP) dated 3/3/2025 identified the resident had an ADL self-performance deficit related to arthritic pain. Interventions directed assist of one with ADL. Physician order dated 2/4/2025 directed Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 108 (90) base two (2) puffs inhale orally every six (60 hours as needed for bronchodilator use as needed for shortness of breath or wheezing. Nursing note dated 3/20/2025 at 1:37 AM (written by LPN #1) identified Resident #1 had an audible wheeze, an as needed (prn) inhaler was administered with effect, temperature was 99.7, and lung sounds were bilateral faint crackles. Acetaminophen was administered, the head of the bed was raised, fluids were encouraged. Review of the 24-hour facility written supervisor's report identified on 3/20/2025 during the 11 PM to 7 AM shift, Resident #1 had increased congestion, temperature 99.7, and crackles in the bilateral bases. Record review failed to identify the RN supervisor was notified of the change in condition, and failed to identify an RN assessment was completed during the 11 PM to 7 AM shift on 3/20/2025. Nursing note dated 3/20/2025 at 10:23 PM identified earlier in the shift, staff had observed Resident #1 had toileted him/herself around 4:45 PM, and was noted to have some shortness of breath with exertion, and course lung sounds in the bilateral lower lobes. Further the note identified Resident #1 had a fall with transfer to the hospital at 7:05 PM for evaluation. Interview, clinical record and facility documentation review on 3/25/2025 at 12:09 PM with LPN #1 identified she notified the 11 PM to 7 AM supervisor (RN #3) regarding Resident #1's change in condition identified on 3/20/2025. LPN #1 further stated although she listened to Resident #1's lung sounds, an RN assessment was needed to be completed due to the change in condition. LPN #1 stated an RN assessment was not completed by the supervisor during her shift. Interview, clinical record and facility documentation review on 3/25/2025 at 1:22 PM with RN #3/supervisor identified although LPN #1 had notified her that Resident #1 had respiratory issues, crackles (lung sounds), afebrile (no temperature), and she was on the unit about 3 AM, RN #3 stated she did not complete an RN assessment and she did not go to see Resident #1. RN #3 stated she passed the information along in morning report at 7 AM to the on-coming supervisor. RN #3 stated she should have completed an assessment. RN #3 stated she trusted LPN #1's judgement and she was aware LPNs can not perform resident assessments. Interview failed to identify why RN #3 did not complete an assessment. Interview, clinical record and facility documentation review on 3/25/2025 at 2:24 PM with the DNS identified when LPN #1 identified a change in condition and she notified RN #3, RN #3 should have gone to see the resident and completed an assessment. Review of the facility Change in Condition Policy directed in part, when a resident has a change in condition, a RN will perform and document appropriate assessments.

Based on observation, facility policy review, and interviews, the facility failed to ensure foods were dated and labeled appropriately, expired foods discarded and the cleanliness of the resident's nutritional refrigerator maintained. The findings include: Observation on [DATE] at 9:45 with [NAME] #1 identified the following in the walk-in freezer: * fajita meat in a large zip lock plastic container dated good through [DATE] * beef roast in a large zip lock plastic container dated good through [DATE] * ham and pork in a large zip lock plastic container dated good through [DATE] * ground ham in a large zip lock plastic container dated good through [DATE] * corned beef wrap with a saran wrap dated good through [DATE] * beef gravy in a large zip lock plastic container dated good through [DATE] * mac and cheese in a large zip lock plastic container dated good through [DATE] Interview with [NAME] # 1 on [DATE] at 10:00 AM identified that the Food Service Director (FSD) was responsible of ensuring there were no outdated food stored in the freezer. She identified that the good through date would be last day that the food item can be used and it should be thrown out after it expiration. She further identified that the expired food items should not be left in the freezer. Subsequent to surveyor inquiry, expired food items were thrown away. Observation on [DATE] at 10:05 AM with the Food Service Director (FSD) identified the following in the walk-in refrigerator: * macaroni pasta in a metal container cover with plastic with no label * open beef base in a manufacturer plastic container dated good through [DATE] Interview with FSD on [DATE] at 10:15 AM identified that all dietary staff should throw away expired food in the freezer and/or refrigerator. She typically checked the freezer and refrigerator for any outdated food items once a week and throw away any expired food. She also noted that any food stored in freezer and/or refrigerator should be appropriately label and no expired food should be kept in the walk-in freezer and/or refrigerator. Observation on [DATE] at 10:40 AM with LPN #1 identified the following in the resident's nutritional refrigerator: * 1 opened 46 ounces box thickened cranberry cocktail from concentrate without label * 1 opened 46 ounces box thickened orange juice from concentrate without label * 1 opened 32 ounces box 100% HC Plus orange juice without label * 1 opened 32 ounces box 100% HC Plus prune juice without label Observation on [DATE] at 10:50 AM with LPN #1 identified the following in the resident's nutritional freezer: * 2 pints of opened Talenti ice cream and covered with freezer burn * 1 pint of price chopper chocolate ice cream and covered with freezer burn * 6 cups of 120 ml ice cream and covered with freezer burn. Further observation of the resident's nutritional refrigerator/freezer identified multiple areas of sticky brown stain material inside the refrigerator and in the freezer. Interview with LPN #1 on [DATE] at 11:00 AM identified that housekeeping and/or dietary was responsible for cleaning the resident's nutritional refrigerator. She also identified the opened juice and ice cream were for the residents use. She further identified that juice should be label once it was opened, but she could not identified how long it was good for once it was opened. Interview with the FSD on [DATE] at 11:20 AM identified that the housekeeping and/or dietary staff was responsible of cleaning the resident nutritional refrigerator. She could not identified when was the last time the refrigerator was last clean. She further identified any un-label food items would be thrown away. Review of the Food and Storage Supply Policy directed that all food, non-food items and supplies used in food preparation shall be stored in a manner that would prevent contamination to maintain safety and safe for human consumption. Food past the use by date should be discarded and open packages would be cover, label and dated.

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews for one of five sampled residents (Resident #3) unnecessary medications, the facility failed to ensure the care plan included interventions to address the possible side effects and the monitoring that should accompany the use of an anticoagulant and for one sampled resident (Resident #26) reviewed for skin condition, the facility failed to develop a comprehensive care plan to address the specific type of support surfaces device being utilized, how often the device should be worn, and the general care or monitoring of the device as it relates to the resident. The findings include: 1. Resident #3's diagnoses included pulmonary embolism (blood clot that prevents or stops blood flow to the lungs), hyperlipidemia, and dementia. The annual MDS assessment dated [DATE] identified Resident #3 had severe cognitive impairment, required total assistance with personal hygiene, transfers, toileting, was non-ambulatory, and utilized anticoagulant medication (blood thinner) that the assessment noted to be a high-risk medication. A physician's order dated 1/31/24 through 2/6/24 directed Lovenox/Enoxaparin Sodium injection (a blood thinner used to prevent blood clots) 80 milligrams (mg) to inject one syringe subcutaneously every 12 hours for bilateral pulmonary embolism (PE). A physician's order dated 2/6/24 through 6/18/24 directed Apixaban/Eliquis (a blood thinner used to prevent blood clots) 5 mg one tablet by mouth twice daily for bilateral pulmonary embolism (PE). Review of Resident #3's care plan dated 3/25/24 failed to identify a plan of care that included the use of anticoagulant medications with interventions that would had included administering the medication as ordered, monitor for: bleeding, unusual bruising, bloody or black tarry stools, bleeding precautions, and sudden change in mental status. According to Eliquis.com, the use of the medication poses a bleeding risk, in that it increases the risk of bleeding and can cause serious, potentially fatal bleeding. Interview and clinical record review with the ADNS, who is the MDS Coordinator on 6/17/24 at 1:43 PM identified Resident #3 care plan did not include a care plan that focused on anticoagulant therapy, but noted the resident should have had one. The ADNS added that she reviews the care plan when the MDS are due and should have identified at the time of the review that interventions addressing the side effects to monitor for a resident taking an anticoagulant medication could have been developed and implemented. The ADNS further identified that it was an oversight on her part as it was her responsibility as well as nursing to update and revise care plans as needed. Interview with the 7:00 to 3:00 PM Supervisor (RN #2) on 6/18/24 at 1:50 PM identified that a baseline care plan would be initiated when a resident was admitted or readmitted to the facility. RN # 2 added the admitting nursing supervisor would ensure care plans for pain, fall, skin conditions, elopement, and activities of daily living were initiated. RN #2 further added that a care plan should be initiated if the resident was currently taking an anticoagulant medication, and if the admitting nurse failed to add the care plan it is usually picked up by the MDS coordinator who reviews the final care plan. Subsequent to surveyor's inquiry a care plan for the use of anticoagulant dated 6/17/24 was developed and implemented with interventions that included administer anticoagulant as ordered, monitor for side effects and effectiveness, monitor for bleeding, and bleeding precautions. Review of the Baseline Care Plan policy identified that a baseline care plan should be developed within 48 hours of admission with the necessary information to properly care for the resident that includes but is not limited to falls, skin, psychotropic medication use, and anticoagulant use. Review of the Comprehensive Care Plan policy identified that the facility is to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychological needs within 7 days after the completion of the comprehensive MDS assessment. Additionally, the policy identified that the care planning/interdisciplinary team is responsible for periodic review and updating of the care plans. 2. Resident #26's diagnoses included dementia, muscle weakness, and dysphagia. The significant change MDS assessment dated [DATE] identified Resident #26 had severe cognitive impairment, and was dependent on staff for personal hygiene, dressing, transfers, mobility, and was non-ambulatory. Observation on 6/12/24 at 12:29 PM identified Resident #26 seated in wheelchair around a table in the dining room wearing a blue colored boots (heel floating boots/bunny boots) to bilateral lower extremities. Observation with the Charge Nurse (LPN #2) on 6/13/24 at 12:15 PM identified Resident #26 seated in wheelchair around a table in the dining room wearing a blue colored boots known as heel floating boots/bunny boots to bilateral lower extremities. Interview and review of the clinical records with LPN #2 on 6/13/24 identified that Resident #26 had a wound to the right medial aspect of the foot inner aspect of the foot and wore the blue boots to bilateral feet. LPN #2 failed to identify a care plan or a physician's order directing the use of the light blue boots or any documentation on the nurse aides care card of Resident #26 for the use of the blue boots. LPN #2 added that an order or the care plan, and the nurse aide care card for Resident #26 should have been completed to indicate when the resident to wear the boots, to check skin integrity and when to remove for care. Interview with the Wound Nurse (RN #4) on 6/13/24 at 2:00 PM identified that Resident #26 wore the blue boots as a pressure relieving device due to a new wound identified on 6/1/24 on the right inner side of the foot. RN #4 further identified Resident #26 did not have a care plan nor an order but identified that the resident should have had one. RN #4 added that she recently took over the position as the wound nurse, and it was the responsibility of the charge nurse or the wound nurse to ensure that an order and a care plan was in place. Interview with the ADNS, who is the MDS coordinator, on 6/13/24 at 2:22 PM identified that the Resident #26 did not need a physician's order as the blue boots are being used preventable measure which was seen as a nursing measure. However, she added that the use of the blue boots should have had been documented in the resident's care plan and nurse aides care card of Resident #26 to indicate how often the boots to be worn, when to be removed, and the checking of the resident's skin integrity. In addition, the ADNS failed to identify a care plan that was developed and implemented regarding the use of the blue boots or the nurse aide care card for Resident #26 identifying the use of the blue boot. The ADNS added that it was both the responsibility of nursing and the MDS coordinator to review and update the resident's care plan, but it was the nurse's responsibility to update the nurse aide care cards. Interview with the Medical Record staff (Medical Record #1) on 6/17/24 at 10:00 AM identified that she would review the nurse aide binder with the resident's care card twice weekly for changes and retype the document. The Medical Record #1 identified that the blue boots were recently added to the nurse aide care card for Resident #26. Interview with the Physical Therapist (PT #1) on 6/17/24 at 10:05 AM identified that the blue boots or bunny boots are pressure redistribution devices which are utilized to prevent pressure injury, and to redistribute pressure by preventing the resident from being resting on a surface over a period. PT #1 identified that the blue boots can be worn at all times if the resident has a wound, however they should be removed for care, to check skin integrity, and to reposition the resident with knees supported to prevent improper body alignment. Interview with the former wound nurse (LPN #2) on 6/17/24 at 12:45 PM identified she had received the order from the wound physician for offloading heel per facility protocol, wherein the blue boots were applied, as she had documented in her notes dated 6/5/24. LPN #2 further identified that the blue boots were offloading. LPN #2 identified it was an oversight on her part and that the order and care plan should have had been updated. Review of the Comprehensive Care Plan policy identified that the facility is to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's needs as identified in a comprehensive assessment with objectives that will be used to monitor the resident's progress, and alternative interventions will be documented as needed.

Based on clinical record review, review of facility policy and interviews for for one of two sampled residents, (Resident #66) reviewed for accidents, the facility failed to ensure Resident #66 had a comprehensive care plan for wandering/elopement after found to be an elopement risk. The findings included: Resident #66 was admitted to the facility on [DATE] with diagnoses that included Heart Failure, AFIB, cognitive communication deficit and GERD. The Admission MDS dated [DATE] identified the resident had intact cognition and had functional range of motion impairment on both upper extremities and no impairment of the lower extremities, but used a walker for ambulation. Review of the nursing progress notes dated 5/1/24 at 2:56 PM identified the resident was found getting off of the elevator on the first floor and told staff he/she was just looking around. Subsequent nursing notes dated 5/1/24 at 3:29 PM identified a wander guard was placed on the resident's left ankle. Review of the Elopement Risk assessment dated [DATE] identified the resident scored an 11 and was at risk of elopement and should have had interventions to minimize risk of elopement. Review of the Physician's Orders dated 5/3/2024 identified order to monitor wander guard every shift for elopement risk. Additionally, that order was discontinued and a new order to monitor the wander guard was placed 5/9/2024. The Comprehensive Care Plan dated 5/9/2024 failed to identify Resident #66 was an elopement risk or had a wander guard bracelet in place. Review of the Treatment Administration Record (TAR) for May 2024 identified a treatment to monitor for attempts to elope every shift for attempted elopement. The first recorded date for monitoring for elopement was charted on 5/3/24 on the night shift. The TAR identified the resident was being monitored from 5/3/24 through the dates of the survey 6/18/2024. Review of the TAR for June 2024 identified two additional treatments to check battery function on elopement bracelet every night shift, which is checked off from 6/5/24 through 6/17/24, and to check for wander guard placement (L ankle) before and after each LOA, which had not been checked off during the month of June. Review of the nurse progress notes dated 6/4/2024 at 11:46 PM identified the resident had been outside alone and was escorted back to the resident floor by a staff member. It was noted that the wander guard was not in place on the left ankle as it should have been. A new wander guard was placed on the left ankle at that time. Review of the Elopement Risk assessment dated [DATE] identified Resident #66 scored a 12. A score of 10 or higher is at risk and interventions to minimize risk of elopement should be implemented. Review of clinical chart nurse progress notes dated 6/7/2024 at 3:52 PM identified Resident #66 was not found on the unit, but outside with a friend. The nurses' note identified that both the resident and the friend were educated on the need to notify a staff member of where the resident goes for safety. The note identified the wander guard was in place on the resident's ankle but did not alarm when the resident left the unit. Observation of Resident #66 on 06/12/24 at 1:06 PM identified the resident did not have a wander guard in place. Resident #66 communicated feelings and identified preferences to daily care without issue and was able to identified the desire to return home. Interview with LPN #3 on 6/13/24 at 1:35 PM identified another staff member brought the resident up to the floor on 5/1/2024 after the resident was found on the 1st floor and that was when the wander guard was placed on the resident. LPN #3 identified the facility completed an elopement assessment and notified the supervisor of the change in score. LPN #3 identified that finding the resident on another floor would be considered elopement I don't fill out any paperwork. I just notify the supervisor. I did check the wander guard prior to her leaving, it was not there when she came back. Interview with the DNS on 6/13/24 at 2:19 PM identified if the resident was found off of the unit, that would be an attempt at elopement and an elopement assessment would be completed and, if appropriate, a wander guard bracelet would be placed. The elopement assessment scores, the cognitive assessment, and status of the resident, and the reason for leaving the unit are taken into account for placement of the bracelet. The orders for the wander guard to check the batteries on 11-7 for function and to check for placement every shift. The DNS identified this would be placed in the care plan. Review of the facility Elopement Policy identified Residents at risk for elopement, through risk score and/or behaviors, will have an Elopement Risk Care Plan implemented and have an elopement band placed on wrist. The policy identified the placement of the elopement bracelet will be monitored every shift and documented in the EMAR. Exit door and elevator monitors will be tested throughout the week by the maintenance department to ensure proper functioning. Review of the Baseline Care Plan Policy identified that in the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning not identified in the baseline care plan, those changes will be incorporated into the care plan within 48 hours of identification. Subsequent to surveyor inquiry, 6/13/2024, the elopement/wander guard was added to the resident care plan.

Based on observations, clinical record review, review of facility policy, review of facility documentation and interviews for one of two sampled residents (Resident #66) reviewed for accidents, the facility failed to provide adequate supervision to prevent an elopement. The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included heart failure, atrial fibrillation, and cognitive communication deficit. The Admission Elopement Risk assessment dated [DATE] identified Resident #66 was not at risk for wandering. The admission MDS assessment dated [DATE] identified Resident #66 had intact cognition, no exhibited behaviors, range of motion impairments to both upper extremities and no impairment of the lower extremities and utilized a walker for ambulation. The nursing note dated 5/1/24 at 2:56 PM identified Resident #66 was found getting off of the elevator on the first floor and told staff he/she was just looking around. The Elopement Risk assessment dated [DATE] identified Resident #66 was at risk of elopement and should have interventions to minimize the risk of elopement. A nursing note dated 5/1/24 at 3:29 PM identified a wanderguard was placed on Resident #66's left ankle The physician's orders dated 5/3/2024 directed to monitor the wanderguard alarm every shift due to elopement risk. Review of the Treatment Administration Record (TAR) from May 3, 2024 through June 18, 2024 identified an intervention to monitor for attempts to elope every shift. Review of the TAR for June 2024 directed to check the battery function of the wanderguard bracelet every night shift. The TAR identified that it was checked off from 6/5/24 through 6/17/24. The TAR also noted to check for wanderguard placement (L ankle) before and after each LOA. The documentation did not reflect that the placement of the wanderguard had been checked. The nurse's note dated 6/4/2024 at 11:46 PM identified the resident had been outside alone and was escorted back to the unit by a staff member, and the wanderguard was not in place to the left ankle. A new wanderguard was placed on the left ankle at that time. The nurse's note dated 6/7/24 at 3:52 PM identified Resident #66 was found outside with a friend and noted that the resident and the friend were educated on the need to notify a staff member of where the resident goes for safety. Further, the note identified the wanderguard was in place but had not alarmed when the resident left the unit. Review of clinical chart nurse progress notes dated 6/7/2024 at 3:52 PM identified Resident #66 was not found on the unit, but outside with a friend. The nurses' note identified that both the resident and the friend were educated on the need to notify a staff member of where the resident goes for safety. The note identified the wanderguard was in place on the resident's ankle but did not alarm when the resident left the unit. Observation on 6/12/24 at 1:06 PM identified Resident #66 did not have a wanderguard in place. Interview with LPN #3 on 6/13/24 at 1:35 PM identified another staff member brought the resident up to the floor on 5/1/2024 after the resident was found on the 1st floor and that was when the wanderguard was placed on the resident. LPN #3 identified the facility completed an elopement assessment and notified the supervisor of the change in score. Interview with the DNS on 6/13/24 at 2:19 PM identified that when a resident is found off of the unit it is considered an elopement attempt and an elopement assessment is completed and if appropriate, a wanderguard bracelet is placed. The elopement assessment score, the cognitive assessment, status of the resident, and the reason for leaving the unit are taken into account for placement of the wanderguard. She further identified that orders to check the batteries for function and placement on the 11-7 shift would also be put in place. In addition, the DNS identified a resident found outside of the building is considered an elopement. Further interview with the DNS identified she was unaware of Resident #66's elopement attempts and noted that, there were no reportable event reports completed and investigations conducted to ascertain how the resident got out of the building on two occurrences. A tour of the building with the DNS on 6/18/24 at 10:30 AM identified alarm sensors located at the exit doors on the units, at exits to the building, and in the elevators, and in order to for the elevators to move when a wanderguard alarm is present, a code that has to be entered into the keypad located in the elevator. At the doors on the units and to exit, when the wanderguard system alarms and the door is pushed open, there is an audible alarm, and the door remains secured for 15 seconds and then will open due to fire safety measures. There is an alarm code that can be entered that will silence the alarm and allow the door to open. The DNS noted that most family members have the codes. Additionally, there is not a way to print a record of activations. The DNS further identified the system is checked weekly for function. Review of the facility Elopement Policy identified Residents at risk for elopement, through risk score and/or behaviors, will have an Elopement Risk Care Plan implemented and have an elopement band placed on wrist. The policy identified the placement of the elopement bracelet will be monitored every shift and documented in the EMAR. Exit door and elevator monitors will be tested throughout the week by the maintenance department to ensure proper functioning. The facility failed to ascertain how the resident eloped from the facility.

Based on observations, review of the clinical record, review of facility policy and interviews for one sampled resident (Resident #369) reviewed for Respiratory Care, the facility failed to provide sanitary care of the nebulizer equipment related infection control. The findings include: Resident #369's diagnoses included chronic obstructive pulmonary disease, obstructive sleep apnea and anxiety. A transfer and discharge report dated 6/9/24 identified an order for Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) milligram per milliliter; 3 milliliters-to be inhaled orally every 6 hours as needed for wheezing, dated 5/20/24. The admission nursing assessment dated [DATE] identified Resident #369 was alert and oriented, required a Continuous Positive Airway Pressure (CPAP) machine, had shortness of breath when lying flat and was an assist of 2 for bed mobility. The care plan dated 6/10/24 identified Resident #369 had limited physical mobility, confusion, and weakness. Interventions included Physical and Occupational therapy referrals. A physician's order dated 6/10/24 directed to administer DuoNeb (Ipratropium-Albuterol) solution 0.5-2.5 (3) milligrams per milliliter, 3 milliliters-to be inhaled orally every 6 hours as needed for wheezing. Observation on 6/12/24 at 11:09 AM in Resident #369's room, identified the nebulizer machine along with the equipment, including the mouthpiece and medicine cup lying on the windowsill without a covering and without a date. The mouthpiece and medicine cup were lying against the window screen. Interview on 6/12/24 at 11:10 AM with Resident #369 indicated she had not recently used the nebulizer machine and could not identify the last time it had been used. Interview on 6/12/24 at 11:22 AM RN #2, floor nurse, indicated the nebulizer equipment is normally dated and kept in a plastic bag, and not lying on the windowsill unbagged. The nurse then indicated she/he would change the equipment immediately, date it and place it in a bag per policy. Subsequent to surveyor inquiry, the nebulizer equipment was changed, dated, and placed in a plastic bag. Interview on 6/17/24 at 9:48 AM with the DNS identified the facility uses a company to help maintain the CPAP equipment, facility staff are required to maintain and provide the cleaning and storage of all respiratory equipment. nebulizer and oxygen equipment should be dated and stored in an oxygen bag in between uses. If a new resident came to the facility, the nebulizer or oxygen equipment is changed over to facility equipment and subsequently dated and bagged to maintain infection control. A Physician's order is then entered for monitoring and care of any oxygen, nebulizer, and CPAP equipment. The nebulizer sets/tubing are changed every Thursday by nursing on the 11-7 shift, dated and placed in an oxygen bag. The Medication Administration Record (MAR) dated 6/1/24-6/30/24 identified DuoNeb (Ipratropium-Albuterol) solution 0.5-2.5 (3) milligrams per milliliter, 3 milliliters-inhale orally every 6 hours as needed for wheezing, was administered on 6/12/24 at 2:42 PM. The Treatment Administration Record (TAR) dated 6/1/24-6/30/24 failed to identify the nebulizer treatment checks or care of nebulizer equipment. Review of the Nebulizer Procedure Policy directed, in part, to rinse tubing with water and let air dry after each use. Wrap tubing in a paper towel and place in a bag. Tubing should be dated and documented on the treatment sheet. Nursing will replace tubing, mask/mouthpiece every Thursday night shift and as needed. Review of the Care of Oxygen/Respiratory Equipment policy directed, in part, that small volume nebulizer's (SNV) and tubing are rinsed after each use and discarded weekly. New SNV's are dated and initialed when put into use. Documentation of any changes or checks are done on the resident's treatment Kardex.

Based on review of clinical records, review of facility policy, review of facility documentation and interviews for one sampled resident (Resident #2) reviewed for hospice care, the facility failed to have complete hospice records that were readily available for review and for one of four sampled residents (Resident #55) reviewed for advanced directives, the facility failed to ensure that a signed copy of the advanced directives consent form was accessible in the resident's medical record. The findings include: 1. Resident #2's diagnoses included congestive heart failure, asthma, and difficulty swallowing. A physician's order dated [DATE] directed: evaluate Resident #2 for hospice services. The care plan dated [DATE] identified Resident #2 was receiving hospice services. Interventions included, provide care that maintained maximum comfort through the next review. The significant change Minimum Data Set assessment dated [DATE], identified Resident #2 was severely cognitively impaired, was dependent for transferring, toileting, bathing and was receiving hospice services. Review of Resident #2's clinical record on [DATE] at 2:30 PM identified the medical record failed to provide documented evidence of the following: Up to date every 2-week Interdisciplinary team notes, beginning after the resident was admitted to hospice, through [DATE], the Plan of Care and Certificate of Terminal Illness (CTI) dated [DATE]-[DATE] and the Medicare/Medicaid Hospice Benefit Election dated [DATE] and hospice medication list. Interview on [DATE] at 2:33 PM with LPN #1 and LPN #2 identified the only hospice documents in the resident's chart were the hospice agency's cover sheet and 4 hospice visit notes. No hospice admission note, admission consents/documents, Certificate of Terminal Illness (CTI), Interdisciplinary Team (IDT) notes, or plan of care were found in the resident's chart or uploaded to the Electronic Medical Record (EMR). No other binders or folders were kept or utilized for hospice documentation, according to LPN #1 and LPN #2. Interview on [DATE] at 9:58 AM with the DNS identified that Social Worker #1 helps with hospice admissions in the facility and the hospice paperwork. Interview on [DATE] at 10:04 AM with social worker (SW) #1, indicated after the physician's orders a hospice evaluation, the SW contacts the hospice agency selected by the resident or family. The hospice agency then updates the SW when an evaluation will occur and when the resident is admitted to a hospice level of care. The hospice agency is responsible for the paperwork. Subsequent to surveyor inquiry, the Hospice Benefit Election form and the facility Care Plan Conference sheet were provided to this Nurse Consultant. Interview on [DATE] at 11:48 AM with Hospice Manager RN #1 indicated, he/she would have to review the hospice admission process to ensure exactly which documents should have been included in the resident's medical record. He/she also indicated once a hospice referral is received from the facility, the hospice staff contacts the family. If the family or resident agreed to hospice services, then the hospice nurse would complete an evaluation and admit the resident to hospice care. The hospice Manager was not aware and was unable to explain why the hospice admission paperwork had not made it to Resident #2's chart. According to RN #1 hospice manager, there should have been a Hospice Medicare/Medicaid Benefit election form, a memo of understanding ([NAME]), between the hospice agency and facility, communication notes, and a cover sheet at least. The admitting hospice nurse brings a nursing home packet when admitting a resident. Which included all the hospice documents. All the hospice consent forms are configured electronically. RN #1 indicated a lack of awareness as to the requirement of the plan of care, Certificate of Terminal Illness (CTI) and the hospice Interdisciplinary (IDT) notes which should be part of the medical record. Subsequent to surveyor inquiry, RN #1 hospice manager, faxed over the Hospice Plan of Care dated [DATE]-[DATE]. RN #1 or the hospice medical record's personnel will fax over the hospice documents to the facility going forward, to ensure the resident's medical record is complete. Review of the Medical Records policy dated [DATE] directed, in part, that all active medical records are kept at the nurse's station, accessible only to authorized personnel. Although requested, a facility policy regarding Hospice documents was not provided. 2. Resident #55's diagnoses included dementia, type 2 diabetes mellitus, and anxiety disorders. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 cognition was severely impaired and required total assistance with personal hygiene, toileting, and was non-ambulatory. Review of the clinical record identified a physician's advance directive form consent dated [DATE] indicated Resident #55's code status of full interventions (full code), a full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR (cardiopulmonary resuscitation). The care plan dated [DATE] identified Resident #55 advanced directive of Do not Resuscitate (DNR) which means that a person has decided not to have CPR attempted on them if his/her heart or breathing stops and Do not Intubate (DNI), which means that a person has decided not to be connected to a ventilator if his/her lungs not working, with a goal to maintain resident wishes through the next review, with interventions that included to follow the facility advance directive protocol (to discuss with the resident or responsible party about advanced directives planning, obtain physician's order and place the order in the electronic medical record and copy in the chart). A physician's order dated [DATE] directed a do not resuscitate (DNR)/do not intubate (DNI)/ nurse may pronounce (NMP) code status for Resident #55. Interview and clinical record review with the Charge Nurse (LPN #2) on [DATE] at 12:30 PM identified in the advance directive tab of the paper chart a physician's advance directive form consent dated [DATE] that indicates full interventions and a black dot on the outside of the chart which indicated DNR. In addition, the electronic medical records indicated DNR/DNI/NMP. LPN #2 further identified that Resident #55 code status was changed on [DATE] to DNR/DNI/NMP. LPN #2 added that when a resident's code status is changed the new physician's advance directive form should be kept in the chart. Also, LPN #2 added that it was the responsibility of the staff who received the new order to ensure that the signed copy of the consent form is in the paper chart in the advance directive section. LPN #2 indicated that if the resident required life-saving measures, the physical chart at the nurse's station was one of the places she would look to confirm the resident's advanced directives as well as the physician's order. The nursing note dated [DATE] at 10:24 AM written by ADNS, who is also the MDS coordinator, identified that an interdisciplinary team meeting was held with the Resident #55's representative and family when they decided to changed Resident #55's code status to DNR/DNI/NMP. Interview with the ADNS on [DATE] at 2:09 PM identified that it was the practice of the facility to review resident's code status at care conference meeting when Resident #55's family made the change from full intervention to DNR/DNI/NMP. She identified that all the required steps were taken which included documentation, physician's order, and the consent form was in place in Resident #55's paper chart. The ADNS added that the overflow chart was checked, and she was unable to locate a copy of the physician advance directive form consent. She added that the Resident #55 was sent to the hospital in March of 2024 wherein the form might had been sent to the hospital in error as there were a signed transfer of Do Not Resuscitate order form that identified a DNR order was written for Resident #55 on [DATE]. The ADNS identified that moving forward the advance directive form consent would be scanned into the resident's electronic medical record. Interview with the Resident #55's representative (Person #2) on [DATE] at 11:00 AM identified that he/she had a discussion with the ADNS at a care conference meeting where the code status was change to DNR/DNI. Review of the Care Plan Conference sheet dated [DATE] at 10:00 AM identified that Resident #55's family was in attendance. The care plan conference sheet further identified that the Resident #55's code status was CPR and was reviewed and changed to DNR/DNI/NMP. Subsequent to surveyor inquiry, a physician's advance directive form consent dated [DATE] was completed with a consent obtained from the Resident #55's representative by two nurses, signed by provider, and placed into the paper chart in the advance directive section. Review of the Advanced Directives policy identified that copies of the advance directives should be placed in the resident's chart. The policy further identified that when changes are made to the advance directives it should be documented in the resident's medial record. Review of the Medial Records policy identified that all active medical records are kept at the nurse's station and accessible to only authorized staff. 48335

Based on clinical record review, review of facility documentation and interviews for 2 of 6 sampled residents reviewed for pressure ulcers ( R#10 and R#75) the facility failed to implement measure to prevent the development of an unstageable heel pressure ulcer and/or to reevaluate a pressure ulcer as per physician orders [REDACTED]. The findings include: 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] identified that the resident required an assist of 2 with ADL's, was alert and oriented to person, and had no pressure ulcers. Review of the Braden scale dated 10/03/15 identified the resident a high risk for skin breakdown. Review of nurse's note dated 10/08/15 at 12:24 PM identifies ICN noted a 4 cm x 3.8 cm intact fluid filled blister to right heel. Review of the pressure ulcer care plan dated 10/08/15 identified a pressure ulcer on the left heel. Interventions included assess/record/monitor wound healing as per facility protocol. Report improvements and decline to the MD. Low air alternating pressure mattress on bed. Review of wound documentation dated 10/08/15 identified an unstageable fluid filled blister to the left heel with a length of 4.0 cm and a width of 3.8 cm. Wound documentation on 10/14/15 identified an unstageable fluid filled blister to the left heel measuring a length of 4.0 cm and a width of 3.8 cm. Interview with RN#1 on 10/20/15 at 11:00 AM and review of the physician order [REDACTED]. Physician order [REDACTED]. Physician order [REDACTED]. RN#1 identified that although these pressure relieving measures were implemented, they were not initiated until after the unstageable area to the left heel was identified. RN#1 indicated that interventions should have been implemented on admission to prevent skin breakdown. Interview with the DNS on 10/22/15 at 10:25 AM identified that he/she would expect that on admission residents that are a high risk for skin breakdown; a low air loss mattress, heel floats, and skin prep is applied bilaterally. 2. Resident # 75's [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE] identified that the resident as moderately cognitively impaired, requiring total assistance and 2 plus persons physical assist with bed mobility and transfers, frequently incontinent of urine and always incontinent of stool, and at risk for pressure ulcers. Review of the Braden scale dated 7/18/15 identified that the resident a moderate risk for skin breakdown. A RCP dated 7/23/15 identified that the resident at risk for pressure ulcers with interventions that included turning and repositioning every 2 hours and pressure redistribution for the bed and chair. Review of a Non - Pressure Skin Condition Report dated 8/31/15 identified that the resident had moisture related skin breakdown on the left buttock measuring 0.6 cm by 0.6 cm with a depth of < 0.1. On 9/10/15 the Non - Pressure Skin Condition Report identified the area as 1.0 cm by 1.0 cm with a depth of < 0.1 with a notation that the area had grown slightly larger. On 9/17/15 the area measured 1.0 cm by 0.5 cm with a notation that the area was slow to heal. On 9/22/15 the area measured 0.5 cm by 0.3 cm by 0.1 cm depth. On 9/30/15 the area was reclassified as a pressure ulcer with measurements of 1.0 cm by 0.8 cm with a depth of 0.2 cm. On 10/07/15 the area measured 0.8 cm by 0.2 cm with a depth of 0.2 cm, on 10/14/15 the wound measured 0.4 cm by 0.4 cm with a depth of 0.2 cm. Interview with RN #1 on 10/21/15 at 1:20 PM identified that he/she had changed the documention from non-pressure to a pressure ulcer because the area was slow to heal and he/she though it may be a pressure ulcer rather than incontinence associated [MEDICAL CONDITION]. a) Interview with the DNS on 10/21/15 at 11:00 AM and review of physician's orders [REDACTED]./08/15. Review of the treatment kardex with RN # 1 identified that although the treatment was completed as ordered from 9/02/15 through 9/08/15 there was no re-evaluation of the treatment as directed by the physician and/or any new treatment ordered for the wound until 9/22/15, when a physicians order was obtained to treat the wound with triad cream to the left buttock and reevaluate in 14 days. Interview with the DNS on 10/22/15 at 12:00 PM identified that he/she was unable to find documentation that the wound had been reevaluated and/or treatment applied from 9/08/15 until 9/22/15. The DNS indicated that the order for reevaluation of the treatment dated 9/02/15 may have been overlooked because on 9/09/15 the facility transitioned from paper kardex to electronic treatment and medication records. b.) Interview with the dietician on 10/20/15 at 12:30 PM and review of the clinical record and the dietician communication book located on the nursing unit identified that he/she had not been notified of R#75's facility acquired pressure ulcer on 9/30/15. The dietician identified that he/she is usually notified when pressure ulcers are identified when nursing staff document the information in the dietician's communication book. The dietician further identified that if he/she had been notified of the resident's pressure ulcer he/she would have recommended a protein supplement and educated the resident and his/her family about ways to increase protein in his/her diet. Subsequent to surveyor inquiry on 10/20/15 a dietary progress note was written with recommendations for 2 ounces a day of liquid protein for improved skin integrity and education was provided to the resident and his/her family member about focusing on protein choices on meal trays. c.) Interview with the DNS on 10/21/15 at 9:45 AM and review and of physicians orders dated 10/09/15 (late entry for 9/30/15) directed to cleanse the left buttock with soap and water, dry, apply skin prep to peri wound then apply triad wound dressing the cover with opsite and change Monday and Thursday for 14 days, then re-evaluate. Review of the October treatment kardex identified that the entry was written on 10/09/15 on the treatment kardex to cleanse the inner left buttocks with soap and water, dry, skin prep to peri wound, apply triad wound dressing and cover with op-site every Monday and Thursday until 10/16/15. The DNS indicated he/she was unsure why there was a late entry written for 9/30/15, and could not find any documentation in the clinical record that the wound had been reevaluated on 10/16/15 or that the wound had been treated from 10/16/15 through 10/23/15 (14 days as per physician orders). Subsequent to surveyor inquiry the physician was notified and a new treatment order was written on 10/21/15 directing to apply triad wound dressing to left inner buttock lower area for 7 days. Observation of the wound on 10/21/15 with RN # 2 at 11:30 AM identified a measurement of 0.8 cm by 0.3 cm with a depth of 0.2 cm, an increase in size since the last measurement taken on 10/14/15 of 0.4 cm by 0.4 cm with a depth of 0.2 cm. Subsequent observation of the wound on the left buttock with RN# 2 identified a new pressure area to the left buttock measuring 2.0 cm by 0.5 cm with 0.1 depth. The DNS further identified that the wound may not have been reevaluated because when RN # 1 entered it into the computer she failed to press the supplemental documentation tab which would have alerted the nurse that the treatment needed to be reevaluated.

Based on clinical record reviews, review of facility documentation and/or investigations, observations, and interviews for 4 of 5 residents with injuries of unknown origin (R#2, R#6, R#34, R#39), the facility failed to assess the origin of the injuries and/or initiate plans to prevent further injuries, and/or for 2 of 2 residents with abusive behaviors (R #55 and R# 74), the facility failed to provide appropriate supervision to prevent repeated physical confrontations, and/or for the only 2 sampled residents with wandering behavior (R#2, 79), the facility failed to provide appropriate supervision and assessment to prevent elopement and/or potentially hazardous situations. The findings include: 1. Resident #2's [DIAGNOSES REDACTED]. The care plan dated 4/28/11 identified a potential for injury related to balance problems, history of falls, the use of psych medications and a visual impairment. Interventions included every half hour checks for safety, encourage resident to call for assistance, and to monitor gait. a. Facility documentation dated 6/22/2011 at 3:50 PM identified Resident #2 had an open area over the right elbow and scrapes over the right upper scapula area the documentation identified the resident was found outside the facility in the parking lot, lying on his/her right side. Facility documentation dated 8/16/11 at 9:00 AM identified an the resident was noted with a bruised area of the right eye. Nurse's notes dated 8/16/11 identified the origin of the right eye bruise was unknown. Interview, and review of the clinical record and facility investigation on 10/20/11 at 11:00 AM with the DNS identified an incomplete investigation into the origin of the bruise of the right eye. Further review noted a lack of an assessment and/or interventions in the care plan to prevent further injuries. b. Review of facility documentation dated 7/15/11 identified R#2 was noted to have small skin tears to the right 3rd and 5th fingers. Nurse's notes dated 7/15/11 at 12:45 PM noted two small 0.5 cm areas to the lateral middle finger and 5th right knuckle. Interview, review of clinical record, and facility investigation on 10/20/11 at 11:00 AM with the DNS failed to provide documentation that a complete investigation was initiated/completed to determine the origin of the resident's injuries and/or that interventions were initiated to prevent further injuries. 2. Resident #6's [DIAGNOSES REDACTED]. The care plans dated 12/9/2010, 3/9/2011, and 6/9/2011 identified an increased risk for altered skin integrity. Interventions included derma savers to arms and legs at all times, weekly skin assessments, and assist of two for all repositioning. a. Facility documentation dated 1/25/2011 identified R#6 sustained a left lower leg skin tear. Nurse's notes dated 1/25/11 at 2:40 PM noted the resident sustained [REDACTED]. The facility investigation lacked an assessment of the resident's environment, investigation of staff handling of the resident, and/or complete interviews with staff to attempt to determine the origin of the injury. b. Facility documentation dated 3/26/11 identified R#6 sustained a skin tear to the left scapula. The investigation identified that the injury occurred a transfer with a mechanical lift. c. Facility documentation dated 4/30/11 identified R#6 sustained a 7 cm skin tear to the right calf which occurred while a NA repositioned the resident. The documentation further identified that only one NA provided care. Nurse's notes dated 4/30/11 at 2:00 AM noted a 7 cm skin tear requiring 5 Seri-strips. d. Facility documentation dated 6/3/11 identified R#6 sustained a 6 cm by 5 cm skin tear to the left shin. Nurse's notes dated 6/3/11 at 2:30 PM identified a 5 cm by 6 cm curved skin tear to the left shin was noted during care. The investigation concluded that the injury "most likely" occurred during a transfer and/or care. The investigation failed to identify if the resident had derma savers on at the time the injury was noted. e. Facility documentation dated 7/11/11 identified that R#6 sustained a 2 cm round skin tear to the right upper thigh. An incomplete investigation that lacked interviews and review of the handling of the resident during care concluded that the injury most likely occurred during care. Interview, review of the clinical record and facility investigations on 10/24/11 at 10:45 AM with the DNS failed to provide documentation that complete investigations were conducted into the origins of the resident's repeated injuries and/or noted that assessments of resident handling during care and/or transfer and/or interviews with staff had been conducted. The care plan lacked interventions to prevent further injuries. 3. Resident #34's [DIAGNOSES REDACTED]. The care plan dated 3/15/11 identified an increased risk for altered skin integrity as evidenced by poor skin turgor and poor safety awareness. Interventions included weekly skin assessments, apply lotion and derma savers to arms and legs at all times. a. Facility documentation dated 5/2/11 identified that R#34 sustained a 2 cm skin tear to the left wrist and a 2 cm bruise to the left outer buttocks. The investigation identified that the areas "most likely" occurred as a result of self infliction and/or during care. The investigation was reviewed and noted only names of staff with the word "unaware" after their name. No other investigation or assessment of the origin of the injuries were documented. b. Facility documentation dated 5/9/11 identified that R#34 sustained a 6 cm by 1 cm skin tear to the left forearm. The skin tear occurred while two NA's were providing incontinent care. No investigation was conducted. c. Facility documentation dated 5/17/11 at 6:00 AM identified that R#34 sustained a 5 cm by 1 cm to the left arm near the elbow while being pulled up in bed. Nurse's notes dated 5/17/11 at 6:00 AM noted the resident sustained [REDACTED]. No investigation was conducted. d. Facility documentation dated 5/22/11 at 11:50 AM identified R#34 sustained a 3 cm skin tear to the left posterior calf. Nurse's notes dated 5/22/11 at 12:20 PM noted a 3 cm long skin tear to the left calf. Steri strips and derma savers were applied. The investigation lacked an assessment of the environment, presence of protective devices, and the interviews consisted of a list of staff names with "unaware" listed next to them. e. Facility documentation dated 5/30/11 identified R#34 sustained a quarter size skin tear to the left shin and a dime sized skin tear to the right posterior leg. The documentation further identified that the areas possibly occurred during care. Nurse's notes dated 5/22/11 at 1:30 PM identified skin tears to the left shin and right posterior calf. Review of the facility investigation noted the only statement was from the nurse aide that found the skin tears with dried blood on them. Other staff names were listed with "unaware" listed next to their names. No environmental assessment was documented. f. Facility documentation dated 6/2/11 noted that when the NA removed Resident #34's derma savers, a 3.5 by 2.5 cm skin tear was found on the left forearm. The documentation further identified that the area may have occurred while removing the derma savers. The investigation lacked an environmental assessment and only staff names with "unaware" were documented as an investigation. g. Facility documentation dated 6/3/11 noted R#34 sustained an 8 cm by 1 cm skin tear to the right upper forearm that required 5 steri strips to close. Facility investigation noted that area most likely occurred when applying and/ or removing derma savers. The investigation lacked an environmental assessment and only staff names with "unaware" were documented as an investigation. h. Facility documentation dated 6/8/11 noted R#34 had a 7 cm by 3 cm skin tear to the right leg. The documentation noted that when the NA's went to lift the resident's leg to place linen between them, the NA's fingers tore the resident's skin. No investigation into how the incident occurred was documented. i. Facility documentation dated 6/13/11 noted R # 34 sustained a 3 cm skin tear to the right elbow during care. No investigation into how the incident occurred was documented. j. Facility documentation dated 6/15/11 noted R#34 sustained two 1 cm skin tears to the right lateral thigh while being repositioned in bed. No investigation into how the incident occurred was documented. Interview, review of the clinical record, and facility documentation on 10/24/11 at 10:45 AM with the DNS failed to provide documentation that environmental assessments were conducted, and/or that caregivers were interviewed to determine the care provided to the resident, and/or that the manner in which care was provided was assessed/reviewed to determine the origin of the multiple injuries and/or prevent further injuries and/or that the care plan was updated to reflect new interventions to prevent further injuries. 4. Resident #39's [DIAGNOSES REDACTED]. An annual assessment dated [DATE] identified the resident was moderately cognitively impaired, displayed no problem behaviors, and required staff assistance for transfer and ambulation. The care plan dated 9/8/11 identified the risk for altered skin integrity. Interventions noted that the resident refused derma savers to the arms; no other preventive measures were noted in the care plan. Nurse's notes dated 6/11/11, 8/5/11 and 8/9/11 noted that R#39 had experienced skin tears. Weekly Skin Assessments dated 7/23/11, and 7/30/11 noted multiple bruises on both upper extremities. On 8/6/11, the resident had a bruise and skin tear to the left forearm. On 8/13/11, the resident had healing skin tears to both forearms and bruised areas on the left forearm. On 10/15/11, fading bruises were noted on both forearms. Observation on 10/21/11 at 10:25 AM noted that the resident utilized a wheelchair, and had reddened/bruises to the right outer elbow and left forearm. Further observation indicated that the resident's wheelchair was in disrepair. The wheelchair was noted to have jagged, roughened edges at the area of the bruises on the right outer elbow. Further observation and interview on 10/21/11 at 10:28 AM with RN #1 noted that the bruises were not new and she was unable to provide documentation that the origins of the bruises were investigated or that the bruises were reported via reportable event documentation. The care plan lacked interventions to prevent further injuries to the resident. 5. Resident # 55's [DIAGNOSES REDACTED]. The RCP dated 11/11/10 identified an alteration in mood related to episodes of anger/touching and striking others. Interventions included to encourage recreation programs, redirect, approach calmly, and psychological evaluation as ordered. Resident #74's [DIAGNOSES REDACTED]. The RCP dated 1/6/11 identified an alteration in mood related to episodes of anger and verbal/physical behavior. Interventions included to encourage recreational activities, redirect, approach calmly, and behavior tracking. Review of R#55 and R#74's behavior monitoring identified repeated incidents of wandering and/or striking out at others. Review of facility documentation identified the following: a. On 1/24/11 Resident #74 punched Resident #55 in the abdomen. b. On 4/2/11, R#74 struck with an open hand, R#55's left eye and face. The eye and face were pink and ice was applied. c. On 5/12/11, R#55 pushed R#74 from behind and R#74 turned around and hit R#55 in the abdomen. d. On 5/30/11, R#74 grabbed and squeezed R#55's left hand and bent it backwards. Interview, review of the clinical records of R#55 and R#74, and review of facility documentation on 10/24/11 at 12:15 PM with the DNS failed to provide documentation that interventions were initiated to prevent the resident to resident assaultive behaviors and/or that appropriate supervision was provided to prevent incidents. 6. Resident # 79's [DIAGNOSES REDACTED]. The MDS dated [DATE] identified the resident was severely cognitively impaired, and displayed daily wandering behavior. The Resident Elopement Assessment Form dated 4/7/11 identified the resident was a high risk for elopement. The resident care plan dated 4/7/112 identified increased risk for elopement related to several attempts to leave the building unattended, wanders without purpose and disoriented to place and time. Interventions included wandergaurd bracelet, check functioning daily, and monitor every half hour. Review of the nurse's notes for 5/2011 identified multiple attempts to elope and /or wandering. A nurse's note dated 5/31/11 at 9:00 PM identified that Resident # 79 was pacing up and down the hall, looking for a way out of the facility. Behavior continued despite medication given. At 8:50 PM Resident #79 was found by staff attempting to leave the facility through a window. Nurse's notes identified that at the time staff intervened, the resident's upper body was observed out of the window. Interview, review of the clinical record and facility documentation on 10/24/11 at 10:00 AM with the DNS identified that no new interventions were implemented to address exit seeking behavior and/or prevent elopement from the facility during the Month of May 2011. Further review of the clinical record failed to provide documentation that the resident's behaviors were being addressed by the physician and/or psychological services. (last Psych consult was 10/2010).