Every finding on record at Polaris Healthcare and Rehabilitation Center

An unannounced Follow-up Survey was conducted on March 26, 2026, for the Annual and Complaint Survey ending February 11, 2026, by the State of Delaware Division of Health Care Quality, Office of Long-Term Care Residents Protection. The facility census on the first day of the survey was ninety-two (92). The sample size was twenty (20) residents. The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of March 17, 2026.An informal dispute resolution (IDR) was conducted for this citation. It was determined that the citation was past non-compliance and corrected by the facility 8/24/25. No additional correction on part of the facility was necessary as a result of the survey.Based on record review, interview, and policy review, the facility failed to ensure resident safety for one of two residents (Resident (R) 108) reviewed for elopement and one of six residents (R83) reviewed for accidents. As a result, R108, who had been assessed as an elopement and fall risk with cognitive impairment and an unsteady gait, exited the facility without staff knowledge. R108 remained outside the facility for approximately one hour before being located by staff in the back employee parking lot. This had the potential to result in serious injury or death.On 02/10/26 at 7:09 PM, the Administrator was notified that Immediate Jeopardy (IJ), which also constituted Substandard Quality of Care (SQC), was identified at F689 at a Scope and Severity (S/S) of J related to the facility's failure to ensure a resident's safety after R108 eloped. The IJ began on 08/24/25 when R8, who had been assessed as an elopement and fall risk with cognitive impairment and an unsteady gait, exited the facility without staff knowledge. On 02/11/26 the facility provided a Removal Plan that was accepted at 3:34 PM. The survey team validated the implementation of the removal plan through observations, staff interviews, and record reviews on 02/11/26 at 6:57 PM, and the scope and severity was lowered to D, isolated, potential for more than minimal harmFindings include:1. Review of R108's Face Sheet, located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included history of falling, muscle weakness, and abnormalities of gait and mobility. Review of R108's Elopement Evaluation, dated 08/21/25 and located in the EMR under the Assessments tab, revealed a score of three indicating the resident was at risk of elopement. Review of R108's Care Plan, dated 08/21/25 and located in the EMR under the Care Plan tab, revealed that it did not include his elopement risk or any interventions.Review of a Nurses Note, dated 08/24/25 at 11:50 AM and located in the EMR under the Progress Notes tab, revealed, Pt [patient] was wandering around unit this morning. After multiple redirections, he was placed in front of the fish tanks. Pt was content. CNA [Certified Nurse Aide] stated she saw him recently prior to incident and he was still sitting on the couch. Pt was found in back employee parking lot tending to the flowers. Patient unharmed and checked out ok. Wander guard to be placed asap [as soon as possible].Review of R108's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/28/25, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severe cognitive impairment. During an interview on 02/09/26 at 1:27 PM, Licensed Practical Nurse (LPN) 1 reported she was the nurse on duty on 08/24/25 that was assigned to the unit R108 was on. LPN1 said on the morning of 08/24/25, R108 kept coming out of his room and walking around the unit. She was concerned about him falling, since he was unsteady on his feet. She made numerous attempts to redirect him back to his room unsuccessfully, but he did sit down in the visiting area by the fish tanks. She told the CNA staff to pass by that area every time they went anywhere on the unit to check on him. She was charting at the nurse's station that was out of view of the resident. A little while later one of the CNA staff asked her, Where did [R108] go? She, along with the two CNA staff and LPN2, immediately started to look for him. They alerted staff on the other unit and security. One of the CNA staff observed R108 through the window from room [ROOM NUMBER] and saw him outside by the street sign. She went out and immediately assessed him and brought him back into the facility. She was unsure of how long R108 was outside but thought it may have been about 20 minutes. She stated staff did hear a faint alarm sound that morning, but then it stopped so they were unaware that the emergency door had been opened. During an interview on 02/09/26 at 2:27 PM, LPN2 stated that on 08/24/25 she was not assigned to R108 but was made aware by staff that he could not be located, and she assisted in looking for him. When she went outside, she observed him and LPN1 together, and a CNA came with a wheelchair. He was in the back of the building in an employee parking lot on the sidewalk and messing with the flowers in the flower bed. He had a tote bag with him. She said the time of 11:48 AM that she wrote down on her statement for the facility's investigation was the time she found him. During an observation and interview on 02/10/26 at 10:30 AM, the Maintenance Director (MD) stated he was told R108 got out of the emergency/egress door located on the 2nd floor unit. He said the door alarm would sound when the emergency bar was pushed, and it would release the door lock after fifteen seconds, but the alarm would stop sounding once the door was pushed open. He stated he installed fire alarms on the door after the incident that required a key to stop the alarm and were louder. He stated they checked the door locks daily, but they never checked the alarm function prior to this incident or since. The MD demonstrated holding down on the bar on the emergency/egress door and the door unlocked. He also opened the door that showed the two flights of steps going down that led to the door that R108 exited through. During review of the facility's video surveillance on 02/10/26 at 11:30 AM, R108 was observed on the video standing in front of the fish tank and there were no staff visible in the camera view. At 10:48 AM on 08/24/25, R108 walked away from his walker, carrying a tote bag, and went straight to the emergency door and pressed down on the emergency bar. After about 15 seconds, the door opened, and R108 walked through the door. Staff were still not observed in the camera view. During an interview on 02/10/26 at 2:05 PM, the Administrator stated surveyors were not allowed to see the facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes, agenda, or any current Performance Improvement Projects (PIPs) the facility was working on. She reported what PIPs were in place and what was being followed in QAPI, and elopement was not being monitored. During an interview on 02/11/26 at 3:42 PM, The Administrator said the nurse who completed R108's admission elopement assessment should have put an immediate intervention in place, and the Interdisciplinary Team (IDT) would have met the following day to see what else, if anything, needed to be put in place. There also should have been a review of his admission records. The unit manager or shift supervisor should have checked to ensure that based on the findings of the elopement assessment that everything was put in place. That process did not happen in this situation. She said when R108 was wandering around the unit and could not be redirected, staff should have tried other things to keep him safe. The staff did not make good use of their resources. They could have gotten other disciplines involved to see what could have been done to supervise him, but they failed in this situation. She said the time of 11:05 AM on 08/24/25 listed in the facility's investigation reflected the moment on the video when staff were seen walking around and appeared to realize the resident was unaccounted for. The time of 11:16 AM that was indicated as the time R108 was found in the facility's investigation was when staff found him. She said she probably wrote that down somewhere, but she did not have anything that documented that time, and she did not preserve the video of the time R108 was returned to the facility. She said she did not think about it because she was more concerned with how he got out. She also stated she was unaware that the alarm system and the wander guard system were not being tested, but she would have expected that to have been completed.Review of the facility's policy titled Wandering and Elopements, revised April 2024, revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk on admission for wandering/elopement, or other safety issues, a wandering/elopementassessment is completed as well as an obtained wandering/elopement history if able. A wanderguard is placed on resident. A care plan is initiated that will include the wanderguard and strategies and interventions to maintain the resident's safety.2. Review of R83's Face Sheet, located in resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included difficulty in walking and muscle weakness.Review of R83's Care Plan, dated 11/17/22 and located in the residents' EMR under the Care Plan tab, revealed The resident has potential for falls related to decreased weakness. Interventions in place were Hoyer lift [non-weight bearing mechanical lift] for transfers. Further review revealed two staff were to be present to provide care at all times. Review of R83's quarterly MDS with an ARD of 06/06/25, located in the EMR under the MDS tab, revealed a BIMS score of 14 out of 15, which indicated no cognitive impairment. Review of a Nurses Note, dated 08/12/26 at 4:05 PM and located under Progress Notes tab, revealed, Patient was received in bed awake. Patient complained of foot pain. Patient was given Tylenol with positive results. Physician made aware and ordered to be sent out for X-ray.Review of Facility 5-day Follow Up, dated 08/21/25 at 5:50 PM and provided by the facility, revealed the allegation of improper transfer was confirmed. They found that staff transferred the resident using a stand-pivot but not a Hoyer lift. X-rays were completed with no findings of injury. During an interview on 02/08/2026 at 1:38 PM, R83 stated on 08/11/25 a new CNA (CNA3) came into her room to provide care. After CNA3 bathed and dressed her, CNA3 told her she was going to get her up out of the bed and place her in the chair. CNA3 placed the wheelchair next to the bed. CNA3 wrapped her arms around R83's waist, lifted her up out of the bed, and R83 stood on her feet. R83 said she yelled, It's painful then CNA3 placed her in the chair. R83 told the nurse what happened.During an interview on 02/10/26 at 12:45 PM, CNA3 said she was unfamiliar with R83 when she provided care to her on 08/11/25. She also stated she was unaware that she could go into the computer and access the resident's plan of care. She went into R83's room by herself, spoke with the resident, cleaned her, provided care, and got her dressed. CNA3 told R83 that she was going to put her in the chair. CNA3 placed the wheelchair next to the bed, had R83 on the side of the bed, put her arms around R83, and had R83 place her arms around her. CNA3 placed her in the wheelchair next to the bed. She said after R83 was in the wheelchair, R83 pointed to the corner of the room at the blue sling that was placed in the chair under some items and told CNA3 that she was supposed to use that to put R83 in the chair. She was unaware that R83 required a Hoyer left for transfers and that two staff were always required to provide care to R83. During an interview on 02/11/26 at 3:42 PM, the Administrator said that during the facility's investigation, they did find that R83 was transferred inappropriately. The CNA transferred R83 by herself without the use of a Hoyer lift. She stated that places both the resident and staff at risk of being hurt.

Based on interviews, record review, and facility policy review, the facility failed to provide evidence that residents or their representatives were informed of the risks, potential side effects, and available treatment options for two of five residents (Resident (R) 12, and R66) reviewed for unnecessary medications who received antipsychotic and/or psychotropic medications This deficient practice resulted in residents receiving medications that may not have been clinically necessary.Findings include:1. Review of R12's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed an admission date of 11/03/25 with diagnoses of major depressive disorder, other recurrent depressive disorders, and dementia.Review of R12's Physician Orders, located in the EMR under the Orders tab, revealed orders dated 11/03/25 for Rexulti (an antipsychotic medication) 0.5 milligrams (mg) at bedtime for agitation associated with dementia and Cymbalta (an antidepressant medication) 60mg one time a day for depression. Also ordered on 11/03/25 was Side Effect Assessment: Does resident have any noted side effects from Depression medication? Y or N. Then indicate Type by letter: [A=voluntary movements, B=tremors, C=dry mouth, D=urinary retention, E=seizures, F=blurred vision, G=rashes, H=sedation, I=dystonia or rigidity, or J=other side effects, please note in progress note] IF YES CALL PHYSICIAN. every shift.Review of R12's admission Minimum Data Set (MDS) assessment, located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/10/25, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS also indicated antipsychotic and antidepressant medications were received during the assessment period.During an interview on 02/10/26 at 4:57 PM, The Director of Nursing (DON) was asked about consents or any evidence that the resident received education of the risks, benefits, or other options available for treatment with antipsychotic and psychotropic medications. The DON replied that the resident came into the facility already on those medications and confirmed there was no evidence that education was provided to the resident.2. Review of R66's admission Record, located under the Profile tab in the EMR, revealed an admission date of 03/06/25 with diagnoses of major depressive disorder, dementia, and metabolic encephalopathy.Review of R12's Physician Orders, located in the EMR under the Orders tab, revealed an order dated 03/06/25, Side Effect Assessment: Does resident have any noted side effects from Depression medication? Y or N. Then indicate Type by letter: [A=voluntary movements, B=tremors, C=dry mouth, D=urinary retention, E=seizures, F=blurred vision, G=rashes, H=sedation, I=dystonia or rigidity, or J=other side effects, please note in progress note] IF YES CALL PHYSICIAN. every shift. On 07/10/25, sertraline (an antidepressant medication) 50mg by mouth one time a day for depression and anxiety was ordered. On 11/19/25, buspirone (an anti-anxiety medication) 5mg one tablet by mouth two times a day for anxiety was ordered.Review of R66's quarterly MDS assessment, located in the EMR under the MDS tab with an ARD of 12/12/25, revealed a BIMS score of nine out of 15, which indicated moderate cognitive impairment. The MDS also indicated antidepressants and anxiety agents were received during the assessment period.During an interview on 02/10/26 at 4:57 PM, the DON was asked about consents or any evidence that the resident received education of the risks, benefits, or other options available for treatment with psychotropic medications. The DON replied there was no evidence that education was provided to the resident.During an interview on 02/11/26 at 9:46 AM, the Administrator was asked what the expectation was about evidence of education provided for antipsychotic and psychotropic medications. The Administrator stated there should be consents signed to confirm education. Review of the facility's policy titled Antipsychotic Medication Use, with a revision date of 07/2022, revealed, 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will . b. re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks [at the initial MDS assessment] to consider whether or not the medication can be reduced, tapered, or discontinued . Review of the facility's policy titled Psychotropic Medication Use, with a revised date of 02/2025, revealed, Policy Statement: Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical Record . informed Consent or Refusal: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal:a. non-pharmacological alternatives; b. the indications and rationale for the recommendation;c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); andd. the resident's/representative's right to accept or decline the treatment .

Based on record review, interviews, and policy review, the facility failed to provide the required Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) notifications to three of three residents (Residents (R) 109, R81 and R110) reviewed for beneficiary notification. This failure had the potential to affect all residents who continued residing in the facility after the end of their Medicare Part A services by limiting their ability to make informed decisions regarding their financial responsibility. Findings include:1. Review of R109's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including muscle weakness and difficulty in walking, and that she remained in the facility after her Medicare Part A covered services ended on 11/04/25.Review of R109's SNF (Skilled Nursing Facility) Beneficiary Notification Review form revealed Medicare Part A skilled services start date was 10/09/25 and the last day covered was 11/04/25. Further review revealed no SNF ABN notification was provided prior to the last date of services.2. Review of R81's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including muscle wasting, difficulty in walking, and lack of coordination and that she remained in the facility after her Medicare Part A covered services ended on 08/02/25. Review of R81's SNF Beneficiary Notification Review form revealed Medicare Part A skilled services start date was 06/28/25 and the last day covered was 08/02/25. Further review revealed no SNF ABN notification was provided prior to the last date of services.3. Review of R110's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including muscle wasting and lack of coordination and that she remained in the facility after her Medicare Part A covered services ended on 09/22/25. Review of R110's SNF Beneficiary Notification Review form revealed Medicare Part A skilled services start date was 08/08/25 and the last day covered was 09/22/25. Further review revealed no ABN notification was provided prior to the last date of services.During an interview on 02/11/26 at 6:09 PM, the Social Worker (SW) said she was unaware that she was supposed to issue the SNF ABN form when a resident's Medicare Part A benefits were ended and they remained in the facility. During an interview on 02/11/26 at 6:57 PM, the Administrator stated she was unaware that SNF ABN notices were not being provided. She said she expected that the policy would be followed and that beneficiaries would be notified timely. Review of the facility's policy titled Beneficiary Notice - NOMNC [Notice of Medicare Non-Coverage] and SNF ABN - Policy and Procedure, dated 2025, revealed, . to ensure that the Facility fulfils its responsibility to inform its residents about potential Medicaid and Medicare noncoverage and the option to continue services with the resident accepting financial liability for those services. Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage [SNF ABN] The Facility will only issue the SNF ABN, CMS-10055 if the resident intends to continue services and the Facility believes the services may not be covered under Medicare. The Facility will inform the resident about potential non-coverage and the option to continue services with the resident accepting financial liability for those services. The SNF ABN provides information to residents so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the Facility provides the resident with the SNF ABN, the Facility has met its obligation to inform the resident of his or her potential financial liability and related standard claim appeal rights.

Based on record review, interviews, facility document review, and policy review, the facility failed to follow its abuse policy and did not conduct a thorough investigation into allegations of abuse involving two of five residents (Resident (R) 59 and R72) reviewed for abuse out of 32 sampled residents. This failure had the potential to result in unrecognized or ongoing abuse that puts other residents in the facility at risk.Findings include:1. Review of R59's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE] with diagnoses of cerebrovascular accident (stroke), seizure disorder, and depression.Review of R59's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/25, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R59 was cognitively intact. 2. Review of R72's Face Sheet, located in the EMR under the Profile tab, revealed the resident was admitted on [DATE] with diagnoses of diabetes mellitus, anxiety disorder, and depression.Review of R72's quarterly MDS with an ARD of 11/27/25, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15 which indicated R72 was cognitively intact. Review of Facility Reported Incident (FRI), signed and dated 08/27/25 by the previous Director of Nursing (PDON) and provided by the facility, revealed the facility received allegations of verbal abuse by a housekeeper from R59 and R70. An investigation was initiated promptly in accordance with facility policy. Interviews were conducted with the involved housekeeper, one staff present on the unit, and the two alert and oriented residents who made the report. There were no indications of any other interviews conducted. During an interview on 02/11/26 at 1:40 PM, the Assistant Director of Nursing (ADON) stated that during an investigation the facility should interview the resident making the complaint, staff working with the resident at the time, and other residents from the floor where the allegation was made. The ADON verified, after reviewing the FRI, that only R59 and R70 were interviewed and stated the PDON should have completed additional resident interviews for a complete and thorough investigation. During an interview on 02/11/26 at 1:50PM, the DON stated that for a thorough investigation, similar residents should be interviewed. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with a revision date of 04/21, revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental,sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms . The individual conducting the investigation will, as a minimum: Interview the person(s) reporting the incident . Interview staff members [on all shifts] who have had contact with the resident during the period of the alleged incident . interview other residents to whom the accused employee provides care or services.

Based on record review, interviews, and facility policy review, the facility failed to ensure a person-centered comprehensive care plan was developed for three residents (Resident (R) 6, R52, and R108) out of a total of 32 sampled residents. This deficient practice placed the residents at risk for unmet care needs, ongoing assessment, and provider notification.Findings include: 1. Review of R6's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R6 was admitted to the facility on [DATE], with the most current re-entry on 12/22/25, with diagnoses that included essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and transient cerebral ischemic attack (stroke symptoms that resolve). Review of R6's Order Summary Report, located under the Order tab of the EMR, reflected an order dated 01/19/26 to Check [NAME] monitor placement each shift every shift for Cardiac monitoring for 30 days. There were no other orders related to the [NAME] monitor. Review of R6's current Care Plan, located in the EMR under the Care Plan tab did not address the [NAME] monitor or any specific, measurable, achievable, relevant, and time-bound goals and interventions to ensure effective, patient-centered, and actionable healthcare outcomes for R6's cardiac monitoring. During an interview on 02/11/26 at 2:16 PM, the Registered Nurse Unit Manager (RNUM) 1 said that any care, treatment, and services provided to a resident should be reflected in the care plan to ensure continuity of care. The interventions would ensure nursing staff assessed the resident's skin for potential reaction to the electrode contact adhesive and that the cardiac [NAME] monitor was in place and did not get wet. RNUM1 said that any nurse could update the care plan to address specific care needs and appropriate interventions. During an interview and record review on 02/11/26 at 3:42 PM, the Minimum Data Set (MDS) Coordinator (MDSC) said that she initiated the comprehensive care plan based on a Care Area Assessment (CAA) that was triggered. The MDSC reviewed the comprehensive care plan and confirmed that the care plan did not reflect objectives and interventions for monitoring the cardiac [NAME] monitor to address the risk of actual wounds. The MDSC said that the care plan should reflect resident goals, desired outcomes, care/services provided, and specific services to be provided as reflected in the comprehensive assessment. The MDSC said that she was responsible for the admission, quarterly, annual, and change in condition MDS completion. The MDSC said that the Unit Managers reviewed the care plans for changes and updates. 2. Review of R52's admission Record, located under the Profile tab of the EMR, revealed R52 was admitted to the facility on [DATE], with the most current re-entry on 01/27/26, with diagnoses that included cellulitis (a common infection of the skin and the soft tissues underneath), unspecified dementia, carcinoma in situ (cancer that remains in the original cells where it started, without spreading to nearby tissues) of skin of scalp and neck and actinic keratosis (precancerous skin lesions that form on sun-exposed areas of the body). Review of R52's Order Summary Report, located under the Order tab of the EMR, reflected an order dated 02/04/26 for Contact Isolation: MRSA ([Methicillin-resistant Staphylococcus aureus] type of bacteria that is resistant to several antibiotics) Skin, nares every shift for MRSA. Review of an order written by R52's dermatologist, dated 02/04/26, located under the Misc tab of the EMR revealed, Patient is MRSA positive, needs respiratory and contact isolation. Review of R52's Care Plan, located in the EMR under the Care Plan tab, initiated on 02/09/26, revealed it did not reflect interventions specific and relevant to respiratory isolation precautions to ensure appropriate personal protective equipment was worn to prevent airborne and droplet transmission of MRSA. During an interview on 02/11/26 at 2:16 PM, RNUM1 said that she did not normally work on the unit where R52 currently resides and was notified that R52 was only on contact precautions for MRSA. RNUM1 said the risk of not wearing a mask and eye protection when entering an isolation room for respiratory precaution would be becoming infected with the pathogens transmitted by the resident when talking, coughing, or sneezing. RNUM1 said that any care, treatment, and services provided to a resident on a transmission-based precaution should be reflected in the care plan to ensure safety of the residents and staff. RNUM1 said that any nurse could update the care plan to address specific care needs and appropriate interventions. During an interview and record review on 02/11/26 at 3:42 PM, the MDSC said that she initiated the comprehensive care plan based on a CAA that was triggered. The MDSC reviewed the comprehensive care plan and confirmed that the care plan did not reflect objectives and interventions for respiratory isolation. The MDSC said that the care plan should reflect resident goals, desired outcomes, care/services provided, and specific services to be provided as reflected in the comprehensive assessment. The MDSC said that she was responsible for the admission, quarterly, annual, and change in condition MDS completion. The MDSC said that the Unit Managers reviewed the care plans for changes and updates. 3. Review of R108's admission Record, located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included history of falling, muscle weakness, and abnormalities of gait and mobility. Review of R108's Elopement Evaluation, dated 08/21/25 and located in the EMR under the Assessments tab, revealed a score of three, indicating the resident was at risk of elopement. Review of R108's Care Plan, dated 08/21/25 and located in EMR under the Care Plan tab, revealed that it did not include his elopement risk or any interventions.Review of R108's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/28/25, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated severe cognitive impairment. During an interview on 02/11/26 at 3:42 PM, The Administrator said the nurse who completed R108's admission elopement should have implemented a care plan and put in an immediate intervention, and the Interdisciplinary Team (IDT) should have met the following day to see what else if anything needed to be put in place. Review of the facility's policy titled Wandering and Elopements, revised April 2024, revealed, If identified as at risk on admission for wandering/elopement, or other safety issues, a wandering/elopement assessment is completed . A wanderguard is placed on resident. A care plan is initiated that will include the wanderguard and strategies and interventions to maintain the resident's safety.Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed, 2. The comprehensive, person-centered care plan is developed within seven [7] days after the completion of the comprehensive MDS assessment [Admission, Annual, or Significant Change in Status]. All CAAs triggered by the MDS will be considered in developing the plan of care . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to follow professional standards or its own established tracheostomy care procedures for cleaning the stoma site, replacing the inner cannula, and ensuring two staff members were present during care for one of six residents (Resident (R) 93) reviewed for respiratory care out of a total of 32 sampled residents. This deficient practice placed the residents at risk for respiratory distress or infection.Findings include:Review of R93's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R93 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (not enough oxygen in blood), tracheostomy status, and hemorrhage from tracheostomy stoma (bleeding from a tracheostomy site).Review of R93's Order Summary Report, located under the Order tab of the EMR, reflected an order dated 09/23/25 to Change inner cannula . Tracheostomy Care - trach ties - change every Monday and Thursday one time a day every Mon, Thu . Tracheostomy Care - pulse ox [pulse oximetry- a measure of the oxygen saturation in the blood] every shift and prn [as needed] every shift . Tracheostomy Care - trach care/Shiley disposable inner cannula 5IC70every shift . Tracheostomy Care - trach care every shift . Change Inner Cannula every 24 hours trach care.Review of R93's Treatment Administration Record (TAR), located under the Order tab of the EMR, on 02/09/26 at 2:10 PM, revealed Licensed Practical Nurse (LPN) 1 initialed the TAR for tracheostomy care - pulse ox every shift, tracheostomy care - trach care/Shiley disposable inner cannula 5IC70every shift, and Tracheostomy Care - tach care every shift on 02/09/26 for the 7a-3p shift.During an interview and record review on Monday, 02/09/26, at 2:10 PM, LPN1 said that she had not performed tracheostomy (trach) care yet. LPN1 said that she was responsible for trach care every Monday and Thursday only. LPN1 could not verbalize the procedure for trach care. LPN1 said that the respiratory therapist (RT) performed trach care that included changing ties and she (LPN1) was only responsible for cleaning the inner cannula. LPN1 reviewed R93's TAR and said that she probably clicked on the orders by accident and pointed out that the order for Tracheostomy Care - trach ties - change every Monday and Thursday one time a day was to be performed on Mondays and Thursdays. LPN1 was informed that it was currently Monday. LPN1 said that she did not realize that it was Monday and agreed to be observed performing trach care.During an observation and interview on 02/09/26 at 2:33 PM, LPN1 obtained a package containing a Shiley 5IC70 disposable inner cannula and a package containing split gauze. LPN1 opened the gauze package and placed it as well as the inner cannula package, on R93's blanket, which covered the resident, without setting up a sterile field. LPN1 did not ensure the procedure area was clean and did not use an antiseptic (liquid that kills germs) solution to clean R93's skin at the stoma site when she removed the old inner cannula and placed the new inner cannula. LPN1 replaced the trach ties with new ties and a foam collar. LPN1 performed the trach care alone and without securing the trach site to prevent dislodgment. LPN1 said that trach care meant to suction if needed, replace the gauze and change ties . only clean around the trach site with saline if drainage was noted.During an interview on 02/11/26 at 5:28 PM, the Director of Nursing (DON) said that the nurses were checked off on skills during on-the-job training (OJT). The DON went on to say that the nurses were responsible for performing the care correctly and it was not her responsibility to oversee the nurses' practice, that she delegated the responsibility to the Staff Development Coordinator (SDC), the Infection Preventionist, and the unit managers to monitor that the nurses performed tasks accurately. The DON said that the nurse could perform trach care without a second person if the nurse performing the task was competent.Review of LPN1's personnel file provided by the Administrator revealed a Classroom Orientation Checklist, Day 3, dated 04/22/25, covered the topic of Trach Care and Emergency Dislodgement during orientation. A Competency Assessment Tracheostomy Care, dated 12/09/25, signed by LPN1 and the SDC, that reflected LPN1 demonstrated competency. Procedure guidelines outlined Assess resident for respiratory distress . Set up supplies on sterile field . Site and Stoma Care: Clean the stoma with two peroxide-soaked gauze pads [using a single sweep for each side] . Rinse the stoma with saline-soaked gauze pads [using a single sweep for each side] . Wipe with dry gauze [using a single sweep for each side].Review of the facility policy titled, Tracheostomy Care, revised November 2023, revealed Site and Stoma Care: 1. Apply clean gloves. 2. Clean the stoma with two peroxide-soaked gauze pads [using a single sweep for each side] 3. Rinse the stoma with saline-soaked gauze pads [using a single sweep for each side] 4. Wipe with dry gauze [using a single sweep for each side] 5. Disinfect the stoma with the antiseptic-soaked gauze pads [using a single sweep for each side]. Allow to air dry or wipe with clean, dry gauze. 6. With two staff members present, remove neck ties and replace with clean ones 7. Apply a fenestrated [split] gauze pad around the insertion site .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure use of personal protective equipment (PPE) in the implementation of respiratory isolation for one of one resident (Resident (R) 52) reviewed for transmission-based precautions out of a total sample of 32 residents. This failure had the potential to lead to the transmission of droplet pathogens from resident to staff not wearing a mask or eye protection.Findings include:Review of R52's admission Record, located under the Profile tab of the EMR, revealed R52 was admitted to the facility on [DATE], with the most current re-entry on 01/27/26, with diagnoses that included cellulitis (a common infection of the skin and the soft tissues underneath), unspecified dementia, carcinoma in situ (cancer that remains in the original cells where it started, without spreading to nearby tissues) of skin of scalp and neck and actinic keratosis (precancerous skin lesions that form on sun-exposed areas of the body).Review of R52's Order Summary Report, located under the Order tab of the EMR, reflected an order dated 02/04/26 for Contact Isolation: MRSA ([Methicillin-resistant Staphylococcus aureus] type of bacteria that is resistant to several antibiotics) Skin, nares every shift for MRSA.Review of an order written by R52's dermatologist, dated 02/04/26, located under the Misc tab of the EMR revealed, Patient is MRSA positive, needs respiratory and contact isolation.Review of R52's Care Plan, located in the EMR under the Care Plan tab, initiated on 02/09/26, did not reflect interventions specific and relevant to respiratory isolation precautions to ensure appropriate personal protective equipment was worn to prevent airborne and droplet transmission of MRSA.During an observation on 02/08/26 at 10:52 AM, an isolation sign was not posted outside of R52's room to inform of transmission-based precautions or of what PPE should be worn. At 2:48 PM, a contact precautions sign was posted outside of R52's room listing the required PPE (gown and gloves) staff should be put on before entering the room.During an interview on 02/11/26 at 9:45 AM, Certified Nurse Aide (CNA) 15 said that she wore a gown and gloves before entering R52's room because there was a contact precautions sign posted outside his room. CNA14 said that she did not know that she should wear a mask or that R52 should be on respiratory isolation.During an interview on 02/11/26 at 10:38 AM, Licensed Practical Nurse (LPN) 2 said that she was an agency nurse and reviewed orders and care plans to orient herself to residents. LPN2 was unaware of respiratory precautions as written on 02/04/26. LPN2 said that she received shift change report from the off-going nurse that R52 was on contact precautions for MRSA related to wounds on his legs. LPN2 said that she verified that by reviewing the orders and care plan that indicated contact precautions.During an interview on 02/11/26 at 12:35 PM, the Infection Preventionist (IP) stated that she was responsible for overseeing the tasks performed by Registered Nurse (RN) 2, the IP in training. The IP said that she was aware that R52 was on contact precautions for MRSA but did not conduct record review as part of oversight of RN2. The IP said that signs for respiratory and contact isolation should be posted as ordered for MRSA. The IP said that it was the responsibility of the nurses to communicate in change of shift report that R52 was on respiratory and contact isolation for MRSA.During a phone interview on 02/11/26 at 1:36 PM, the Doctor of Osteopathic Medicine ([DO] dermatologist) stated that the wound culture she performed on R52 legs resulted with MRSA. The DO said that she wrote the order to place R52 on respiratory and contact isolation for MRSA. The DO said that it was her medical professional opinion that R52 be placed on respiratory isolation in addition to contact isolation because MRSA could be dormant in the nares and spread by respiratory droplets. Review of the facility's policy titled, Isolation - Categories of Transmission-based Precautions, revised September 2022, indicated Policy Statement Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; . or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents . 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC [Centers for Disease Control and Prevention] precaution[s], instructions for use of PPE, and/or instructions to see a nurse before entering the room . 1. Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets [large-particle droplets larger than 5 microns in size that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning] . 3. Masks are worn when entering the room. 4. Gloves, gown and goggles are worn if there is risk of spraying respiratory secretions.

Based on observation, interviews, record review and other facility documentation, the facility failed to provide sufficient nursing staff to meet the needs of residents for 7 of 20 residents reviewed for staffing. The facility did not ensure adequate availability of staff to respond to resident care needs in a timely manner. Findings Include:As of December 2024, the facility assessment documented the following: 5 residents were independent with ADL's; 35 to 40 residents required assistance from 1-2 staff members; 50 to 55 residents were dependent on staff for ADL support.Despite this, residents experienced prolonged call bell response times and unmet care needs. At the time, the census on the Riverwalk unit was 58.1. Interview with a resident who wished to remain anonymous:8/6/25 2:51 PM - F1 reported multiple instances of delays when resident A1 called for assistance with toileting. On 7/16/25 7:30 PM A1 rang bell and contacted F1 about no one answering or providing assistances. F1 contacted E18 who contacted a supervisor to find assistance for A1. R3 contacted F1 at 8:30 PM to let her know someone had come to assist her to the bathroom. On 8/1/25 6:45 PM - A1 rang the call bell at 6:45 PM. At 7:55 PM, A1 contacted F1 who contacted the E18 (Former DON) due to lack of response. A1 reported finally being assisted and returned to bed by 8:45 PM.8/11/25 in the morning an interview with E6 (Supervisor) it was confirmed that he did receive calls about A1 waiting for assistance and would need to find someone to assist with toileting.2. Interview with a resident who wished to remain anonymous:8/7/25 10:00 AM to 10:40 AM - An observations of A2's call bell ringing continuously for 40 minutes before staff responded. During this time, A2 reported to the surveyor of needing assistance with changing and noted such delays were common, stating that sometimes staff just shut the light off and do not return promptly.3. R6's review revealed:7/19/25 11:30 PM - A concern form documented that R6 was not placed in bed until 11:30 PM, indicating a significant delay in bedtime assistance.8/6/25 7:00 PM to 8:00 PM - During an observation while on the Riverwalk unit there were two staff bathing a person, two staff in a room providing care and one staff person picking up trays and answering call bells. During this time an interview was conducted with R6, and it was explained that assistance was required by staff to help R6 to bed. R6 further revealed that there are times that we do wait more than 30 minutes or longer for call bell to be answered or to be put to bed.4. R11's review revealed:8/11/25 8:53 AM - During an interview R11and F2, long wait times for assistance were reported when for call bell response. F2 stated F11 was often found lying in urine and feces, prompting F2 to clean and change A2 personally due to lack of staff response.5. R13's review revealed:8/7/25 2:23 PM - During an interview with R13 it was revealed that call bell responses often take longer than 20 minutes to get assistance.6. R19's review revealed:7/21/25 3:48 PM - A concern form noted that on Sunday morning, 7/20/25, R19 waited approximately 1.5 hours for call bell response. R19 disclosed needing to use the bathroom and had to wait for F3 to assist, indicating staff were unavailable when needed.7. R20's review revealed:8/11/25 9:48 AM - 10:13 AM - R20's call bell rang continuously for 25 minutes before a staff person responded.8/11/25 3:05 PM - Findings were reviewed during the exit meeting with E1, E2 (Regional), and E3 (Regional nurse).

Based on observation, interview and record review, it was determined that for one (R6) out of three sampled residents for dental services, the facility failed to ensure the resident received dental services. Findings include:A review of R6's clinical record revealed:9/27/23 - R6 was admitted to the facility.7/25/24 - A dental progress note documented that R6 wanted her teeth extracted and to receive dentures. The note documented that the treatment plan for R6 was to have new upper and lower dentures along with the extraction of the bottom teeth.12/17/24 - A dental progress note documented that R6 stated that she wanted her lower teeth extracted and full dentures made.3/31/25 - A dental exam note documented that R6 requested to have extractions.4/10/25 - A dental exam note documented that R6 was seen to be reviewed for teeth extractions.8/7/25 9:15 AM - During an interview, R6 stated that she has four teeth remaining on the bottom and has been asking to have them pulled for over a year. R6 stated that she wanted to have dentures. An observation was completed and it was noted that R6 has four remaining teeth on the bottom front. During this observation, R6 demonstrated how one of the four teeth can be moved all the way forward because it is loose.8/8/25 8:45 AM - During an interview, E4 (unit secretary) stated that the dental team can perform teeth extractions in the facility. E4 stated that they understand that R6 wants to have her teeth extracted and the dental team is coming to the facility on 8/29/25. E4 stated that she is unaware if R6 is scheduled to have them extracted.8/8/25 9:05 AM - During an interview, PC1 (dental company scheduler) stated that R6 is not scheduled to have extractions at that time. The appointment on 8/29/25 is for the new dentist to conduct their initial exam with R6.8/11/25 1:30 PM - During an interview, E1 (NHA) confirmed the delay in R6's teeth extraction and starting her denture process.8/11/25 3:05 PM - Findings were reviewed during the exit meeting with E1, E2 (Regional), and E3 (Regional nurse).

Based on record review and interview, it was determined that for two (R299 and R46) out of five residents reviewed for unnecessary medication, the facility failed to ensure residents were free from a significant medication error when staff failed to administer insulin. Additionally, staff failed to conduct finger stick blood sugar monitoring, which included sliding scale insulin coverage based on the results. The facility's failure placed the residents at risk for a serious adverse outcome including diabetic ketoacidosis, diabetic coma or even death from untreated elevated blood sugar. Due to this failure an Immediate Jeopardy (IJ) was called on 1/23/25 at 11:52 AM. The IJ was abated on 1/23/25 at 11:00 PM. Findings include: 1. Review of R299's clinical record revealed: 10/4/24 5:00 PM - R299 was admitted with diagnoses including but not limited to diabetes mellitus. 10/4/24 - A discharge summary from hospital documented R299 had a diagnosis of diabetes mellitus, orders for insulin, and orders to monitor blood sugar. 10/4/24 - R299's medication administration record (MAR) lacked evidence of a blood glucose reading at dinner time and bed time. The MAR also lacked evidence of coinciding sliding scale insulin administration based on blood glucose reading. 10/5/24 12:04 AM - A telephone physician's order for Lispro (insulin) was entered into the electronic medical record. The order read as follows: Insulin Lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/mL: Inject as per sliding scale: 0-150 = 0 units; 151-200 = 2 units; 201-250 - 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; greater than 400 give 10 units and call MD; give subcutaneously before meals and at bed time. 10/5/24 - An admission MDS documented R299 was diabetic and was receiving insulin. 10/5/24 8:00 AM - R299's MAR documented a blood glucose of 432 mg/dL (normal blood glucose is 80 mg/dL to 120 mg/dL) and fifteen units of Lispro was administered. 10/5/24 11:30 AM - A progress note documented Patient's (R299) family observed giving patient medications from home. Supervisor educated family that medications from home could not be given because there is no way to tell what exactly was given. Family stated patient needed pain medication. Supervisor explained to family the procedure with pain medications and informed them they were being delivered today. [Provider Group] NP and DON made aware. 10/5/24 untimed - A pharmacy manifest documented R299's medications were delivered to the facility. The manifest lacked evidence that R299's Lispro was delivered or ordered. 10/5/24 5:00 PM - A progress note documented that R299 was discharged . 1/16/25 2:20 PM - A copy of the emergency facility medication stock revealed that insulin was not available for emergency use. 1/17/25 8:30 AM - An interview with E2 (DON) confirmed that Lispro is not available in the facility emergency medication stock. 1/22/25 10:55 AM - An interview with FM1 revealed that at 9:00 PM on 10/4/24 R299 had not received bed time medications and FM1 notified the staff. FM1 stated that staff told her that medications needed to be ordered and were not available at this time. 1/22/25 11:03 AM - An interview with FM2 revealed that FM2 requested to speak to a supervisor after dinner on 10/4/24 to address multiple concerns. FM2 stated that the supervisor confirmed that R299's medications would not be delivered until 10/5/24 in the morning. 1/22/25 11:35 AM - An interview with E3 (ADON) stated the expectation for medication reconciliation and submission of orders is within an hour of admission. The primary nurse is expected to call the on call provider to review medication orders and input into the electronic medical system. E3 confirmed that R299 did not receive a blood glucose check on 10/4/24 at 5:00 PM or 9:00 PM and coinciding sliding scale insulin. 1/23/25 2:13 PM - An interview with E16 (LPN) revealed that E16 was unable to recall details of R299's admission. 1/23/25 3:34 PM - An interview with E17 (RN, UM) revealed that E17 was unaware of the expectation of reconciling medications within an hour of admission and unable to recall details of R299's admission. 32810 2. Review of R46's clinical record revealed: 11/17/22 - R46 was originally admitted to the facility with several diagnoses including diabetes. 11/15/24 - A physicians order was written for R46 to receive Insulin Glargine inject 20 units at bedtime for diabetes. 11/22/24 - An annual MDS assessment documented that R46 was cognitively intact and received insulin injections. 12/23/24 9:09 PM - An orders administration note in R46's clinical record documented that the ordered Insulin Glargine was not given due to awaiting for delivery. 12/24/24 8:42 PM - An orders administration note in R46's clinical record documented, that the ordered Insulin Glargine was not given due to being on order. 12/28/24 8:48 PM - An orders administration note in R46's clinical record written by E9 (LPN) documented, this med was reordered on 12/22, and this nurse call[ed] the pharmacy [to] ask for [Insulin Glargine] pen to be delivered the next day because the resident was out of this meds. The pharmacist hang up in my face sic Supervisor and the DON is aware of the situation. Still no delivery. December 2024 - Review of R46's MAR lacked evidence that R46 received the ordered dose of 20 units Insulin Glargine at bedtime on 12/23, 12/24, 12/28, and 12/29. It is unclear how R46 received the insulin on 12/25, 12/26, and 12/27 when the refill had not been delivered and there were no insulins in the back up medication/Pixus. 1/16/25 10:23 AM - During an interview E7 (LPN) explained that all medications are Reordered in the software if low and that we have insulin in the reserve/emergency box. 1/16/25 10:37 AM - During an interview E2 (DON) stated that refills Can take 24 to 48 hours but that the pharmacy delivers at least twice a day to the facility. E4 (CCS) then stated We did identify some issues and have been working with them to improve. E2 then stated We started working to improve at least a few weeks ago. 1/17/25 8:30 AM - E2 (DON) provided a pharmacy order summary that indicated a request for a refill of R46's Insulin Glargine medication was sent on 12/22/24. 1/17/25 10:20 AM - During an interview with E9 (LPN) the re-ordering process was clarified and E9 stated that to refill medications staff Clicks on re-order meds to go straight to the pharmacy and maybe call to make sure you have it for the next day. If they have in the Pixus you can go to the supervisor for the Pixus. Insulin is not usually in the back up so most of the time we reorder that. The first time I ordered and called they said it was too early and we need a supervisor. I did go to the [DON] and he said he would take care of it. When I came back the med was not there and I called again and the pharmacy hung up on me. 1/17/25 10:41 AM - E2 (DON) provided the surveyor an inventory list of emergency medications held in the facility and confirmed Insulin Glargine was not on the list. 1/17/25 12:05 PM - During an interview E11 (NP) confirmed knowledge of R46's missed doses of the Insulin Glargine. E11 stated, They called me and I told them to monitor. E11 then showed the surveyor a composition note book with a dated hand written note regarding R46's missed doses of insulin. 1/23/25 8:42 AM - E2 provided the surveyor with an undated pharmacy memorandum regarding refilling of medications. E2 stated it was part of an education to staff provided a month ago and it's improved things. The memorandum read the following Attention Nursing Personnel then listed pharmacy contact information as well as a table of timeframe's to order medications and expected delivery time. The memorandum also indicated that STAT orders must be called into the pharmacy to notify the pharmacy that it's a STAT order. 1/23/25 1:53 PM - During an interview E13 (agency LPN) was unable recall R46 being out of the ordered insulin Glargine, E13 (LPN) stated, They are often out of medications at that facility and some people use other residents insulin's but I don't. 1/23/25 1:56 PM - During an interview E14 (agency LPN) was unable to recall R46 being out of the ordered insulin Glargine. E14 stated, If the resident is out then we have to give it depending whatever the insulin is. They keep a lot of insulin in the refrigerator and sometimes if its not then I guess we call the pharmacy and the doctor but I haven't run into that situation. The four missed doses of the ordered Insulin Glargine for R46 placed the resident at risk for having a serious adverse outcome including diabetic ketoacidosis, diabetic coma or even death. 1/23/25 11:52 AM - Based on interviews and review of the facility documentation and other sources, an Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA) and E4 (Corporate Clinical Support). 1/23/25 11:00 PM - The facility's Immediate Jeopardy was abated at this time. The acceptable abatement plan included implementation of new policies titled Verifying Diabetic Medications for New Admit Residents and Diabetic Medication administration for current residents. The proposed plan included education to one hundred percent of working staff and ongoing for the remaining staff currently unavailable and not working, and new hires. Staff confirmed no new admissions were scheduled for the rest of the day. Staff interviews confirmed completion of staff training. Staff confirmed that all current residents had insulin available on hand and current medication orders. E4 stated the facility is in the process of updating identified delivery issues with current pharmacy provider and will add insulin as an emergency medication to the supply. 1/28/25 11:30 AM - The facility's abatement was reviewed with E1 (NHA) and E4 (Corporate Clinical Support). It was determined through observation, interview and record review that the facility met all requirements for abatement on 1/23/25 at 11:00 PM.

Based on record review and interview, it was determined that for one (R85) out of three residents reviewed for pain, the facility failed to provide pain management according to professional standards of practice. R85 was not provided pain medication, causing unrelieved pain for approximately sixty four hours resulting in harm. Findings include: Cross refer F657. April 2002 - The pain management standards by the American Geriatrics Society included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management. November 2009 - The American Academy of Pain Medicine, Pharmacological Management of Persistent Pain in Older persons, stated to refer to the previous American Geriatrics Society for specific recommendations for pain assessment in older persons that remain relevant. Review of R85's clinical record revealed: 12/12/24 - R85 was admitted to the facility with diagnoses including but not limited to low back pain, fibromyalgia, muscle weakness, and unspecified abnormalities of gait. 12/12/24 11:09 PM - An admission assessment documented R85 had no complaints of pain, lacked an acceptable level of pain, and lacked treatment for pain. 12/15/24 - A care plan was initiated for R85 that documented potential for alteration in comfort related to pain. The care plan documented the goal as pain medication will be effective in controlling discomfort by next review. The following interventions were included: assess for verbal and non-verbal signs and symptoms of pain, assist with turning and repositioning, medication as ordered and notify the physician if not effective or side effects, and provide disversional activities. 12/19/24 - An admission MDS assessment documented that R85 was on a scheduled pain regimen in the last five days, received PRN (as needed) pain medication, and received no non-medication interventions. The MDS also documented that R85 was having pain frequently, pain occasionally affecting sleep, pain occasionally affecting therapy activities, pain that was occasionally affecting day to day activities, and a pain score of 10/10 with no verbal description indicator. The MDS also documented that R85 had a BIMS score of 15 indicating R85 is cognitively intact. 12/2024 - A review of the December MAR documented that R85's pain level ranged from a score of 2/10 to 8/10. R85's pain level was noted at 10/10 prior to pain medication administration and scored as effective or score of 8/10 or below post pain medication administration. 1/2/25 5:41 PM - A physician's order documented oxycodone (narcotic pain medication) 10 mg tablet, give one tablet every six hours as needed for pain for six days ending on 1/6/25. 1/6/25 1:25 AM - The Januaury MAR documented R85 received a dose of PRN oxycodone 10 mg tablet documented 10/10 pain and a result of effective post pain assessment. The facility failed to use a pain scale for evaluation of pain with consistent measurement of pain pre and post administration. 1/6/25 - 1/8/25 - A review of the MAR documented R85's pain score was 10/10 every shift. R85 received PRN Tylenol during the aforementioned dates indicating 10/10 pain level and post administration score of ineffective during this time. The MAR lacked evidence of an oxycodone order in place or administered. The facility failed to use a pain scale for evaluation of pain with consistent measurement of pain pre and post administration. 1/7/25 1:38 PM - A progress noted documented Patient was unable to do PT today because she did not have her pain medication. The order was discontinued per provider. I gave her Tylenol but patient states that does not help at all . 1/8/25 00:01 AM - A physician's (E20) progress note documented a follow up visit with R85 to discuss pain medication use. The note stated that R85 continues to complain of low back pain and will be looking at long term use of narcotic pain medication use. E20 documented that he would provide temporary pain medication twice daily as needed and consult to pain management. 1/8/25 5:58 PM - A physician's (E20) order documented oxycodone 10 mg tablet, give one tablet every twelve hours as needed for chronic pain, fibromyalgia for ten days. 1/8/25 7:02 PM - A progress note documented .Patient has chronic pain and complains of pain being a 10/10. Patient was referred to pain management due to pain and narcotic dependence . 1/13/25 10:04 AM - An interview with R85 revealed she has had chronic pain in her lower back and was currently on a scheduled pain medication regimen. R85 revealed that recently that her pain medication perscription was no longer active and R85 was without scheduled pain medication for multiple days. R85 stated that when her pain was uncontrolled she was unable to participate in therapy and unable to get out of bed. R85 stated that she reported these pain levels to staff and no medication was ordered during that time. 1/17/25 8:30 AM - An interview with E2 (DON) confirmed that oxycodone is available in the facility emergency medication stock. 1/17/25 12:11 PM - An interview with E11 (NP) revealed that R85 was under E20's care for pain management. E11 stated that [R85] is pain medication seeking and I will not prescribe [R85] narcotics. Also E11 stated that is why R85 is under E20's care. E11 stated staff did not notify her that R85 was out of pain medication. 1/17/25 12:22 PM - An interview with E25 (scheduler) and E26 (RN UM) confirmed that R85 was referred to pain management with an outside provider and it was ordered on 1/8/25. E26 confirmed that the appointment was made on 1/16/25 due to E26 not being told of the aforementioned appointment. E26 stated R85 will be seen on 2/26/25 by pain management. 1/22/25 2:30 PM - An interview with E27 (RN) confirmed that R85 did not have a current order for pain medication from 1/6/25 to 1/8/25 and notified E11 on 1/7/25. E27 was unable to provide documentation that she reported R85 was out of medication. 1/23/25 2:44 PM - An interview with E20 confirmed he was not notified of the oxycodone prescription being discontinued and did refer R85 to pain management. E20 confirmed he will continue the current pain medication regimen until R85 is seen by pain management. E20 also stated he was unaware that the E11 was notified that R85 did not have any pain medication. 1/23/25 3:00 PM - Review of findings with E1 (NHA) confirmed that the facility did not have an active order for pain medication from 1/6/25 to 1/8/25 and should have consulted the provider regarding the ineffective pain medication administered in the absence of oxycodone. At this time, E1 confirmed that the facility failed to provide medication to control R85's pain resulting in approximately sixty four hours of severe uncontrolled pain rated at a level of 10 out of 10. 1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON), and E4 (Corporate Clinical Support).

Based on record review and interview it was determined that for eight (R3, R4, R27, R46, R57, R63, R89 and R91) out of thirty-seven residents investigated the facility failed to develop person centered care plans. Findings include: 1. Review of R46's clinical record revealed: 11/22/24 - An annual MDS assessment documented that R46 received insulin. 11/15/24 - A physicians order was written for R46 to receive Insulin Glargine 20 units at bedtime. 11/16/24 - A physicians order was written for R46 to receive Insulin Aspart (with Niacinamide) 12 units one time a day for diabetes. 1/16/25 - Review of R46's care plans lacked evidence of a care plan that addressed the residents use of insulin and diagnosis of diabetes. 1/16/25 2:20 PM - E1 (DON) provided a care plan that addressed R46's diabetes and use of insulin. The creation date of the care plan was 1/16/25. E1 confirmed the finding. 2. Review of R57's clinical record revealed: 8/27/24 - Physicians orders were written for R57 to receive an anti-anxiety and an anti-depressant medication. 9/6/24 - An annual MDS assessment documented that R57 received anti-anxiety and anti-depressant medications. 12/7/24 - A quarterly MDS documented that R57 received anti-anxiety and anti-depressant medications. 1/15/24 - Review of R57's care plans lacked evidence that they addressed R57's anxiety and depression, use of anti-anxiety medications and anti-depressant medications. 1/15/25 1:53 PM - E1 (DON) confirmed the findings and created corresponding care plans to address R57's use of antidepressant and anti-anxiety medications. 40163 3. Review of R63's clinical record revealed: 4/18/22 - R63 was admitted to the facility with dementia. 4/24/24 - An annual MDS assessment documented that R63 was severely cognitively impaired. 1/13/25 8:53, 1/14/25 1:46 PM, 1/15/25 11:41 AM, and 1/17/25 8:33 AM, R63 was observed with approximately one half of an inch of gray and black facial hair on her chin. 1/17/25 8:33 AM - During an interview E10 (CNA) confirmed R63's extensive facial hair. E10 stated that R63 is combative with care and especially showers. E10 added that R63 will not let anyone shave her because she does not like anything near her face. 1/17/25 8:37 AM - During an interview, E12 (LPN) confirmed that R63 did not have a care plan for refusals of shaving and bathing. 4. Review of R89's clinical record revealed: 5/22/24 - R89 was admitted to the facility with multiple sclerosis, a stroke and was paraplegic. 5/22/24 - R63's fall care plan included for her call bell to be in reach and to apply non-skid footwear except during hygiene. 5/29/24 - A quarterly MDS assessment documented that R89 was totally dependent on staff for all care and could not walk. Although R89 had a fall care plan in place, it was not comprehensive and patient centered related to R89's paraplegic status, and resultant inability to utilize the call bell and or walk. 1/22/25 approximately 1:45 PM - E2 (DON) confirmed that R89's care plan was not appropriate for R89's status. 5. Review of R91's clinical record revealed: 11/5/24 - R91 was admitted to the facility with a tracheostomy and dependent on a ventilator. 11/12/24 - An admission MDS assessment documented that R91 had a tracheostomy and was ventilator dependent. Review of R91's care plan revealed that the facility failed to create a comprehensive care plan to include her respiratory status. 1/22/25 approximately 1:45 PM - E2 (DON) confirmed that R91 did not have a care plan for her respiratory status. 46988 6. Review of R3's clinical record revealed: 9/26/23 - R3 was admitted to the facility with a diagnosis of dementia. 1/2/25 - A quarterly MDS documented that R3 was severely cognitively impaired and had a diagnosis of non-Alzheimers dementia. Review of R3's careplan revealed that the facility failed to create a comprehensive care plan to include dementia care. 1/23/25 3:34 PM - An interview with E17 (UM RN) confirmed that R3 did not have a care plan for dementia care. 7. Review of R4's clinical record revealed: 12/5/24 - R4 was admitted to the facility. 12/18/24 - An admission MDS documented that R4 was always continent of urine and occasionally incontinent of bowel. Review of R4's careplan revealed that the facility failed to create a comprehensive care plan to include bowel incontinence. 1/23/25 3:34 PM - An interview with E17 (UM RN) confirmed that R4 did not have a care plan for bowel incontinence. 8. Review of R27's clinical record revealed: 10/14/24 - R27 was admitted to the facility with vascular dementia. 10/21/24 - An admission MDS documented R27 was cognitively intact and diagnosis of non-Alzheimers dementia. Review of R27's careplan revealed that the facility failed to create a comprehensive care plan to include dementia care. 1/23/25 3:34 PM - An interview with E17 (UM RN) confirmed that R27 did not have a care plan for dementia. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

Based on interview and record review it was determined that for one (R85) out of thirty-seven residents reviewed in the investigative sample, the facility failed to ensure care preferences were being honored. Findings include: Review of R85's clinical record revealed: 12/12/24 - Resident was admitted to the facility. 12/13/24 - A resident preference evaluation documented that it was very important for R85 to choose between a tub bath, shower, bed bath or sponge bath. The evaluation indicated that R85 preferred a shower. 12/18/24 - A physician's order documented showers two times a week on Wednesday and Saturday 7:00 AM to 3:00 PM shift. 1/13/25 9:55 AM - An interview with R85 revealed that the facility did not ask R85 regarding her preference to time or day of showers. 1/17/25 8:40 AM - An interview with E48 (CNA) revealed that the residents shower schedule in the electronic medical record does not match the typed schedule posted at the nursing station. 1/17/25 8:50 AM - An interview with E17 (UM, RN) confirmed that the unit shower schedule is based on room number and will be adjusted if the resident or family tells the facility they don't like the schedule. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

Based on record review and interview it was determined that for two (R43 and R79) out of three residents reviewed for personal funds the facility failed to ensure residents had access to the their funds. Findings include: The facility policy entitled, Deposit of Resident Funds last updated March 2021 indicated, Should the resident permit the facility to hold, safeguard, and manage his or her personal funds, the facility will: provide the resident access to funds of fifty dollars or less within twenty four hours, and access to funds in excess of fifty dollars within three banking days. 1. 11/2/24 - An MDS assessment documented that R79 was cognitively intact. 12/23/24 - A receipt in the facility records documented that R79 received 50.00 in personal funds from E17 (BOM). 1/13/25 10:48 AM - During an interview R79 stated, They had a change in the person who was disbursing the money and she had to be oriented. I wanted it for Christmas and I got it two days before Christmas. Which was too late because I wanted to send Christmas cards. I made the request at least the beginning of the month and I didn't get it until the week of (sic). I was talking about it to [E1 (NHA) and E17 (BOM)]; I usually just have to call and then I sign a slip. 1/22/25 10:54 AM - During an interview R79 reported requesting personal funds from [E17 (former BOM)] and then I told reception. Then I had to wait. 2. 12/24/24 - A receipt in the facility records documented that R43 received 100.00 in personal funds from E17 (BOM). 12/27/24 - An annual MDS assessment documented that R43 was cognitively intact. 1/21/25 11:45 AM - During an interview E17 (BOM) I came in mid December before that the (BOM)position was empty for quite some time. E17 confirmed that residents should be able to access personal funds within 24 hours if less than fifty dollars and no more than three business days for larger amounts. E17 provided the surveyor with two logs of personal funds received residents for December 2024 with no funds documented as disbursed from 12/13/24 - 12/23/24. 1/22/25 11:07 AM - During an interview R43 stated, I told [E18] (former BOM) that I wanted to take out some money but then she left and I had to wait for the other one [E17 BOM] to get acclimated so I had to wait. I did eventually get the money. 1/22/25 11:27 AM - E1 (NHA) notified the surveyor that E18 (former BOM) last date of employment was 11/5/24 and that E17 (BOM) started on 12/16/24. E1 stated I believe we had a regional person covering and reception was helping out as well. The facility lacked evidence of how this information was relayed to the residents. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

Based on interview and record review, it was determined that for one (R81) out of five residents reviewed for Advance Directives, the facility failed to offer an opportunity to formulate an advance directive. Findings include: Review of R81's clinical record revealed: 3/25/24 - R81 was admitted to the facility. 3/30/24 - An admission packet for the facility was completed for R81 and revealed that Exhibit G: advanced directed form documented R81 was a full code. The remainder of the form was left blank relating to questions regarding formulating an advanced directive. 10/2/24 - A quarterly MDS assessment documented a BIMS score of 15 indicating R81 was cognitively intact. 1/13/25 11:34 AM - An interview with R81 revealed that he was not offered to formulate an advanced directive. 1/14/25 1:35 PM - An interview with E41 (SW) revealed that advanced directives get discussed during the initial care plan meeting. 1/14/25 2:33 PM - An interview with E6 (Admissions) revealed that nursing staff is expected to ask resident questions on admission sheet regarding advanced directive. E6 confirmed that she did not ask R81 if he would like to formulate an advanced directive. 1/14/25 2:45 PM - An interview with E27 (RN) confirmed that nursing staff is responsible to discuss advanced directive with newly admitted residents. E27 presented R81's preferred intensity of medical care and treatment form from the clinical record dated 3/25/24 and 8/9/24. E27 confirmed that these forms were completed with R81 post admission. The aforementioned form addresses a resident's preferred code status and lacks evidence of information regarding advanced directive. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

Based on interview and record review, it was determined that for one (R64) out of two residents reviewed for change in condition, the facility failed to consult the provider and notify the responsible party when R64 experienced a significant change in condition and plan of care. Findings include: Cross refer F773 Review of R64's clinical record revealed: 11/27/24 - R64 was admitted to the facility. 12/4/25 - An admission MDS documented R64 was a BIMS of 7 indicating severe cognitive impairment. 1/10/25 - A progress note documented that FM3 reported that R64 was lethargic and not at her baseline. E27 (RN) documented R64's assessment and called the on-call provider. 1/10/25 1:34 PM - A progress note documented that R64 had a non-productive cough, mild confusion, speech unclear at times, elevated heart rate, was drowsy nd not her usual self. Additionally, R64 was given cough medicine, Tylenol, and Tums per provider order. 1/10/25 7:56 PM - A progress note documented that R64 refused dinner and continued with an elevated heart rate. Additionally, the progress note documented the on call provider was notified with new orders. 1/10/25 11:00 PM - A physician's order for R64 documented complete blood count (CBC), comprehensive metabolic panel (CMP), and infuse normal saline at 100 mL/hr total 1 liter. 1/11/25 1:37 PM (Saturday) - A lab result report for R46 documented the white blood cell count was high. 1/11/25 3:48 PM - A progress note documented that R46 pulled out peripheral line from left arm. 1/13/25 4:30 PM - A physician's order for R64 documented a chest x-ray with two views and Rocephin (antibiotic) inject one gram intramuscularly immediately (STAT) for white blood cell elevation. 1/14/25 3:25 PM - A physician's order for R64 documented Bactrim (antibiotic) 800-160 mg give one tablet two times a day for left base infiltrate (pneumonia) for five days. 1/15/25 1:15 PM - In an interview FM3 revealed she was unaware that R46 had a chest X-ray done, received labwork, was diagnosed with pneumonia, started on antibiotics as well as being changed to thickened liquids. FM3 stated she had not received an update on R46's condition since 10:00 PM on 1/10/25 when staff nurse called to notify her that R46 was ordered an IV related to dehydration. 1/15/25 1:45 PM - Interview with E27 (RN) confirmed that the progress notes lacked evidence of notification to FM3 about changes to plan of care for R46. 1/15/25 2:13 PM - Interview with E17 (RN, UM) confirmed that the progress notes lacked evidence of notification to the provider of R46's lab results. The facility lacked evidence of notification to the provider of R46's lab results and lacked evidence of updating R46's responsible party of change in condition that changed the plan of care. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

Based on interview, record review and review of other facility documentation, it was determined that for one (R64) out of one reviewed for grievances, the facility failed to ensure that resident concerns received by the facility included prompt efforts to resolve the resident's problems. Findings include: Review of R64's clinical record revealed: 11/27/24 - R64 was admitted to the facility. 12/30/24 - A grievance form was filed by FM3 regarding missing clothing for R64 and a complaint related to staff care. The form documented that the grievance was resolved on 1/6/25 by E2 (DON). 1/13/25 12:33 PM - An interview with FM3 revealed that R64 was missing a pair of pajama bottoms and that a staff member threw them away. FM3 stated that on 12/30/24 she was in to visit R64 and she told FM3 about her pants being missing. FM3 stated that R64 was very upset and told her that the person who threw the pants away was not nice to her on the date in question. FM3 also stated that the facility did not rectify the missing pants with her or offer to replace them. 1/15/25 11:23 AM - An interview with E1 (NHA) and E2 (DON) confirmed that the facility had addressed the grievance. E2 stated that the staff member mentioned in the grievance was given education about customer service. E2 stated he did not offer to replace the pants or provide reimbursement. E1 called FM3 and requested a receipt for the pajama pants to reimburse. The facility failed to ensure that resident concerns received by the facility included prompt efforts to resolve the resident's problems. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

Based on record review and interview, it was determined that for one (R18) out of two (2) residents reviewed for misappropriation of resident property, the facility failed to recognize and consequently report an allegation of misappropriation of resident property/funds no later than 24 hours. Findings include: The facility policy on abuse dated 12/2016 indicated Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Investigate and report any allegations of abuse within timeframe's as required by federal requirements. 3/4/25 - A grievance form was completed on behalf of R18 by E8 (AD) that documented, [R18] said he saw charges that were not his own on his credit card. He also said that someone has taken out a loan in his name. He was assisted with calling customer service. Further documentation on the grievance indicated the investigation was assigned by E7 (SW) to E5 (BOM) to complete the investigation of the grievance. E5 documented, [R18] was approached by BOM and a security officer. We asked if he would like to call the police and file a report. He declined. The grievance documented the resolution date as 3/6/25 and was signed by E1 (former NHA). 4/2/25 1:30 PM - During an interview E5 (BOM) confirmed being assigned to review R18's grievance related to missing money and stated that E1 (former NHA) was aware of R18's allegations. 4/2/25 1:54 PM - During an interview E4 (DON) stated he was previously unaware of R18's grievance related to an allegation of misappropriation of resident funds. 4/2/25 2:21 PM - During an interview E1 (former NHA) confirmed knowledge of R18's allegation of misappropriation of resident funds. E1 stated, I thought it was an old allegation of money way before I was there don't recall the resident or details. 4/3/25 11:45 AM - During an interview E5 (BOM) confirmed that R18's grievance related to missing money was not recognized as an allegation of misappropriation of funds and therefore was not reported to the State Agency. 4/3/25 2:12 PM - During an interview E7 (SW) confirmed that R18's grievance related to missing money was not recognized as an allegation of misappropriation of funds and therefore was not reported to the State Agency. 4/3/25 3:45 PM - Findings were reviewed during the exit meeting with E2 (NHA) and E4 (DON).

Based on record review and interview, it was determined that for one (R18) out of two (2) residents reviewed for allegations of misappropriation of resident property, the facility failed to provide evidence that the allegation was thoroughly investigated. Findings include: The facility policy on abuse dated 12/2016 indicated Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Investigate and report any allegations of abuse within timeframe's as required by federal requirements. 3/24/25 - The facility submitted an incident report to the State Agency that alleged [R18] reported a previous employee was stealing money. Investigation started immediately. Police contacted. 4/1/25 9:07 AM - The surveyor requested a copy of the investigation related to R18's allegation of misappropriation of property. 4/3/25 12:32 PM - During an interview E4 (DON) confirmed the facility did not conduct interviews, obtain statements or complete an investigation regarding R18's allegation of misappropriation of property. E4 stated, We called the police. 4/3/25 3:45 PM - Findings were reviewed during the exit meeting with E2 (NHA) and E4 (DON).

Based on interview, record review and review of other facility documents it was determined that for one (R148) out of three residents reviewed for discharge the facility failed to ensure that discharge requirements were met when the facility initiated discharge regarding R148 occurred on 10/9/24 without notice to the resident. Findings include. Cross refer to F626. Review of R148's clinical record revealed: 8/23/24 - R148 was admitted to the facility with multiple diagnoses including a history of major depressive disorder with severe psychotic symptoms, anxiety, and suicidal ideation. 8/26/24 - A five day MDS assessment documented that R148 was cognitively intact with a goal of remaining in the facility. 10/9/24 7:53 AM - A note in R148's clinical record documented that the resident was sent to the hospital for suicidal ideation. 10/9/24 - The Transfer/Discharge notice indicated the reason for R148's transfer as it is necessary for your welfare and needs cannot be met at the facility. The location of the transfer was to hospital ER. The notice was signed by R148. Accompanying the transfer notice was a notification of bed hold policy that was signed by R148, and an Acute Care Transfer document checklist. 10/9/24 2:56 PM - A social service note in R148's clinical record documented, Called [another nursing home] at 2:54 PM to see how to send over a referral for the resident. 10/9/24 - A discharge return not anticipated MDS assessment was completed for R148 with no discharge plan or referrals documented. 10/15/24 2:51 PM - A social service note documented, Returned the call from [inpatient psychiatric facility staff] on behalf of [R148] and they requested information on transferring the resident back to the facility. Social service director gave the information to the unit manager [E24(RN)]. October 2024 - The facility transfer list provided to the Ombudsman documented that R148 was transferred out for medical leave. 1/10/25 1:17 PM - During an interview E22 (SW) at inpatient psychiatric facility stated The facility would not allow [R148] to return and I got that from E6 (Admissions) but [R148] has been placed somewhere else. 1/22/25 10:21 AM - During an interview E6 (Admissions) stated that R148 Was having suicidal ideation with a plan that's why they sent her out to psych and the hospital sent her out to [inpatient psychiatric facility]. E6 confirmed that R148 was denied readmission to the facility following discharge from the inpatient psychiatric facility because At the time she owed us a large bill like seventy thousand and corporate was not letting me readmit her. E21 (Controller) my Corporate Director denied the readmission because the bill was so large and would not allow R148 to return until Medicaid approval. Then Medicaid denied. 1/22/25 11:51 AM - During an interview E24 (RN) former unit manager stated, [E6] (Admissions) said we wouldn't be allowing R148 back because of a large bill. 1/22/25 11:58 AM - During an interview E21 (Controller) confirmed that R148 was not allowed readmission to the facility. E21 stated that R148 Came in through the state program they stopped paying for her and we applied for Medicaid and it was denied. She was here eight months without payment. There should be a regular discharge letter. The surveyor requested a copy of the Medicaid denial, any appeal documents, a bill, and discharge notice. The requested documents were not received from the facility. 1/23/25 9:19 AM - During an interview E1 (NHA) confirmed the facility had no evidence of a discharge notice or discharge summary for R148. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

Based on interviews, record review and review of facility documentation, it was determined that for one (R57) out of five residents reviewed for accidents, the facility failed to ensure residents were provided adequate supervision to prevent accidents resulting in harm. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 10/24/22. Findings include: Review of R57's clinical record revealed: 9/28/22 - R57 was admitted to the facility with diagnoses including but not limited to quadriplegia, spinal muscular atrophy, morbid obesity and tracheostomy. 9/28/22 - A care plan documented that R57 had a potential for (actual falls) related to decreased mobility, poor safety awareness. 10/11/22 - R57 was readmitted to the facility. R57's fall risk evaluation was a score of 7, revealing a low fall risk. 10/17/22 - R57's admission MDS documented that R57 had a documented BIMS score of 15, revealing an intact cognitive state and was an extensive assist of two staff for transferring. R57 had impairments on both sides for upper and lower extremities. 10/19/22 11:10 AM - A facility incident report revealed that, resident (R57) being transferred from shower stretcher to bed and slipped out of Hoyer lift. 10/19/22 11:50 AM - A facility progress note by E21 (former LPN) documented, This nurse notified via phone by RT that resident had fallen from Hoyer lift to floor. Entered resident room to find her lying on the floor. 911 was initiated by RT. Supervisor notified. A&O x 4, c/o pain in back of head, denies blurred vision, denies LOC. Pressure applied to back of head r/t moderate bleeding. VSS, EMT and Paramedics arrived and took over care. Family (resident's mother) notified by phone. 10/19/22 1:00 PM - A physician note by E22 documented that, Patient (R57) seen status post fall, patient had a fall and sustained a hematoma on the back of her head, with bleeding noted left-sided wound. Patient's neuro remained intact vital stable, patient reported 4 out of 10 pain in the back of her head. Patient was sent to ED for further evaluation and treatment. 10/19/22 untimed - A facility investigation report revealed a written statement by E26 (Former CNA) that documented, . I (E26) always look for help when their [sic] isn't any, I try. I got her (R57) in the air and tried transferring her feet to the bed. While turning her (R57) feet, she started to slip. I yelled help twice grabbing her feet to try to keep her in the air. By the time help came in . she (R57) was on the floor . 10/19/22 untimed - A facility investigation report revealed a written statement by E27 (RT) had documented that E27 had returned to the nurse's station after a break and saw the curtains closed for R57's room. R57 returned to her room from the shower room and stuck her head through the curtain and asked E26 if she needed any help. E26 replied that she did not need any help. E27 replied that she would be sitting at the nurse's station. A few minutes later E26 and R57 screamed for help. E27 ran into the room and R57 was on the floor. 10/23/22 11:56 AM - A skin evaluation note by E21 documented, . Skin is warm dry and intact with exception of laceration with 4 staples to back left side of head related to previous fall . 11/8/22 - E26 was terminated from the facility. The Facility's 5 day follow up summary documented the root cause of the incident was that the lift was not completed by two employees; the outcome of the investigation was that 1. Staff member failed to ask for help with transfer 2. Sling was placed improperly; the system changes that were put in place were in-servicing and competencies on Hoyer lift for the nursing staff. 4/10/24 12:02 PM - An interview with R57 revealed that on 10/19/22 E26 was bringing her back to her room after getting a shower. E26 began to use the Hoyer lift to move her back to bed. R57 stated she asked E26 if the Hoyer lift was for a 2 person assist and that E26 stated there was no staff to help. R57 recalled being raised up in the air and then sliding out of the sling headfirst when she then hit her head and blacked out. 4/11/24 8:51 AM - An interview with E20 (former DON 2) revealed that E26 attempted to put R57 back to bed by herself resulting in the fall. E20 stated that she interviewed E26 who stated that she knew she should not have tried to use the Hoyer lift by herself. 4/11/24 11:16 AM - An interview with E1 (NHA) revealed that E26 was suspended pending an investigation and they did not return when she was terminated on 11/8/22. The facility audited the evaluations on the Hoyer lift for the residents. The facility had in-service training and physical return demonstrations with signatures for the trainings that began 10/19/22 and completed 10/24/22. The facility's in-service training documentation included: Mechanical lift use policy, How to use a Mechanical lift Caregiving series education, Safe Lifting and Movement of Residents policy, a Video on the use of a Mechanical lift and a Patient Lifts Safety Guide. Based on the review of the facility's thorough investigation, documented response, completion of in-service training and audits, staff interviews and no further incidents related to injuries using a Hoyer lift, R57's accident was determined to be past non-compliance harm. The plan of correction was initiated on 10/19/22 and completed on 10/24/22. These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 and E2 (DON).