Every finding on record at Prosper Health and Rehabilitation Center

Based on observation, clinical and administrative record review and interview, the facility failed to ensure that residents received the necessary care and services for wound care. This is evidenced by the staff failure to provide evidence of thorough assessment when a wound is noted as open; failed to complete the weekly skin checks appropriately; failed to correctly identify skin issues in a timely manner; and failed to ensure wound care is done as prescribed and dated appropriately. This failure affected 2 of 3 sampled residents reviewed for wound care, Resident #1 and Resident #2. The findings included:1. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Parkinson Disease, immunodeficiency, muscle atrophy, dementia and history of cerebral infarction. The resident requires total assistance with his activities of daily living and is incontinent of bowel and bladder. An observation of the wound care on Resident #2 was conducted on 06/16/26 at 10:25 AM with the Wound Care Nurse and the Certified Nursing Assistant (CNA), Staff A. The nurse revealed the wound dressing noted on the resident's buttock. The wound dressing was dated 06/12/26 and had the wound care nurses' initials on it. The WCN confirmed that the date on the dressing was 06/12/26 (4 days ago). The resident was apparently sleeping soundly during this observation, and he did not respond throughout the wound care observation. Review of the physician order revealed that on 05/01/26, the physician prescribed Sacrum: Cleanse with NSS (normal saline solution) or wound cleanser, pat dry, apply collagen sheet and calcium alginate, cover with silicone border dressing. every day shift for pressure wound. Additionally, a later review of Treatment Administration Record (TAR) revealed documentation for the above wound care. Further review of the TAR revealed the wound care nurse's initials were noted on 06/12/26 and 06/16/26, indicating the dates she performed the dressing change. The other dates of 06/13/26, 06/14/26 and 06/15/26 had other nurses' initials noted on the TAR. The 06/02/26 wound care physician progress note documented the resident has a Stage 4 pressure injury since 01/30/26 currently measuring 1.8 cm x 0.8 cm x 0.5 cm with undermining of 0.6 cm from 10-2'o'clock. Wound with small amount of serous exudate, 80% granulation and 20 % slough. On 06/02/26, the physician provided additional clinical recommendations as follows:Offload WoundTurn and reposition per facility protocoloffload heels with pillowsheel bootsDietary evaluationConsider skin substitute for wound closure.Observations of the resident on 06/16/26 at 10:25 AM and 3:25 PM revealed the resident was wearing non-skid socks and the resident feet were resting directly on the mattress. The resident's feet were not offloaded, and he was not wearing offloading heel boots. The resident remained in bed on this date and again the resident was apparently sleeping and did not respond during the observations.An interview was conducted with Staff A, CNA, during the 3:25 PM observation. Staff A confirmed the resident's feet were not offloaded, and he did not have the boots.An interview was conducted on 06/16/26 at 3:38 PM with the Licensed Practical Nurse, Staff B, who was assigned to the resident for the 7AM-3PM shift. At this time Staff B had been observed giving report to the oncoming nurse and she was preparing to leave for the day. The surveyor asked Staff B regarding the care needs for Resident #2. She stated she had to look it up. The surveyor inquired regarding the preventative care the resident was to have and if she was aware the resident was receiving the care that he was prescribed. She too was not aware that the resident was to have his heels offloaded and she confirmed the resident was in bed this date. 2. Record review revealed Resident # 1 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Muscle Weakness Muscle Wasting and Atrophy, Dementia, and Dysphagia. The initial nursing assessment documented the resident had a right lower leg (front) skin tear. A weekly skin check was done on 02/24/26 (second skin check) which was noted to document indicate below skin injuries / ulcers such as pressure ulcers, venous insufficiency/ischemia ulcers (i.e., Venous stasis and arterial ischemic ulcers), diabetic neuropathic ulcers, bruises, abrasions, lacerations and abnormal skin discoloration by marking the body. Comment on color, moisture, temperature, integrity and/or turgor as appropriate. The 02/24/26 note noted the following: Right anterior lower leg: skin tearAbdomen, peg tubeSacrum, healed Stage 4 woundLeft ischium, healed Stage 4 woundBilateral lower extremities gangrene. The subsequent weekly skin checks beginning on 02/28/26, 03/07/26, 03/14/26 and 03/17/26 noted an open area to the lower right leg. There was no further description of the open area identified on the resident's right lower leg nor were there any treatment orders for this area. There was no documentation of a right heel injury until 03/21/26 (when the right heel is noted as stable eschar) or left anterior lower leg injury noted. These two additional areas were documented in March, by the wound care physician. The order for a wound care consult was prescribed on 03/19/26 for the right heel. The initial Wound Care physician's progress notes on 03/23/26 documented for: Site 1 right heel wound measuring 2.5 x 5.0 x 0.0, black necrosis (eschar) 100%; Site 2 - right anterior lower leg (the area that has been documented as open since 02/28/26 without specific documentation identifying the wound). The physician documented the right lower leg anterior measuring 4.5 cm x 4.0 x 0.1 cm, moderate amount of serous drainage. On 02/23/26, the physician prescribed Wound Care-Skin Prep: May apply skin prep to bilateral heels every Shift x14 days and it was discontinued on 03/09/26. There were no further orders noted for the right heel until the physician prescribed wound care on 03/19/26 and 03/23/26. There was nothing documented on the weekly skin checks regarding the heel until after the Wound Care physician involvement. An interview was conducted on 06/16/26 at approximately 11:30 AM with the Wound Care Nurse (WCN). After finally receiving the wound care list from February to present, the surveyor reviewed it with the WCN, why Resident #1 was not identified on the wound care list until April 7, 2026. She had no explanation to this oversight. The surveyor inquired of the reason that there was no description of the open area noted on the weekly skin checks for the right lower leg anterior beginning 02/28/26. The WCN only stated that we can't stage wounds. The surveyor questioned that there was no documentation of the resident having any concerns on his heels until the wound care physician was consulted on 03/19/26 and assessed by the wound care physician on 03/23/26 and noted an eschar. The WCN then stated she didn't know because the resident's heels were red and that's why they were applying skin prep. The surveyor expressed this was not documented or identified on the weekly skin checks nor was the resident identified on the wound list. A telephone interview was conducted with the Wound Care Physician on 06/16/26 at 1:15 PM, who expressed that the resident has severe advanced Peripheral Vascular Disease and he doesn't take care of skin tears. He confirmed he did not get involved with the resident's wound care until March 23, 2026, and further stated he could not attest to anything prior, but it may have been a skin tear with advanced PVD [peripheral vascular disease]. The surveyor said that the staff initially documented the area as a skin tear but later documented that the wound was opened but did not provide any further details regarding the wound. The surveyor stated that the staff did not identify any concerns regarding the resident's heel until the order to consult Wound Care and then the right heel was documented as eschar.

Based on observations, interviews, and record review, the facility failed to collect urine specimen timely for 1 of 1 sampled resident, Resident #67, reviewed for Urinary Tract Infection (UTI), resulting in a delay of antibiotic treatment for the UTI.The findings included: Record review for Resident #67 revealed the resident was admitted to the facility on [DATE] with the diagnosis that included Type 2 Diabetes.Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Review of Section GG revealed the resident was dependent on staff for toileting and hygiene. Review of the Physician's Orders showed Resident #67 had an order dated 07/03/25 for a Urinalysis, related to a possible Urinary Tract Infection (UTI). The record revealed no evidence of the collection of urine for the urinalysis. Review of the progress notes from 07/03/25 to 07/11/25 did not indicate a reason for delay in the collection.During an interview conducted on 07/31/25 at 9:21 AM with Staff N, Unit Manager (UM), the surveyor asked to review the process for lab orders, specimen collection and follow-up. Staff N revealed that when an order is received, it is entered into the lab collection binder on the date of the order. The specimen is collected by the night shift unless the order is emergent. If the specimen was not collected, the information should be communicated during hand-off and the on-coming shift would collect the specimen. During a side-by-side review of the lab collection binder, Staff N identified the lab order for Resident #67. The order was logged in on 7/02/25 with a handwritten entry not collected. This surveyor asked where the nurse would document any notes, and UM stated it would be in the progress notes section of electronic health record EMR). During a side-by-side review of the residents' medical records, there was no documentation to indicate the urine specimen was collected util 07/10/25. Review of the EMR showed that the specimen was collected on 07/10/25 and resulted on 07/11/25. There was a physician order dated 07/11/25 for Levaquin Tablet 500 milligrams for UTI for 7 Days. The UM agreed that there was a delay in collection and that there were no progress notes to explain why the specimen was not collected or if the delay was communicated with the physician.An interview was conducted on 07/31/25 11:15 AM with Staff M, Registered Nurse. Staff M explained the process for lab collection and stated that the specimens are normally collected at night to be picked up in the morning. If not collected, the night shift will notify the day nurse, and we would try to collect. Staff M stated that the nurse should document if unable to obtain the specimen, for example if the resident refused and the nurse should also let the supervisor know.

Based on interview and record review, the facility failed to ensure facility is administered in a manner that enables it to use its resources effectively and efficiently to ensure staff act in a manner consistent with compliance with federal, state and local laws and professional standards regarding abuse with the potential to affect 98 out of 98 residents. The findings included: Review of the facility's policy titled, Governing Board, with a most revised date of 01/01/25 included in part the following: Responsibilities of the LNHA (Licensed Nursing Home Administrator). Administer the facility in a manner that enables it to use is resources effectively and efficiently to attain or maintain the highest practicable physician, mental, and psychosocial well-being of each resident. Conduct document and update any legally required facility wide assessments to determine what resources are necessary for care for its resident competently during both day-to-day operations and emergencies and as otherwise provided by law. Set an example for all staff members, consultants and others affiliated with the facility which recognizes commitment that the institution exists to serve the interest of and the needs of the resident, which emphasizes compliance with the law, Quality Assessment, Performance Improvement and the importance of a resident's right to independence regarding all aspect of institutional lie and encourages residents to participate together with staff in resolving conflicts and problems which frequently arise in a group residential setting. Act and insist that others act, in compliance with federal, state, and local laws and professional standard. Review of the Administrator Job Description signed and dated 05/02/24 by the Administrator included in part the following: The Administrator shall assume those administrative responsibilities delegated by the Governing Board and may delegate responsibilities to an appropriate staff member of the facility as necessary to provide a well-defined and operating organization. The Administrator is responsible for the oversight of health, care and treatment of residents in the nursing home. This responsibility also includes the maintenance and operation of the facility that will ensure safe, adequate and appropriate care, treatment and health of residents. Review of the in-service training from 07/09/25 for nursing staff, titled, Abuse, Neglect, and Exploitations, by Centers for Medicare and Medicaid Services, with no date included in part the following: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation involve abuse or result in serious bodily injury. Review of the computer based training titled, Abuse, Neglect, Exploitation, Misappropriation of Property, Mistreatment and Injury of Unknown Source, with no date and was provided to all staff from 07/01/25 to 07/30/25, included in part the following: Facility Reporting and Investigation: Reporting requirements for any suspected occurrence of abuse: Within 2 hours if the events involve abuse or result in serious bodily injury. Reporting Abuse or Suspected Abuse: What to Do: Stay calm and ensure the resident is safe. Report immediately to your supervisor, charge nurse, or administrator. Document what you say or heard - include facts, not assumptions. Follow the facility's abuse reporting policy. An interview was conducted on 07/28/25 at 9:30 AM with the Administrator who was asked if they have a memory care and she said no. She said they have residents with Dementia, but they do not wander. She added we don't have locked units or wander guards. An interview was conducted on 07/28/25 at 3:15 PM with the Director of Nursing (DON), who stated she has been in the DON role for about 1 year, and the Administrator, who has been at the facility for 3 years. When asked regarding documentation for allegation of abuse between Residents #48 and #101, they stated the only documentation for each resident on the day of the incident was a skin assessment done on 07/09/25 for both residents involved.The Administrator and the DON were asked about the incident involving Resident #33 going into Resident #48's room, was wearing a brief, had pulled it down exposing himself to Resident #33 on 07/26/25, and Resident #33 had reported this to staff who ushered Resident #33 out of the room. They both stated they were not aware of the situation. They both acknowledged there was no documentation of the incident in the residents' record. The Administrator and the DON were asked about the incident involving Resident #38 and Resident #86 on 07/26/25 where Resident #86 reported to staff that Resident #38 had punched her in the hand, she was asked to produce a written statement for them and was being provided ice for her hand. They both stated they were not aware of the incident. When asked about documentation in the record for each resident involving the incident, they both acknowledged there was no documentation in either of the resident's record. An interview was conducted on 07/30/25 at 8:55 AM with the Administrator and the Director of Nursing present, when the Administrator was asked about what education has been provided to staff on or after 07/28/25 when they were made aware of the two incidents that happened on 07/26/25. The Administrator stated they have only provided education to the direct staff involved. An interview was conducted on 07/31/25 at 8:40 AM with the Administrator who stated that all staff do the abuse training on the computer system annually and they also provide in-service abuse training with each abuse allegation and that it is targeted toward the nursing staff. The Administrator stated she feels their abuse education may not be effective, based on the most recent allegations of abuse that neither she nor the DON were made aware of by the staff involved. The Administrator stated she has been working on making a new abuse quiz with scenarios and will start implementing the abuse training with the new quiz today. An interview was conducted on 07/31/25 at 8:50 AM with the Administrator, the [NAME] President of Risk Management (VPRM) and the [NAME] President of Operations (VOO). The VPRM acknowledged they chart by exception, and they would be providing direct education to the nurses involved in the abuse allegations regarding reporting, notifying family and physician, and documentation being performed in a timely manner. The VOO added they are looking into changing the abuse training corporate wide. A telephone interview was conducted on 07/31/25 at 11:10 AM with Staff F, Certified Nursing Assistant (CNA), who stated she has worked at the facility for 3 years. Staff F stated that on 07/26/25 around 11:20 PM, she was talking at the nursing station and Resident #48 approached the nursing station and asked her to help get Resident #33 out of her room, as he was in her bathroom. When she went to the room Resident #33 refused to leave stating he was using the bathroom, so she shut the door. She notified Staff G, Registered Nurse (RN), that Resident #33 refused to leave. Staff G stated he was able to get Resident #33 out of the bathroom. When asked if she reported it to anyone, she said no because the nurse already knew about it. When asked if she had received any training on abuse, she said she did it on the computer and an in-service but unable to remember the dates. A telephone interview was conducted on 07/31/25 at 11:25 AM with Staff H, CNA, who stated he has worked at the facility since December 2024. When asked about the incident on 07/26/25 with Residents #48 and #33, he stated he was called by another CNA to help get Resident #33 out of Resident #48's bathroom. Staff H stated he put on gloves and escorted Resident #33 out of Resident #48's room. When asked if he had reported this to anyone, he said he did not know there was any issue to report but knew Resident #33 was confused. When asked about abuse training, he said he just had an in-service yesterday. An interview was conducted on 07/31/25 at 12:51 PM wit Staff D, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 1 month. When asked about the incident on 07/09/25 involving Residents #48 and #101, the LPN stated Resident #48 approached her to inform her that Resident #101 was in her bed, she got the other nurse (Staff G RN) to help her get Resident #101 out of the bed and move him to a vacant room in another pod. She said she reported it to Resident #48's daughter and the other nurse reported it to the son for Resident #101. She said she spoke with both nurse practitioners for each resident. The LPN stated she had reported it to the DON and the Administrator that same night and also spoke with a police officer. When asked if she documented the incident in the chart for each resident, she stated she believed so. When asked about abuse training, she said she took the computer-based abuse training upon hire and has not had any additional abuse training. An interview was conducted on 07/28/25 at 3:15 PM with the Director of Nursing (DON) who stated she has been in the DON (Abuse Coordinator) role for about 1 year and the Administrator (Risk Manager) who has been at the facility for 3 years. When asked about documentation for allegation of abuse between Residents #48 and #101, they stated the only documentation for each resident on the day of the incident was a skin assessment done on 07/09/25 for both residents involved.The Administrator and the DON were asked about the incident involving Resident #33 going into Resident #43's room, was wearing a brief, had pulled down exposing himself to Resident #33 on 07/26/25 and that Resident #33 had reported this to staff who ushered Resident #33 out of the room. They both stated they were not aware of the situation. They both acknowledged there was no documentation of the incident in the resident's record.The Administrator and the DON were asked about the incident involving Resident #38 and Resident #86 on 07/26/25 where Resident #86 reported to staff that Resident #38 had punched her in the hand, she was asked to produce a written statement for them and was being provided ice for her hand. They both stated they were not aware of the incident. When asked about documentation in the record for each resident involving the incident, they both acknowledged there was no documentation in either of the resident's record.The Administrator and the DON were asked about the incident involving Resident #81 who had allegation of abuse on 07/09/25 by staff member toward him. The Administrator and DON stated they were aware and acknowledged there was no documentation in the resident's record. The Administrator stated she did investigate and reported the incident. The Administrator and the DON were asked about the incident involving Resident #86 reported allegation of visitor abuse toward her on 01/28/25 they stated they were aware of the incident and there was documentation of a nursing note in the resident's medical record. An interview was conducted on 07/30/25 at 8:55 AM with the Administrator with the DON present,. When the Administrator was asked what education has been provided to staff on or after 07/28/25 when they were made aware of the two incidents that happened on 07/26/25, the Administrator stated they have only provided education to the direct staff involved. An interview was conducted on 07/30/25 at 3:52 PM with Staff G, Registered Nurse (RN), who stated she has worked at the facility as an RN since 07/02/25 and before that she was a CNA at the facility for 8 years. She was the nurse who took care of both Resident #48 and #101 on 07/26/25. Staff G stated that on that night Resident #101 went into Resident #48's room to use the bathroom and Resident #48 woke up and she had alerted Staff F CNA who came into the room and had tried to remove Resident #101 but was unable to do so she got Staff G and they both entered the bathroom, and she spoke to Resident #101 who had taken off his soiled underwear. Resident #101 had refused to leave the bathroom and did not want to be touched so they waited until he was finished using the toilet. She had spoken to Resident #48 and apologized for the incident. When Resident #101 was finished with the toilet, Staff F and herself were able to escort Resident #101 out of Resident 48's bathroom and room. Resident #101 did not go back to his room until another Staff H (CNA) came and escorted Resident #101 back to his room. When asked if she documented the incident anywhere either in Resident #48 or Resident #101 medical record, she said no she did not. When asked if she reported the incident to anyone she said yes, the following Monday (07/28/25), she reported the incident to DON and the Administrator but only after they had asked her about the incident. When asked if she notified the family for each resident, she said 'no, she did not notify the family for either resident'. She also acknowledged she did not notify the physician for either resident. When asked if she had abuse training, she said yes and had completed it on the Master computer system. The new abuse training had just come out since the incident on 07/26/25 and she had started it but has not finished it as of yet. The procedure when something like this happens, she was unaware she needed to inform the family, the physician and needed to report it to the DON or Administrator. An interview was conducted on 07/31/25 at 8:40 AM with the Administrator who stated all staff complete the abuse training on the computer system annually, they provide in-service abuse training with each abuse allegation and that it is targeted toward the nursing staff. The Administrator stated she feels their abuse education may not be effective, based on the most recent allegations of abuse that neither she nor the DON were made aware of by the staff involved. The Administrator stated she has been working on making a new abuse quiz with scenarios and will start implementing the abuse training with the new quiz today. An interview was conducted on 07/31/25 at 8:50 AM with the Administrator, the [NAME] President of Risk Management (VPRM) and the [NAME] President of Operations (VOO). The VPRM acknowledged they chart by exception, and they will be providing direct education to the nurses involved in the abuse allegations regarding reporting, notifying family and physician and documentation being performed in a timely manner. The VOO added they are looking into changing the abuse training corporate wide. An interview was conducted on 07/31/25 at 12:51 PM with Staff D, LPN, who stated she has worked at the facility for 1 month. When asked about the incident on 07/09/25 involving Residents #48 and #101, the LPN stated Resident #48 had approached her to inform her that Resident #101 was in her bed, she got the other nurse (Staff G, RN) to help her get Resident #101 out of the bed and move him to a vacant room in another pod. She said she reported it to Resident #48's daughter and the other nurse reported it to the son for Resident #101. She said she spoke with both nurse practitioners for each resident. The LPN stated she had reported it to the DON and the Administrator that same night and also spoke with a police officer. When asked if she documented the incident in the chart for each resident she believed so. When asked about abuse training, she said she took the computer-based abuse training upon hire and has not had any additional abuse training

Based on observation, interview and record review, the facility failed to secure medications for 1 of 28 sampled residents, Resident #37. The findings included: Review of the facility's policy, titled, Medication Storage and Labeling, with a revised date of 01/2024, documented in part the following: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. Record review for Resident #37 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Need for Assistance with Personal Care. Review of the Minimum Data Set (MDS) assessment for Resident #37 dated 06/22/25 documented in Section C, a Brief Interview of Mental Status (BIMS) score of 13 indicating an intact cognitive response. Review of the Physician's Orders for Resident #37 revealed in part the following:An order dated 05/30/25, Behavior: Enter # in Supplementary Documentation: 0 No behaviors; 1 Aggressiveness 2 Wandering; 3 Agitated; 4 Angry Comments; 5 Anxiety; 6 Avoidance/Resisting Care; 7 Compulsive Actions; 8 Crying; 9 Delusion/Paranoia; 10 Depressed/Withdrawn; 11 Fear/Panic; 12 Hallucinations; 13 Insomnia; 14 Jittery/Nervous; 15 Mood Changes; 16 Noisy/Yelling; 17 Pacing; 18 Pulling Tube (NG, Cath, IV); 19 Other enter note every shift for Use of Psychoactive Medication NON-PHARM INTERVE: 0 Not applicable; 1 1:1; 2 Activity; 3 Back-rub/Touch; 4 Change Position; 5 Change Environment 6 Give Fluids; 7 Food; 8 Redirect; 9 Toilet; 10 Other - enter nurses note. Effectiveness I Improved, NC No Change, W Worse.An order dated 07/24/25 for Midodrine HCl Oral Tablet 5 MG Give 1 tablet by mouth every 4 hours as needed. An order dated 06/02/25 for Rosuvastatin Calcium Oral Tablet 20 MG Give 20 mg by mouth one time a day.An order dated 05/24/25 for Pregabalin Oral Capsule 100 MG Give 1 capsule by mouth every 12 hours.An order dated 05/24/25 for Docusate Sodium Oral Tablet 100 MG Give 1 tablet by mouth one time a day. An order dated 03/24/25 for oxycodone HCl Oral Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed.An order dated 03/13/25 for Sertraline HCl Tablet 25 MG, Give 1 tablet by mouth one time a day.An order dated 03/05/25 for Multiple Minerals-Vitamins Tablet Give 1 tablet by mouth one time a day. An order dated 11/09/24 for Potassium Chloride ER Tablet Extended Release 10 MEQ Give 1 tablet by mouth one time a day. An order dated 09/09/24 for Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed.An order dated 09/06/24 for Rivaroxaban Oral Tablet 2.5 MG Give 2.5 mg by mouth two times a day.An order dated 09/06/24 for Aspirin 81 Oral Tablet Chewable Give 1 tablet by mouth one time a day. Review of the Care Plan for Resident #37 dated 09/06/24 with a focus on the resident has a history of exhibiting the following behaviors: chronic/frequent refusals of care and/or services., resists care, verbally aggression, refuses meals at times, refuses medications at times, refuses to have peg tube reinserted. Resident has history of digging stool from her brief, throws stool on the floor, places stool on bedside table, food tray, utensils, plates, bowls, cups, etc. Refuses to be weighed monthly. Refuses showers at times. Refuses activities of daily care at times. Resident spits out medications at times. The goal was for the resident to have fewer episodes of the identified behavior through the next review date. The interventions included in part the following: Acknowledge/commend the resident's progress/improvement in behavior. Administer medications as ordered. Monitor/document for side effects and effectiveness. Client centered therapy. Cognitive behavioral therapy. Encourage and assist the resident to develop more appropriate methods of coping and interacting as able. Encourage the resident to express feelings as needed. Encourage resident to interact with staff members as tolerated. Explain procedures to the resident before starting and allow the time to adjust to changes as needed. If reasonable/appropriate, discuss the behavior with the resident. Explain/reinforce why behavior is inappropriate and/or unacceptable. Intervene and/or redirect resident behavior as necessary. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention/redirect behavior as indicated. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Offer Psychology/Psychiatry services as needed. On 07/28/25 at 11:30 PM, an observation was made of Resident #37 lying in bed. On the floor between the bed and the window were a total of 6 pills (4 pink and 2 white all various sizes and shapes). The resident's fingernails were noted with a dried dark matter on the top around the cuticle and under the fingernails. Also noted was a dried dark matter on the resident's overbed table and on her water cup. During an interview conducted on 07/28/25 at 11:35 AM, when the resident asked if she received her pills this morning, she said yes. When asked if they leave the pills at the bedside for her to take, she said 'no, they stay with me to make sure I take all of my pills'. When asked about bathing, she said she never gets bathed, when asked when the last time was that she was bathed, she said this morning. An interview was conducted on 07/28/25 at 11:40 AM with Staff T, Licensed Practical Nurse (LPN), who stated it was her second day working at the facility. When asked about Resident #37, the LPN stated she gave the resident her pills between 8:00 AM and 9:00 AM this morning and the resident took all of her pills. When asked if she noticed pills on the floor, she said no. During a side-by-side observation with the LPN in Resident #37's room, she acknowledged the 6 pills on the floor and said she did not see them this morning. When asked about the dark dried matter on and under the resident's fingernails, the dried dark matter on the overbed table and the water cup, the LPN stated the Certified Nursing Assistant (CNA) (later identified as Staff U), was in the room when she was giving the resident her meds and told her she needed to clean up everything including the table and water cup and fingernails. A side-by-side observation was conducted on 07/28/25 at 11:45 AM with Staff N, Registered Nurse/Charge Nurse (RN/CN), who stated she has worked at the facility for 3 years. The RN/CN acknowledged the 6 pills on the floor and picked them up. She also acknowledged the dark dried matter on the resident's fingernails, overbed table and the water cup. An interview was conducted on 07/28/25 at 11:55 AM with Staff U who was asked about Resident #37. She said the resident has a habit of digging in her feces and this morning she had put it on the floor. The CNA said she had cleaned up the resident twice this morning with a bowel movement each time. When asked about the pills on the floor, the CNA said she did not see any pills. When asked about the resident's fingernails, overbed table and water cup, she said she cleaned everything this morning.

Based on observation, interview, record and policy review, it was determined the medication error rate was 8 percent (%), Two (2) medication errors were identified while observing a total of 25 opportunities, affecting Resident #19, and Resident #107. The findings included:Review of the facility's policy, titled, Medication Administration, issued 10/2020 and revised 01/2024, revealed, The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1.Record review revealed Resident #19 was admitted to the facility 10/28/24 with a primary diagnosis of Unilateral Primary Osteoarthritis, Left Hip. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of Resident #19's care plan revised 07/16/25 and initiated 10/29/24 documented The resident has pain and/or is at risk for pain related to chronic physical disability, contracture, peripheral neuropathy with an intervention that documented, Administer analgesia medication as per orders. During a medication administration observation on 07/29/25 at 9:00AM Staff M, Registered Nurse (RN) administered the scheduled oral medications and applied Lidocaine patches to both of Resident #19's knees. Review of the active orders revealed Resident #19 had an order, dated 11/08/24, for Lidocaine External Patch 4%, that included directions that stated, Apply to knee, hip topically one time a day for Pain and remove per schedule. On 07/29/25, Resident #19's Medication Administration Record / Treatment Administration Record (MAR/TAR) revealed from 07/01/25 to 07/29/25, the Lidocaine Patch had been applied to both knees; on 07/03/25, it was applied to the right knee; and on 07/27/25, it was applied to the left knee. There was no documentation found to indicate the Lidocaine patch was applied to the hip on any day. An interview was conducted on 07/29/25 at 2:14 PM, when asked why Resident #19 was ordered Lidocaine patches, Staff M stated it was for knee pain and arthritis. When asked where the Lidocaine patches were ordered to be applied and who determined that, Staff M stated to both knees and the doctor determined that. During a side-by-side review of Resident #19's active orders, Staff M read the order out loud and stated, Lidocaine patch 4% apply to knee and hip. When asked how she knew which knee and which hip, Staff M did not reply. When asked who has determined the application of the Lidocaine patches to bilateral knees and not the hip, Staff M did not reply. Staff M stated she would clarify the order with the doctor and added, As a Registered Nurse, I should have reached out to the doctor to clarify and double checked my orders. An interview with the Director of Nursing (DON) was conducted on 07/29/25 at 2:25 PM. During a side-by-side review of Resident #19's Lidocaine Patch order, when asked how she interprets the order the DON stated, the order doesn't specify which knee or which hip. The DON reviewed recent doctor's notes to see if there were any clarifications of the orders, but none were found. The DON was made aware of the medication administration observation and agreed with the findings and stated she would get the order clarified. During an interview on 07/30/25 at 1:00PM when asked how long she had been receiving Lidocaine Patches on both knees, Resident #19 stated she had been receiving patches on both knees for about 3 months. 2. Record review revealed Resident #107 was admitted to the facility on [DATE] with diagnoses that included Traumatic compartment syndrome of right lower extremity, subsequent encounter, Pedestrian injured in unspecified traffic accident, subsequent encounter, and Unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing. On 07/29/25 at 9:10 AM, an observation was conducted with Staff A, Licensed Practical Nurse (LPN), giving medication to Resident #107. She was instructed by the surveyor to pull out the medication card from the drawer, pop the pill and show the card to the surveyor. A total of 11 medications were administered at the time of the observation. The surveyor watched Staff A pull the cards from the drawer and pop the pills from the card. After observing Resident #107 take his medications, the surveyor reconciled the medication given vs the physician order. Upon reconciliation, the card for Venlafaxine read Venlafaxine HCL oral tablet 25 milligrams (mg) give 2 tabs by mouth three times a day for depression. The order on the Medication Administration Record (MAR) read Venlafaxine HCL oral capsule extended release 24-hour 150 mg give 1 capsule by mouth one time a day for depression. An order was found under discontinued medication for the Venlafaxine 25mg. On 07/29/25 at 11:00 AM, the surveyor asked Staff A where the card was for the Venlafaxine. Staff A showed the surveyor the 150mg capsule card. She was asked if she had another card for Venlafaxine in the cart. She showed the surveyor the 25mg card and said that she did not give that one, she gave the 150mg medication. The surveyor explained the process that was discussed at the beginning of the medication observation and explained that the 25mg card was the card she had showed the surveyor and the card that the surveyor observed her pop the pills out of so that was an error.

Based on record review and interview, the facility failed to ensure adequate monitoring for behaviors for a resident receiving a psychotropic medication for 1 of 1 sampled resident reviewed, Resident #12. The findings included:Record review revealed Resident #12 was admitted on [DATE] with diagnoses to include Anxiety Disorder, Restlessness and Agitation, Depression, Alzheimer's Disease, and Unspecified Dementia with Agitation. Review of Resident #12's physician orders revealed an order for Alprazolam (Xanax) 0.25 MG 1 pill by mouth every 12 hours as needed for Anxiety. The resident's prior order, back to February, included Alprazolam 0.25 MG or 0.5 MG every 8 hours.Review of the current care plan documented Resident #12 uses an anti-anxiety medication related to anxiety disorder. The interventions included to 'Monitor / record occurrence of for target behavior symptoms and document as indicated. Date Initiated: 03/03/25.'Review of the resident's Medication Administration Record (MAR) documented an order for behavioral monitoring for psychotropic medication to be completed every shift. Review of the month of July 2025 documented Resident #12 was given Alprazolam nineteen times in July but documented no behaviors for the month of July. Review of June 2025 MAR documented Resident #12 was given the Alprazolam thirteen times with only one day, on 06/23/25, documenting her behaviors. Review of May 2025 MAR documented Resident #12 was given the Alprazolam eighteen times and documented the resident had no behaviors. An interview was conducted on 07/30/25 at 12:32 PM with Staff S, Registered Nurse (RN), who was asked if Resident #12 is given Alprazolam for Anxiety and what behaviors would the resident exhibit for the medication to be given. Staff S stated, 'when resident is making a lot of noise and bothering her roommate, getting agitated'. When asked if they document her behaviors in the MAR for the reason, they gave the 'as needed' anxiety medication, the RN stated we document when we give the medication. She showed the surveyor how she documented in the MAR but it did not document her behaviors. She stated, So I should be documenting her behaviors when I give her one. An Interview was conducted on 07/30/25 at 2:45 PM with the Director of Nursing (DON) who was asked if the nurses should be documenting behaviors if resident is given Alprazolam as needed. She stated yes and acknowledged that the nurses have no documentation under behaviors but should be documenting what behaviors the resident is having, that would show why she is giving the medication. The DON stated If the resident is having behaviors such as agitation or anxiety, the resident would be given the Xanax (Alprazolam) for the behavior, if she has no behaviors she would not be given it.

Based on observations, interviews, and record review, the facility failed to apply a resting hand splint for 1 of 1 sampled resident, Resident #3, reviewed.The findings included: Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Multiple Sclerosis (an auto immune condition which symptoms includes loss of power in the arms and legs) and Quadriplegia (which is characterized by the complete or partial loss of movement and sensation in all four limbs (arms and legs)).Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired. Review of Section GG of the MDS dated [DATE] revealed Resident # 3 was impaired on both sides (both upper and lower extremities) and was dependent on staff for care.Review of the Physician's Orders documented Resident #3 had an order dated 02/18/25 for the resident to utilize right resting hand splint and right elbow splint up to 3 hours. Review of the physician orders dated 04/21/25 noted a late entry for 02/18/25 which documented to discharge to restorative nursing program (RNP) for right resting hand splint and right elbow splint application.Review of the Care Plan dated 04/21/25 documented Resident #3 had a need for restorative nursing program (RNP) for the right upper extremity hand and elbow splint/brace due to the presence of contractures. Goals were for the resident to tolerate the splint/brace schedule without exhibiting any signs and symptoms of pain or discomfort. Interventions were to communicate and educate restorative program goals and participation with the resident and to observe changes in tolerance level and notify the nurse.During observations on 07/29/25 at 8:54 AM and 12:29 PM, no splint was observed on the right hand of the resident.During an observation conducted on 07/30/25 at 8:42 AM, Resident #3 was laying on her right side without evidence of a splint present on right hand.On 07/30/25 at 12:46 PM, Resident #3 was observed resting on the left side with right hand contracted, resting on her upper body and no splint was noted. During an interview with Staff N, Unit Manager (UM), conducted on 07/30/25 at 12:15 PM, Staff N stated she occasionally served as the restorative nurse, but the facility had a restorative Certified Nursing Assistant (CNA), Staff K. During a side-by-side review of the RNP log binder for Resident #3's therapy log, there was a Restorative Program Communication / Education form signed and dated 07/25/24 which described the type of restorative program needed. During an interview conducted on 07/30/25 at 2:24 PM, with Staff K, CNA, the surveyor asked, if she was the restorative CNA and Staff K responded yes, I was appointed the role approximately one month ago but has not been trained. During an interview conducted on 07/31/25 at 8:51 AM with Staff L, CNA, the surveyor asked if Staff L was familiar with Resident #3 having a hand splint. She responded yes, it is in the drawer in the bedside table. During an interview with Registered Nurse, Staff M, conducted on 07/31/25 at 8:56 AM when asked if Resident #3 had a splint, Staff M replied that she is not familiar if the resident has a splint or not. During an interview on 07/31/25 at 9:56 AM, the Director of Nursing (DON) was asked about the RNP, who stated we do not currently have a restorative program. My team is new, and Staff K will be taking an active role, but she is not yet trained. The surveyor asked for the last time they had restorative services at the facility. The information was not provided prior to exiting of the facility.

Based on observations, interviews, policy review and record review, the facility failed to administer scheduled medications in a timely manner for 1 of 1 sampled resident, reviewed for pain management, Resident #86, as evidenced by medications being administered outside the 60 minutes window before or after the scheduled time, unless specified by the prescriber. The findings included:Review of the facility's policy titled, Standards and Guidelines: Medication Administration with a revised date of January 2024, documented, Procedure: .6. Medications are administered within one (1) hour before or after their prescribed time, unless otherwise specified (for example, before and after meal orders, a bedtime).Review of the record revealed Resident #86 was initially admitted to the facility 06/19/24 with a primary diagnosis of Unilateral Primary Osteoarthritis, Right Knee. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #86 had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident was moderately cognitively intact.Review of Resident #86's care plan revised 07/17/25 documented, Resident #86 has pain and/or is at risk or pain related to general discomfort and pain, Breast Cancer status post mastectomy, history of total knee replacement, and shoulder repair with an intervention on Administer analgesia medication as per orders; observe for and report to nurse any resident complaints of pain, requests for pain treatment and non-verbal s/s of pain: facial grimacing, changes in breathing, rubbing or holding body parts, crying, groaning, furrowed brow, etc. and pain medication review as needed/indicated.Review of Resident #86's active physician orders revealed a scheduled order for Gabapentin Oral Capsule 300 MG 2 capsule given by mouth three times a day for neuropathy; and Oxycodone HCl Oral 5 MG 1 tablet given by mouth every 6 hours for pain.During an interview on 07/28/25 at 12:06PM when asked about her care, Resident #86 stated she doesn't receive her scheduled pain medications on time, There are times I have had to go out in the hall and chase the nurse's down to get my medications. Resident #86 stated she has had to call 911 before due to not having received her pain meds because she didn't know what else to do.Review of Resident #86's grievances were reviewed for:12/4/24; 12/11/24; 12/17/21; 12/27/24; 01/3/25; 01/25/25; 02/5/25; 02/20/25; and 06/12/2,5 all including medication related concerns that included the untimely the administration of medications. The grievances that had concerns of untimely medication documented the Director Of Nursing (DON) checked the Medication Administration Record / Treatment Administration Record (MAR/TAR). All grievances were signed off by the Administrator as reviewed and approvedDuring an interview on 07/31/2025 at10:22 AM when asked how she resolves grievances that involve late medications or not receiving medications, the DON stated she looks at audits, looks at MAR/TAR, interviewed staff, resident and family if needed. When asked how she had resolved Resident #86's medication grievances she states that they have gotten pain management and neurologists involved, hospital visits as needed and looked at the Resident's MAR/TAR time stamps.Review of Resident #86's MAR/TAR for July 2025 did not show time stamps for the scheduled pain medications administered.Review of a more detailed report provided of the administration summary (report of the time the medication was actually signed off as administered) for Resident #86 from 07/01/25 to 07/31/25 for the medications Gabapentin 300MG and Oxycodone HCl 5 MG revealed the following:Gabapentin 300MG:On 07/03/25 for the scheduled time of 10:00 PM, the medication was administered at 11:01 PM.On 07/10/25 for the scheduled time of 6:00 AM, the medication was administered at 7:20 AM.On 07/11/25 for the scheduled time of 9:00 AM, the medication was administered at 10:40 AM.On 07/18/25 for the scheduled time of 9:00 AM, the medication was administered at 10:05 [NAME] 07/23/25 for the scheduled time of 9:00 AM, the medication was administered at 10:38 [NAME] 07/25/25 for the scheduled time of 9:00 AM, the medication was administered at 12:12 PMOn 07/25/25 for the scheduled time of 1:00 PM, the medication was administered at 2:27 PMOn 07/26/25 for the scheduled time of 9:00 AM, the medication was administered at 11:11AMOn 07/26/25 for the scheduled time of 1:00 PM, the medication was administered at 2:25 PMOxycodone HCl 5 MG:On 07/06/25 for the scheduled time of 12:00 AM, the medication was administered at 2:03 [NAME] 07/12/25 for the scheduled time of 12:00 PM, the medication was administered at 1:01 PMOn 07/16/25 for the scheduled time of 12:00 PM, the medication was administered at 1:13 PMDuring an interview on 07/31/25 at 12:00 PM, the [NAME] President for Risk Management stated nurses have 1 hour before and 1 hour after the scheduled time to administer a medication.During an interview on 07/31/25 at 12:45 PM, when asked how much time nurses have to administer a medication, Staff M, Registered Nurse (RN) stated they have 1 hour before and 1 hour after the scheduled administration time. When asked what is considered 'a late medication', Staff M stated anything given more than one hour late from the scheduled time. When asked if they had a late medication where would it be documented, Staff M stated she would document it as a progress note and notify the doctor.During an interview on 07/31/25 at 12:48 PM, when asked how much time they had to administer a medication, Staff R, Licensed Practical Nurse (LPN), stated they have 1 hour before and 1 hour after the scheduled administration time. When asked what is considered 'a late medication', Staff R stated anything past the hour after the scheduled medication time. When asked if they have a late medication where would it be documented, Staff R stated she would document the reason why as a progress note and notify the doctor to approve the late medication.Resident #86's progress notes were reviewed and did not reveal any documentation to support late medication administrations.On a follow up interview on 07/31/25 at 12:50 PM, when asked if she had made any grievances lately on late medications, Resident #86 stated she didn't think they were addressed due to it still being a problem, and she gave up on making grievances since they didn't do anything about it.

Based on record review and interview, the facility failed to review and revise care plans for discontinued physician orders for psychotropic medication for 2 of 28 sampled residents, Resident #6 with discontinued physician orders for antipsychotic medication, and Resident #49 for discontinuation of Transmission Based Precautions, peripherally inserted central catheter (Pic) line and antibiotics. The findings included:Review of Resident #6's medical records revealed Resident #6 was admitted on [DATE] with a diagnosis to include Major Depressive Disorder and Unspecified Dementia without Behavioral Disturbances, Psychotic Disturbance, Mood Disturbance and Anxiety. Review of Resident #6's care plan documented the resident uses antipsychotic medication. Further review of the physician orders does not show a current order of antipsychotic medication. Review of the discontinued orders documented the resident had been on Aripiprazole 2 MG at bedtime for Depression and it was discontinued on 07/25/25. Review of Resident #49's medical records revealed Resident #49 was admitted to the facility on [DATE]. Review of Resident #49's care plan documented the resident is on antibiotics for Cellulitis and Methicillin-resistant Staphylococcus aureus (MRSA), has a Pic line (peripherally inserted central catheter) for antibiotics, and is on Transmission Based Precautions (TBP) for MRSA. Review of the current physician orders did not document any of these orders. Further review revealed the antibiotics, the TBP and pic line were all discontinued, and the care plan should have been updated.An interview was conducted on 07/30/25 at 2:35 PM with the Director Of Nursing (DON) who was asked if Resident #49 was on TBP for MRSA. She stated she thinks he was, and his last dose of antibiotics was 07/07/25 for the MRSA. The DON confirmed that when the resident came in on 07/07/25, they reviewed his chart, he did have his last dose of antibiotic on 07/07/25, and the resident's isolation would have been over. She acknowledged his care plan was not updated to reflect his. An interview was conducted on 07/31/25 at 1:30 PM with the MDS (Minimum Data Set) Coordinator who was asked about the timeframe for updating the care plans when orders have been discontinued. The coordinator stated she refers back to the RAI and reviews the residents progress notes. She stated they have meetings everyday first thing in the morning and it's her responsibility to print out an updated report. She said it's called an order listing that she would run with what is happening in the building, that includes anyone who has medication changes or an order change. She stated she would pull this listing during morning meeting. She stated this occurs when we meet on Monday, we look at the previous Friday to Monday orders, and when we meet Tuesday, we look at Monday orders and so on. She acknowledged that Resident #6 and Resident #49s' care plans should have been updated.

Based on observations, interviews and record review, the facility failed to implement written policy and procedures to prevent abuse for 3 of 3 abuse allegations affecting Residents #33, #48, #101, #86, and #38, as evidenced by lack of communication by staff to management, lack of documentation of events, and lack of documentation of notification to management, physicians and families. The census at the time of survey was 98 residents. The finding included: Review of the facility’s policy titled, “Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI)” with a revised date of 03/2025 included in part the following: Training and Prevention: c) what constitutes abuse, neglect, exploitation, misappropriation, mistreatment, and injury of unknown origin. Reporting policies and procedures established by the center. Reporting: Annually notifying covered individuals, of that individuals obligation to comply with the following reporting requirements a) each covered individual shall report to the state agency and one or more law enforcement entities for the political subdivision in which the facility is located nay reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from eh facility b) each covered individual shall report immediately, but no later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Staff are required to report any allegation of ANEMMI to the facility risk manager, direct supervisor, and/or abuse coordinator immediately upon knowledge of the allegation. Allegations of possible ANEMMI will be reported to state agencies per the federal regulation timeframe. State agencies may include (but are not limited to): Abuse Hotline (Department of Children and Families) State Agencies (Agency for Health Care Administration) Local Law Enforcement. For alleged violations of ANEMMI including injuries of unknown source, the surveyor reviews whether the facility maintains evidence that alleged violations are thoroughly investigated. There is no specific investigation process that the facility must follow, but the facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary (if any) for the protection of resident. Depending upon the type of allegation received, it is expected that the investigation would include but is not limited to conducting observation of the alleged victim, including any identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other resident, and interactions/relationships between resident to other resident. Conducting interviews with as appropriate the alleged victim and representatives, alleged perpetrator, witnesses, practitioner, interviews with personnel from outside agencies such as other investigatory agencies and hospital or emergency room personnel. Conducting record review for pertinent information related to the alleged violation, as appropriate, such as progress notes, financial record, incident reports (if used), reports from hospital / emergency room records, laboratory or x-ray reports, medication administration records, photographic evidence, and reports from other investigatory agencies. Review of the facility’s policy, titled, “Documentation” with a revised date of 01/2024 included in part the following: The following information is to be documented in the resident medical record a) objective observations, b) medications administered, c) treatments or services performed, d) changes in resident’s condition. Documentation in the medical record will be objective (not opiniated or speculative), complete and accurate. 1.Review of the record revealed Resident #86 was initially admitted to the facility 06/19/24 with a primary diagnosis of “Unilateral Primary Osteoarthritis, Right Knee.” Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #86 had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident was moderately cognitively intact. Review of the record revealed Resident #38 was admitted to the facility 4/19/22 with a primary diagnosis of “Cerebral Atherosclerosis” (a condition where fatty deposits, called plaque, build up inside the arteries that supply blood to the brain) and a secondary diagnosis of Vascular Dementia, mild, with mood disturbance. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #38 had a Brief Interview for Mental Status (BIMS) score of 03, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. An interview was conducted on 07/28/25 at 12:06 PM and when asked about her care, Resident #86 stated on Saturday 07/26/25 that Resident #38 came into her room and Resident #86 tried to re-route her back out when she was punched on both of her hands by Resident #38. Resident #86 stated they did not call a doctor or did imaging and had told them her right hand was in pain; and she had to request for ice herself because she was not given any by staff. Resident #86 stated she was asked by staff to write down her witness statement, “I had to use my injured hand to write it.” Review of Resident #38 and Resident #86’s electronic medical record (EMR) did not reveal documentation from staff of the incident that occurred 07/26/25. Further review of the record did not reveal physician orders or documentation related to this incident for the day of the incident. An interview was conducted on 07/28/25 at 3:23PM with the Administrator and the Director of Nursing (DON). When the resident-to-resident incident between Resident #86 and Resident #38 was discussed, the Administrator and the DON both stated they had not been made aware of the incident. When asked if they could provide documentation from the EMR regarding this occurrence, they were not able to find any documentation in the EMR. The incident had not been investigated because their staff had not made them aware of what had occurred on 07/26/25. On 07/29/25 at 8:55 AM, the Administrator was asked who had been educated on Abuse and Neglect when the incidents occurred and the Administrator stated that only staff involved were educated but the educations were not facility wide. During a follow up interview on 07/29/25 at 9:40AM, Resident #86 stated the police came to talk to her yesterday, asked her what happened and left. When asked for clarification on what staff she had told on 07/26/25 that she had been punched by another resident, Resident #86 stated she couldn’t remember her name, but it was the nurse who was taking care of her who was made aware. Resident #86 stated, “She came in right after it happened.” Review of the Investigation was conducted regarding the incident from 07/26/25, involving Resident #38 and Resident #38 which was reported on 07/28/25 after the surveyors had made the Administrator and DON aware. Witness statements from Staff O, Certified Nursing Assistant (CNA) and Staff D, Licensed Practical Nurse (LPN) were both added to the investigation. Both of these staff members were aware of Resident #86’s allegations the night the incident occurred. Review of the physician orders revealed two new orders: A diagnostic order for the right wrist and fingers named, “WRIST RT 3V* | FINGERS RT 3V”, documented it was sent on 07/28/25 at 4:06PM and another order that documented “apply ice pack to right finger for 20 minutes as needed, every 4 hours for discomfort for 3 Days” dated 07/29/25. Both orders were added 2-3 days after the incident had occurred. A late entry note from Staff D dated 07/28/25 at 10:02 PM documented, “resident informed writer of alleged resident to resident altercation. Writer attempted to interview resident, and she was unwilling to give statement, writer attempted to do a head-to-toe assessment, and she refused. Writer then went into alleged perpetrator room and observed her resting in bed with assigned aide at bedside. MDs and families notified.” No documentation was found to support the notification to the doctor or families made. An interview was conducted with the DON on 07/29/25 at 8:45AM who when asked to provide evidence that the family was notified of the incident for Resident #86, the DON was not able to obtain any documentation in the EMR. A phone interview was conducted on 07/30/25 at 12:00 PM with Staff O, Certified Nursing Assistant/CNA, who recalled the incident from 07/26/25 but was not aware of the incident until Monday 07/28/25. Staff O stated, “Resident #86 did not tell me anything happened on Saturday”. Staff O stated she had not worked with Resident #86 frequently but that night both Resident #38 and Resident #86 were on her assignment. Staff O stated that Resident #86 always makes allegations of other residents hitting her. Staff O stated she was assisting Resident #38 that night and stated she never got out of bed nor is she capable of walking by herself. When asked how she found out about the incident if she was not made aware by Resident #86, Staff O stated that on Monday 07/28/25, she saw the police show up and go into Resident #86’s room; the nurse pulled her aside and told her what happened and then she was asked by the DON to provide a statement. This statement was conflicting with the statement Staff O provided to the facility as part of their investigation. An interview was conducted on 07/30/25 at 1:12 PM with Staff P, Advanced Registered Nurse Practitioner (ARNP), who when asked if she was made aware of the resident-to-resident incident that Resident #86 was involved in, Staff P stated she was made aware over the weekend by several nurses. She could not recall what nurses called her. Staff P stated she gave orders for imaging, Tylenol, Ibuprofen, and ice. Staff P stated Resident #86 had made similar allegations in the past. When asked if she documented her orders or the encounter, Staff P stated she did not document it but had given the orders to the nurses taking care of Resident #86. Staff P stated she would add a late entry note from during the weekend. Review of the late entry note entered by Staff P dated 07/30/25 at 10:23 PM documented, “…There was an incident on 7/26/25, which was reported to me over the weekend via phone by two nurses. [Resident #86] reported a resident attacked her. She reported the resident twisted her right index finger, x-ray of Right hand and wrist were ordered. Patient to apply ice to affected extremity. Patient also with complaints of right knee pain. No evidence of injury. Ice packs provided. Patient to apply ice pack 20 minutes on/off 20 minutes x 3 days. Tylenol / ibuprofen were recommended for pain if needed. These orders were provided to nurses over the weekend, during conversation regarding the incident. X-ray results discussed with patient today. No acute findings…” A phone interview was conducted on 07/30/25 at 1:58 PM and continued on 07/31/25 at 1:00 PM in person with Staff D, LPN. Staff D stated, “[Resident #86] approached the nurses’ station, and said I have just been beat up. I could not see any signs of injury. She stated, the resident who hit her was Resident #38, went to Resident #38’s room and the resident was lying in bed and Staff O was providing care to her.” Staff D stated she voiced to Staff O the allegation that Resident #86 had made against Resident #38; Staff O replied, how she has been in bed. Staff O stated she told her unit manager at the time, Staff Q, (LPN), who told her to get a witness statement from Resident #86. Staff D stated when she went into room and asked to assess Resident #86, the resident threw the paper and pen at her and Staff D left the room. Staff D stated that no statement was received from Resident #86. Staff D stated both residents' doctors and families were notified. The Power of Attorney (POA) for Resident #86 did not call back. Staff D couldn’t recall the name of the ARNP who she notified for Resident #86, she stated the ARNP replied by stating “Okay I will notify the primary attending and if she has any further questions she can reach out tomorrow, thanks. Staff D stated no orders were given on 07/26/25. When asked if she documented the incident or notification to the ARNP, Staff D stated she did not document anything and made a late entry note when the Administrator and DON talked to her about it on Monday, 07/28/25. When asked why she didn’t notify anyone else of the incident she stated she didn’t think the incident could have happened since Resident #38 was bed-bound and Resident #86 always makes allegations that other residents hit her. Staff D stated she understands it is not for her to determine if the incident happened or not and she should have reported it. Staff D stated, “From now on I’m going to document everything that happens.” A phone interview was conducted on 07/31/25 at 12:20PM with Staff Q, LPN, who when asked about the incident regarding Residents #38 and #86, Staff Q recalled that Staff D stated Resident #86 had made an allegation of being hit by another resident (Resident #38). Staff Q told Staff D to take a statement. She had been told by Staff D that Resident #86 kicked her out. Later Staff Q followed up with Resident #86 who refused to talk to her. She stated she also followed up with Resident #38 who was in bed all evening according to an interview Staff D had with Staff O. When asked if she notified anyone else of the incident, Staff Q stated she did not notify anyone else. When asked if she notified a nurse practitioner, she stated she did not call anyone. Staff Q stated she thought there was no way the incident could have happened, so she didn’t notify anyone. When asked about any abuse and neglect educations that were provided prior to this incident, she stated she should report any suspicions of abuse including allegations of abuse. When asked if the incident between Resident #86 and Resident #38 would be considered something to report, Staff Q stated yes, I should have reported it but didn’t because I thought there was no way that could have happened. When asked if Staff Q should have made that determination, Staff Q stated she understood she should have reported the incident, and it was not for her to determine if it happened. When asked if she had documented the incident, she stated she did not. During an interview on 07/31/25 at 3:37 PM, when asked if she was involved in the incident that happened Saturday 07/26/25, Staff N, Registered Nurse (RN), stated she was not working Saturday. Staff D told her about the incident on Monday 07/28/25 and went to assess Resident #86; she got orders for an x-ray and ice since there was already pain medications ordered. Staff N stated she was the one that contacted Staff P on Monday to notify her of the incident. 2. Record review for Resident #48 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Transient Cerebral Ischemic Attack, Anxiety Disorder, Major Depressive Disorder Recurrent and Weakness. The MDS assessment dated [DATE] documented in Section C a BIMS score of 15, indicating an intact cognitive response. Record review for Resident #101 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Unspecified Dementia Unspecified Severity with Other Behavioral Disturbance, Muscle Weakness (Generalized), Depression, and Unspecified Mood (Affective Disorder). The MDS assessment dated [DATE] documented in Section C a BIMS score of 3, indicating severe cognitive impairment. Review of the Progress Note for Resident #48 with a created date of 07/28/25 with an effective date/time of 07/09/25 at 8:33 PM included in part the following: Late Entry: Resident #48 informed this writer that a male resident (Resident #101) was in her bed. Upon entering the room, Resident #101 was observed sitting on the side of Resident #48’s bed. Resident #101 was redirected to his room and then immediately transferred to another location on the other side of the building. Physician and family were notified. Administrator and DON were made aware. Record review for Resident #101 revealed no documentation of the incident on 07/09/25 involving the resident wandering into Resident #48’s room and crawling into her bed with her present and touching her. There was no documentation of the family or physician being notified. Review of the Report dated 07/09/25 filed by the Administrator involving Residents #48 and #101 documented the following: Staff D, Licensed Practical Nurse (LPN), became aware of the incident on 07/09/25 at 9:00 PM. Resident #48 stated that around 9:00 PM while lying in bed, she felt someone next to her. She identified Resident #101 as the perpetrator. She immediately got out of bed and went to notify the nurse on duty (Staff D, LPN). Resident was assessed by nursing supervisor, her mood was normal no distress noted, skin assessment was completed with no injuries noted. Resident #101 was immediately placed on close monitoring pending further investigation and was removed and relocated to another room on another unit in the facility. Resident #101 was confused and unable to respond to any questions. Psychiatric consult was initiated by the facility. Resident #48 was alert and oriented and able to provide police officer with a statement of events. Summary of the facility’s interviews with the participants included in part the following: Another nurse [Staff E, LPN] came to assist Staff D, LPN. Summary of corrective action(s) taken: Resident #101 was discharged to a memory care unit. Staff education was completed on Alzheimer’s and Dementia. Review of the in-service training from 07/09/25 for nursing staff, titled, “Abuse, Neglect, and Exploitations” by Centers for Medicare and Medicaid Services with no date, included in part, the following: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation involve abuse or result in serious bodily injury. Review of the computer based training titled, “Abuse, Neglect, Exploitation, Misappropriation of Property, Mistreatment and Injury of Unknown Source” with no date and was provided to all staff from 07/01/25 to 07/30/25 included in part the following: Facility Reporting and Investigation: Reporting requirements for any suspected occurrence of abuse: Within 2 hours if the events involve abuse or result in serious bodily injury. Reporting Abuse or Suspected Abuse: What to Do: Stay calm and ensure the resident is safe. Report immediately to your supervisor, charge nurse, or administrator. Document what you say or heard – include facts, not assumptions. Follow the facility’s abuse reporting policy. An interview was conducted on 07/28/25 at 9:30 AM with the Administrator who was asked if they have a memory care unit and she said no. She said they have residents with Dementia, but they do not wander. She added we don’t have locked units or wander guards. An interview was conducted on 07/30/25 at 8:55 AM with the Administrator and the Director of Nursing present, when the Administrator was asked about what education has been provided to staff on or after 07/28/25 when they were made aware of the two incidents that happened on 07/26/25, the Administrator stated they have only provided education to the direct staff involved. An interview was conducted on 07/30/25 at 3:52 PM with Staff G, Registered Nurse (RN), who stated she has worked at the facility as and RN since 07/02/25 and before that she was a CNA at the facility for 8 years. She was the nurse who took care of both Residents #48 and #101 on 07/26/25. Staff G stated that on that night, Resident #101 went into Resident #48’s room to use the bathroom and Resident #48 woke up and she had alerted Staff F, Certified Nursing Assistant (CNA), who came into the room and tried to remove Resident #101 but was unable to do so, so she went to get Staff G and they both entered the bathroom, and she spoke to Resident #101 who had taken off his soiled underwear. Resident #101 refused to leave the bathroom and did not want to be touched; they waited until he was finished using the toilet. She spoke to Resident #48 and apologized for the incident and when Resident #101 was finished using the toilet, Staff F and herself were able to escort Resident #101 out of Resident 48’s bathroom and room. Resident #101 did not go back to his room until another Staff H, CNA, came and escorted Resident #101 back to his room. When asked if she documented the incident anywhere either in Resident #48 or Resident #101 medical record, she said no she did not. When asked if she reported the incident to anyone she said 'yes, the following Monday (07/28/25) she reported the incident to DON and the Administrator only after they had asked her about the incident'. When asked if she notified the family for each resident, she said 'no she did not notify the family for either resident'. She also acknowledged she did not notify the physician for either resident. When asked if she has had abuse training, she said yes and had completed it on the Master computer system. The new abuse training had just come out since the incident on 07/26/25 and she started it but has not finished it as of yet. The procedure when something like this happens, she was unaware she needed to inform the family, the physician and needed to report to the DON or Administrator. An interview was conducted on 07/31/25 at 8:40 AM with the Administrator who stated all staff do the abuse training on the computer system annually and they also provide in-service abuse training with each abuse allegation and that it targeted toward the nursing staff. The Administrator stated she feels their abuse education may not be effective, based on the most recent allegations of abuse that neither she nor the DON were made aware of by the staff involved. The Administrator stated she has been working on making a new abuse quiz with scenarios and will start implementing the abuse training with the new quiz today. An interview was conducted on 07/31/25 at 8:50 AM with the Administrator, the [NAME] President of Risk Management (VPRM) and the [NAME] President of Operations (VOO), the VPRM acknowledged they chart by exception, and they will be providing direct education to the nurses involved in the abuse allegations regarding reporting, notifying family and physician and documentation being performed in a timely manner. The VOO added they are looking into changing the abuse training corporate wide. An interview was conducted on 07/31/25 at 12:51 PM with Staff D, LPN, who stated she has worked at the facility for 1 month. When asked about the incident on 07/09/25 involving Residents #48 and #101, the LPN stated Resident #48 approached her to inform her that Resident #101 was in her bed, she got the other nurse (Staff G RN) to help her get Resident #101 out of the bed and move him to a vacant room in another pod. She said she reported it to Resident #48’s daughter and the other nurse reported it to the son for Resident #101. She said she spoke with both nurse practitioners for each resident. The LPN stated she had reported it to the DON and the Administrator that same night and also spoke with a police officer. When asked if she documented the incident in the chart for each resident, she stated she believes so. When asked about abuse training, she said she took the computer-based abuse training upon hire and has not had any additional abuse training. 3. Record review for Resident #48 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included in part the following: Transient Cerebral Ischemic Attack, Anxiety Disorder, Major Depressive Disorder Recurrent and Weakness. The Minimum Data Set (MDS) assessment dated [DATE] documented in Section C that Resident #48 had a Brief Interview of Mental Status (BIMS) score of 15 on a 0-15 scale, indicating the resident was cognitively intact. Record review for Resident #33 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Unspecified Sequalae of Cerebral Infarction, Cognitive Communication Deficit, and Unspecified Dementia Unspecified Severity with Agitation. The MDS assessment dated [DATE] documented in Section C that Resident #33 had a BIMS score of 4 on a 0-15 scale, indicating severe cognitive impairment. An interview was conducted on 07/28/25 at 11:37 AM with Resident #48 who was asked if she feels safe in the facility, she replied, “No, just the other night a male resident [Resident #33] came into my room and used my bathroom, and his diaper was partially down, and he was exposed.” Resident #48 reported that this incident happened on Saturday, 07/26/25. When asked if she had advised staff, she reported that she went to the nurse’s station and three staff members (Staff F, G and H) had to come into her room to assist Resident #33 out of her bathroom. Record review for Resident #33 and Resident #48 revealed no documentation of the incident on 07/26/25 involving Resident #33 going into Resident #48’s bathroom and had exposed himself to her when he pulled down his diaper to use the toilet. For both residents, there was no family or physician notification of the incident. On 07/28/25 at 3:18 PM, the Administrator and the Director of Nursing (DON) were asked about the incident on 07/26/25 involving Resident #33 going into Resident #48’s room to use the bathroom and Resident #33 was wearing a diaper that was partially down exposing himself to Resident #33 and that Resident #48 had reported this to Staff F, G and H who assisted Resident #33 out of the room. The Administrator and DON both stated they were not aware of the situation. They both acknowledged there was no documentation of the incident in the residents’ record. A telephone interview was conducted on 07/31/25 at 11:10 AM with Staff F, Certified Nursing Assistant (CNA), who stated she has worked at the facility for 3 years. Staff F stated that on 07/26/25 around 11:20 PM, she was talking at the nursing station and Resident #48 approached the nursing station and asked her to help her get Resident #33 out of her room, he was in her bathroom. When she went to the room of Resident #33, the resident refused to leave stating he was using the bathroom, so she shut the door. She notified Staff G, Registered Nurse (RN), that Resident #33 refused to leave the bathroom. Staff G said to get Staff H, CNA, to assist her in removing Resident #33 and he was able to get Resident #33 out of the bathroom. When asked if she reported the incident to anyone, she said no because the nurse already knew about it. When asked if she had received any training on abuse, she said she did it on the computer and the in-service but was unable to remember the dates. A telephone interview was conducted on 07/31/25 at 11:25 AM with Staff H, CNA, who stated he has worked at the facility since December 2024. When asked about the incident on 07/26/25 with Residents #48 and #33, he stated he was called by another CNA to help get Resident #33 out of Resident #48’s bathroom. Staff H stated he put on gloves and escorted Resident #33 out of the Resident #48’s room. When asked if he had reported this to anyone, he said he did not know there was any issue to report, he just knew Resident #33 was confused. When asked about abuse training, he said he just had an in-service yesterday. An interview was conducted on 07/28/25 at 3:15 PM with the Director of Nursing (DON) who stated she has been in the DON (Abuse Coordinator) role for about 1 year and the Administrator (Risk Manager) who has been at the facility for 3 years. When asked about documentation for an allegation of abuse between Residents #48 and #101, they stated the only documentation for each resident on the day of the incident was a skin assessment done on 07/09/25 for both residents involved. The Administrator and the DON were asked about the incident involving Resident #33 going into Resident #43’s room and was wearing a brief and had pulled down exposing himself to Resident #33 on 07/26/25 and that Resident #33 had reported this to staff who ushered Resident #33 out of the room, they both stated they were not aware of the situation. They both acknowledged there was no documentation of the incident in the resident’s record. The Administrator and the DON were asked about the incident involving Resident #38 and Resident #86 on 07/26/25 where Resident #86 reported to staff that Resident #38 had punched her in the hand and she was asked to produce a written statement for them and was being provided ice for her hand. They both stated they were not aware of the incident. When asked about documentation in the record for each resident involving the incident, they both acknowledged there was no documentation in either of the resident’s record. The Administrator and the DON were asked about the incident involving Resident #81 who had allegation of abuse on 07/09/25 by staff member toward him, the Administrator and DON stated they were aware and acknowledged there was no documentation in the resident’s record.

Based on observation, interviews, record and policy review, the facility failed to write a grievance as presented for 1 of 1 sampled resident reviewed for grievances, Resident #78. The findings included:Review of the facility's policy titled Grievances-Resident Rights issued 4/2027 and revised 6/2023 revealed, All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to verbally and/or in writing upon request including a rationale for the response. Record review revealed Resident #78 was admitted to the facility on [DATE] with diagnoses that included Arthritis and Anxiety. She scored 15 on the Brief Interview for Mental Status (BIMS) on the admission Minimum Data Set (MDS) dated [DATE]. This indicated that the resident had intact cognition. Section GG of the MDS revealed the resident needed partial, moderate assist with toileting hygiene. On 07/29/25 at 10:00 AM, the surveyor interviewed Resident #78. She stated she was generally happy with the care in the facility but last week on 07/23/25, a Certified Nursing Assistant (CNA) came into her room at 10:30 PM after she pressed the call light. The resident stated she needed to be changed. The resident stated the CNA told her she was on break now, and she would be leaving at 11:00 PM so she would have to wait for the next shift to be changed. The resident stated she made a grievance. review of the grievance that the resident made read Resident states no one came when push call button. The grievance was signed by Staff C, Social Worker Assistant. On 07/30/25 at 12:58 PM, Staff C was interviewed by the surveyor in the presence of the Administrator. Staff C was asked if this was the only thing that the resident told her. She stated that it was not. Staff C then stated that the resident told her that the CNA was on break right now and then she was going home, and she could stay wet until the next shift. Staff C was asked why she didn't put the full grievance on the form, and she could not give an answer. Because the full grievance was not on the form, it was not investigated fully. The finding was reviewed with the Administrator at the time of the interview with Staff C.

Based on observation, interview, record and policy review, the facility failed to provide medication in a dignified manner for 1 of 4 sampled residents for dignity, Resident #51. The findings included:Review of the facility's policy, titled, Resident Rights, issued 9/2021 and revised 1/2024, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be treated with respect, kindness, and dignity. Record review revealed Resident # 51 was admitted to the facility on [DATE] with diagnoses that included Bilateral primary osteoarthritis of knee, and Effusion right knee and left knee. The documented Brief Interview for Mental Status (BIMS) score was 14 on the quarterly MDS (Minimum Data Set) dated 07/11/25, indicting the resident had intact cognition. On 07/29/25 at 10:12 AM, the surveyor was sitting in the 100 pod making observations of the residents. Resident #51 was sitting at the table doing a puzzle. The surveyor observed Staff B, Unit Manager, Licensed Practical Nurse (LPN), bring Resident #51's medication to the table and put it down along side of him. She said nothing to the resident. He took the medication, and she took the cup of water away.On 07/29/25 at 11:15 AM, an interview was conducted with Staff B, who stated she did not know that she could not give medication at the table. She thought she just could not give injections at the table. She acknowledged she gave Resident #51 Cholecalciferol Tablet 1000 UNIT one tablet.On 07/29/25, Staff B wrote in the progress note while pt sits on pod doing his puzzle Nurse attempted to direct resident to his room for medication administration, resident refused voltaren gel to bilateral knees and states he prefers to take his meds at the table on the pod, resident's rights honored, medications administered as ordered, md/fam aware.Interview with resident on 07/30/25 at 12:15 PM revealed he acknowledged that his pill was given at the table yesterday and he did not ask the nurse to give it to him there.The finding was reviewed with the Administrator on 07/31/25 at 5:00 PM.

Based on record review and interview, it was determined, the facility failed to ensure discharge planning was implemented in a safe manner. The failure affected 1 of 2 sampled residents, Resident #1.The findings included:Clinical record review conducted on 07/01/25 revealed Resident #1 was admitted to the facility on [DATE] with diagnosis of Hemiplegia, Dysphagia, Diabetes, Stroke, and status post Coronary Artery Bypass Graft and Craniotomy.The clinical record documented Resident #1 was transferred to the emergency department on 03/30/25, as per the resident request. The resident had called 911 alleging the aide hit him over the head, the police and EMS (Emergency Medical Services) came, and the police verified there was no hitting on the video the resident presented to them. The resident was then taken to the hospital for evaluation. The resident returned the same day, as this is where he was residing at the time.On 07/01/25 at 12:54 PM, the Administrator (NHA) stated that [another State Government Agency] did not take the case when they called it in, but that on 04/04/25, the representative showed up to investigate the allegation of abuse for 03/30/25.On 04/04/25, the resident was discharged home, had gone back to the hospital that same day (04/04/25), then went to another nursing home facility, and is currently residing at home with family. Review of the Minimum Data Set (MDS) Discharge Assessment, with reference date of 04/04/25, documented the resident required partial to moderate assistance with bathing and dressing, was dependent with transfers and used a manual wheelchair for mobility. The resident was frequently incontinent of bladder and always incontinent of bowel and had an active discharge plan to return to the community. Review of the record documented the resident was alert and oriented to person, place, others, and time. Review of the Physician/Practitioner Progress Notes for service date of 04/02/25 documented: CHIEF COMPLAINT: Need for Assistance with Mobility and ADL's (Activity of Daily Living) secondary to recent caregiver neglect and pneumonia, now with medical debility.PAST MEDICAL HISTORY:CHF (Congestive Heart Failure), CAD (Coronary Artery Disease) with CABG (Coronary Artery Bypass Graft) X 2, HTN (Hypertension) and Brief Psychotic Disorder.HOSPITAL COURSE: . presented to the hospital on [DATE] with heart failure and was admitted to the ICU for Surgical Optimization for planned mitral valve replacement. Post Operative course was complicated by Acute Stroke with subsequent Hemorrhagic conversion, mitral valve thrombus, required emergency decompression craniotomy 2 days later. After rehabilitation, the resident had a readmission to the acute care hospital on 2/17/25 for complaints of caretaker abuse and neglect. Prior Level of Function: Per Family: Patient lived alone and was independent of all ADLs. Current Level of Function per therapists, the resident requires maximal assistance for bed mobility; dependent for transfers and ambulation. Review of the Social Service Notes dated 04/02/25 documented, Met with resident and spoke with [family member-X] via phone to discuss details of requested discharge on [DATE]. Family member requested I speak with [family member-Y]. Detailed message left requesting return phone call. Referral faxed to home health agency for nursing, therapy and home health aide. Referral faxed for a hemi-walker. Family to provide transport. Review of the Social Service Notes dated 04/04/25 documented, Resident did not discharge on [DATE] as his [family member-X] had his house keys and was not responding to phone calls. The [family member] came by today and dropped off the house key. I inquired if she would be at the house, she stated the other [family member] handles that. Spoke with the veteran's home health and they arranged for 30-35 hours per week, per resident request to advise discharge is for today and resident would like to resume services. [Family member] agreed she would check on him but is not available 24/7. Transportation arranged with [company] transport. A message left for [family member] advising her transportation will pick him up between 4:30 to 5 PM, requesting she be at the house. Resident advised. Review of the Discharge Planning/Summary Notes dated 04/04/25 documented, Resident is alert and oriented. Discharge instructions given by writer resident verbalized understanding. Resident left facility with [company] transport, all personal belongings in resident's possession confirmed. Resident escorted out of building via wheelchair by staff and transporter. All safety measures met. Review of the Home Health documentation revealed they were unable to reach the resident or family members on 04/03/25, 04/04/25 and 04/07/25. The facility staff wrote on 04/10/25 that the home health agency would not take Resident #1' s case due to high liability and the facility staff questioned why they did not notify the facility. An interview with the Social Worker (SW) conducted on 07/01/25 at 12:04 PM revealed that upon discharge, Resident #1 already had services set up from the veteran's association, in addition she set up home health services for therapy and nursing follow up. The resident wanted to go home and there was an issue with the [family member], who had the keys to his home, at some point he was living with the [family member] but now he wanted to go back to his own home. The facility set up transportation and two staff members accompanied the resident. The social worker recalled leaving a message with the [family member] to advise her of the time the resident was being transported so she could be present. The SW doesn't know if the family was at home when he arrived but recalls the Medicare agency was having a hard time getting hold of him and that he eventually ended up at the hospital. An interview with the Transporter conducted on 07/01/25 at 1:14 PM revealed himself and another staff followed the transport company to assist with getting Resident #1 home. Upon arrival, they knocked on the door and no one responded then the resident gave him the keys to open the door, and he requested to go into the bed. The bed was very high, and he suggested he sit in the recliner. The resident agreed and the resident was assisted to the recliner and the staff confirmed there was no one else at the house at the time. They left and closed the door. An interview with the Labor Coordinator, conducted on 07/01/25 at 1:20 PM revealed she accompanied the transporter to the resident's home but did not enter the house. An interview with the Director of Nursing and the Administrator conducted on 07/01/25 at 1:54 PM clarified that on 04/04/25, the [another State Government Agency] Investigator came into the facility to review an allegation of unsafe discharge. The family member did not want him home, but Resident #1 wanted to go home and did not appeal the discharge notice. The facility added that the resident was discharged to the same home, that he was previously discharged from another nursing facility. The Administrator was aware the resident was left by himself at the home. An interview with the [another State Government Agency] Investigator conducted on 07/01/25 at 2:37 PM confirmed the visit to the facility on [DATE]. The visit was due to an allegation of abuse, at the same time, he received a notice for unsafe discharge and asked the facility to hold the discharge until he was able to assess the resident. Upon completion of his visit, he asked the facility not to discharge the patient home alone as it was not safe. The [another State Government Agency] Investigator partnered with the local fire rescue to monitor the resident's discharge and also advised the family members that if the patient was discharged home by himself, they could call fire rescue for assistance. The [another State Government Agency] Investigator explained Resident #1 was home alone for over an hour, the family had to call fire rescue to enter the property and was subsequently transferred to a local hospital. Resident #1 was not able to care for self, transfer himself and the family was not willing to care for him. The [another State Government Agency] investigation determined the facility arranged for Resident #1, a vulnerable adult with physical limitations, to be discharged to home with home health services. The resident required maximum assistance with wheelchair mobility, was dependent for transfers in and out of a chair and bed and required substantial assistance with activities of daily living (ADLs). Per the [another State Government Agency] Investigator and the Administrator, Resident #1 had a documented history of caregiver abuse and neglect related to his two family members. The facility staff set up transportation to the home, and was aware of the family dynamics, and subsequently instructed two staff members to follow the resident's transport to home to ensure his safety. Resident #1 was assisted into his home by the facility staff and the transportation company and left alone with no supervision. The facility failed to determine whether appropriate and adequate support was in place, including the capacity and capability of the resident's caregivers at home. There was no evidence that family members, significant others or the resident's representative that should have been involved in this determination, with the resident's permission, were willing participants of the discharge process. The facility actions posed a risk to the resident's wellbeing.

Based on record review, interview and policy review, it was determined, the facility failed to report an allegation of abuse. The failure affected 1 of 2 sampled residents, Resident #1.The findings included: Review of the facility policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI), last revised 03/2025, documents Reporting: Allegations of possible ANEMMI will be reported to state agencies per federal regulation time frame. State agencies may include, Abuse Hotline, State Agencies and Local Law Enforcement.Initial reporting: allegations are reported immediately, but no later than two hours .within five working days of the incident, the facility must provide in its report, sufficient information to describe the results of the investigation and indicate any corrective actions taken. Clinical record review revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation services. Review of the Minimum Data Set admission (MDS) assessment with reference date of 03/13/25 documented the resident was assessed as independent with skills for daily decision making and had no behaviors. The clinical record documented Resident #1 was transferred to the emergency department on 03/30/25, as per the resident request. The clinical record documented Resident #1 was transferred to the emergency department on 03/30/25, as per the resident request. The resident had called 911 alleging the aide hit him over the head, the police and EMS came and the police verified there was no hitting on the video the resident presented. The resident was then taken to the hospital for evaluation. The resident returned the same day, as this is where he was residing at the time.On 07/01/25 at 12:54 PM, the Administrator (NHA) stated that another State Government Agency did not take the case when they called it in, but that then on 04/04/25, the representative showed up to investigate the allegation of abuse for 03/30/25. On 04/04/25, the resident was discharged home, had gone back to the hospital and then to another nursing home facility. Review of the Grievance log documents Resident #1 filed a grievance on 03/31/25, noting the resident states the aide came in the room more than one time to harass him. Review of the Social Worker Assistant note documented the following on the form titled, Resident Interview and Questionnaire Related to Abuse dated 03/31/25 documents as follows:Did you report the alleged abuse? Response, NO.Ask why didn't you report it to the nurse? Response, I called the person that came to mind,Did you report the alleged abuse to any external entities? Response, call 911 and fire rescue arrived. Review of the Police report dated 04/02/25 documents Made contact with Administrator who stated that one of her patients informed her that on 03/30/25, he got hit on the head by a nurse and that she was contacting [another State Government Agency]. The interview with the Administrator conducted on 07/01/25 at 12:54 PM also revealed Resident #1 never reported the allegation of abuse to her. The police came to the facility and reviewed the resident's phone video and determined there was no abuse. The administrator confirmed she contacted [another State Government Agency] for the incident and did not complete the required reporting to the regulatory agency, because she did not feel it met the criteria for abuse. The Administrator stated after the fact and researching the hospital records, she was made aware of the open [another State Government Agency] case alleging the resident was neglected at home, involving one of his family members. An interview with the [another State Government Agency] Investigator conducted on 07/01/25 at 2:37 PM confirmed he was at the facility on 04/04/25 to investigate an allegation of physical abuse for Resident #1. The investigation determined the facility failed to report the allegation of abuse to the regulatory agency.

Based on observation, record review, interview, and policy review, the facility failed to ensure proper care and services for the indwelling urinary catheters for 2 of 3 sampled residents, related to improper catheter care for Resident #1, and failure to properly anchor the indwelling urinary catheters for Residents #1 and #67, for the prevention of urinary tract infections (UTIs). The findings included: Review of the Indwelling Urinary Catheter Care Competency, (not dated), documented, in part, 11. Hold catheter near meatus (insertion site) to prevent pulling when handling and cleanse catheter using clean area of washcloth, washing away from the body and down the catheter at least 3 - 4 inches. Review of the Indwelling Urinary Catheter Insertion/Removal Competency, (not dated), documented, in part, 20. Anchor catheter (thigh if appropriate and coil tubing on bed and attach to mattress). 1. Review of the record revealed Resident #1 was admitted to the facility on [DATE]. Review of the current care plan initiated on 03/26/24, documented the resident was on an antibiotic for a Urinary Tract Infection (UTI). An observation on 05/03/24 at 9:13 AM revealed Resident #1 in bed, with a urinary catheter bag to bedside drainage. The urine in the tubing was very dark and cloudy. Photographic Evidence Obtained An observation of care to the indwelling urinary catheter was made on 05/03/24 at 10:49 AM. Resident #1 had an anchor attached to his thigh, but the catheter tubing was not secured in the anchor. Staff B, Certified Nursing Assistant (CNA), first provided personal care and changed the water basin. The CNA then held the catheter tubing about 8 to 10 inches away from the insertion site, wiping the tubing from the insertion site outward, pulling on the catheter during cleansing. Some visible brown debris was removed from the outside of the catheter tubing as the white washcloth was noted with brown debris. While cleansing the catheter tubing, the tubing that was pulled outward, had a ring of brown debris at the insertion site, that was not cleansed by the CNA. The catheter tubing remained out of the anchor throughout the care and the tubing was pulled taunt during care and while turning the resident from side to side. The CNA applied an adult brief, covered the resident, and went to the resident's bathroom to wash her hands. The CNA confirmed she was done with care. The CNA had not attempted to put the tubing into the anchor and the tubing remained taunt. During an interview on 05/03//24 at 2:44 PM, Staff C, Licensed Practical Nurse (LPN) stated she looked at the catheter this morning during rounds. When asked how the catheter was this morning, the nurse stated it was fine. When asked if she looked at the tubing, she said it was ok. The nurse was unaware of the cloudy urine or the lack of an attached catheter anchor. During an observation and interview on 05/03/24 at approximately 3:00 PM, the Director of Nursing (DON) agreed with the failure to utilize the anchor and that the urine was cloudy and should have been identified and acted upon by the direct care nurse, Staff C. 39167 2. Record review revealed Resident #67 was admitted to the facility on [DATE] with recent readmission on 04/24/24, with a diagnosis to include End Stage Renal Disease (ESRD). The Minimum Data Set (MDS) assessment, reference date 03/03/24, recorded a Brief Interview for Mental Status (BIMS) score of 06, indicating Resident #67 was moderately cognitively impaired. Clinical record review showed, Resident #67 had a history of UTI (urinary tract infection), as evidenced by antibiotic administration, which started on 09/10/23, of ciprofloxacin 500 mg for 5 Days for UTI. In addition, Resident #67 had an indwelling catheter in place related to a Stage 3 wound of the sacrococcygeal area. On 05/03/24 at 12:38 PM, perineal / catheter care observation was started. The care was being conducted by Staff A, CNA. During the care, it was observed that the anchor to the catheter was not adhered to the resident's skin, to secure and prevent it from being pulled and moving. After the completion of the perineal / catheter care, at 12:43 PM, wound care was commenced by Staff B, Wound Care Nurse. During the wound care, as the staff turned and moved the resident in the bed, the catheter was being pulled, due to it not being secured and adhered with an anchor. When the surveyor pointed to the unattached anchor and brought it to the attention of Staff A and Staff B, Staff A voiced she was going to inform the attending nurse, Staff D, LPN, to apply a new one. Approximately 30 minutes later, a subsequent observation revealed the anchor of the catheter had not been replaced.

Based on observation, interview, and record review, the facility failed to ensure the provision of mechanical lift slings (used for the Hoyer lifts) for 7 of 12 sampled residents who require a mechanical lift for transferring (Residents #1, #18, #19, #44, #67, #89, and #100). Three of 12 sampled residents had a lift sling, but there was no name on the sling to identify it to the resident, as per the facility process (Resident #20, #23, #63). Eleven of 13 random non-sampled residents either did not have a lift sling, had one with no name on it, or had one belonging to another resident. At the time of the survey there were 24 residents who were assessed as needing the mechanical lift for transferring. The facility also failed to provide a wheelchair for 1 of 1 sampled resident (Resident #89), and failed to ensure proper bed and or mattress for 2 of 2 sampled residents (Residents #98 and #260). The findings included: 1) On 04/04/24 at 2:00 PM when asked for a policy for mechanical lift transfers, the regional consultant stated the facility did not have one. Review of the record revealed Resident #89 was admitted to the facility on [DATE] and had resided on the 200 pod the entire time. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was totally dependent on staff for transferring. Review of the current care plan initiated on 01/02/24 documented Resident #89 had a self-care deficit and used a mechanical lift for transfers. During an interview on 04/01/24 at 11:40 AM, the son of Resident #89 stated yesterday was the first time in 21 days that his mother had been up out of bed. When asked why, the son explained the staff can never find a lift sling, and they had finally gotten another one yesterday. The son stated they had brought in their own sling and it was now lost. The son explained that either he or his sister are with their mother 24 hours a day, explaining they sleep on a recliner chair. During an interview on 04/01/24 at 5:09 PM, the daughter of Resident #89 stated she was told to bring in her mother's own wheelchair as they were running low on them. An observation at that time revealed her personal blue wheelchair, similar to a facility companion chair. Facility wheelchairs were black. During a supplemental interview on 04/03/24 at 10:44 AM, the daughter volunteered staff were always having trouble finding the mechanical lift slings to transfer her mother out of the bed and into her wheelchair. The daughter stated she brought her own lift sling in, and it was now lost, showed the surveyor that the current lift sling in the room that had the name of Resident #19 hand written on the label (Photographic Evidence Obtained). The last lift sling the staff had for her mother belonged to a resident on the 300 pod. The daughter stated she thought maybe the resident from the 300 pod had been discharged , but she walked over to that unit, and the resident was still at the facility. On 04/03/24 at 11:01 AM, Staff F, Personal Care Attendant (PCA) returned the personal mechanical lift sling to Resident #89. The PCA stated he found it in a plastic bag, noted the name of Resident #89 on the sling, and so he returned it. During an interview on 04/03/24 at 12:04 PM, Resident #19, who resided on the 600 pod, stated he did not have his lift sling. The resident stated he was upset as staff had not been able to get him up all week because his lift sling was missing. Resident #19 stated it was sent to the laundry on Friday and he hadn't seen it since. The resident became upset, and stated he had a medical appointment in two days, and the facility better find it. During an interview on 04/03/24 at 12:15 PM, the Nursing Home Administrator (NHA) was made aware that the lift sling belonging to Resident #19 was found by the surveyor, in the room of Resident #89. The NHA stated she was made aware of the missing lift sling the previous day. The NHA stated every resident who was transferred via the mechanical lift should have their own lift sling with their name on it. The NHA went to the room of Resident #89 to get the lift pad for Resident #19, so she could take it to laundry. The daughter of Resident #89 was in the room and stated her mother had never had a lift sling from the facility, designated for her mother. The NHA stated she was unaware the daughter had brought in her own lift sling. On 04/03/24 at 12:20 PM, the Central Supply staff was observed with a lift sling and wrote the name of Resident #89 on the label. The Central Supply staff stated she only had one more sling available at that time, but had ordered four the previous week. On 04/03/24 beginning at 3:40 PM interviews and observations with the Unit Manager, were completed for the 24 residents who were identified as needing a mechanical lift for transfers. With permission from each resident, observations were made in search of the mechanical lift slings. The following was identified for the sampled residents: a) Resident #20 had a mechanical lift sling in her dresser drawer without a name on it, but the resident stated that was not the one that staff used for her transfers. The resident had no idea where staff were obtaining the sling for her use. b) Resident #23 had a lift sling in a dresser drawer that did not have a name on it. c) Resident #63 had a lift sling with no name. d) No lift sling was found for Resident #67. e) No lift sling was found for Resident #44. f) The lift sling for Resident #19 had been found earlier by the surveyor in the room of Resident #89. g) No lift sling was found for Resident #1. h) No lift sling was found for Resident #18. i) Resident #100 had the lift sling for Resident #67. Eleven of 13 additional random non-sampled residents either did not have a lift sling, had one with no name on it as per facility stated process, or had one belonging to another resident. During these observations, the Unit Manager agreed each resident who was assessed as needing a mechanical lift sling, should have one. The Unit Manager agreed with the above findings. 32078 On 04/04/24 at 10:10 AM, the staff responsible for Central Supply stated, I order supplies once a week, and when I see we are running low on something, I will put an order in. I just put in an order for 38 Hoyer lift slings yesterday. When asked how many slings are currently in Central Supply, she stated, I have only 1 sling here in Central Supply right now. There are also some out in the residents' rooms. This staff member was unable to state when the slings were due for arrival. She stated, I would have to contact the corporate office to get tracking information for the delivery date. 38893 3). Resident #260 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, an Admission Readmission Nursing Evaluation, dated 03/27/24, Resident #260 was alert, easily arousable and oriented to person place time situation. During an interview, on 04/01/24 at 11:01 AM, with Resident #260, Resident #260 stated that the bed was not inflating properly on the resident's right side. Resident #260 stated that she had been laying like that in the bed since admission. The mattress was observed to be deflated on the resident's right side. During an interview, on 04/01/24 at 11:10 AM, with Staff A, CNA, when asked about the bed that Resident #260 was provided, Staff A replied, she has been in that bed since at least yesterday (03/31/24). We didn't have any Maintenance on Sunday to address the bed. I came in yesterday and the bed was like that. During an interview, on 04/01/24 at 11:20 AM, with the Director of Environmental Services, when the concern was brought to his attention, the Director of Environmental Services stated, she was on a regular bed and she was rolling out and we got her a bed with bolsters and we changed it out on Saturday and she sleeps on the side that is lower at the edge. They tried to get her to sleep in the middle. We have to check Central Supply to get her a wider bed. They just told me about it on Saturday. My assistant was here yesterday. During an interview, on 04/03/24 at 11:03 AM, with Staff E, Maintenance Assistant, when asked about the resident's bed, Staff E replied, Her bed was like that on Friday and I wasn't made aware of it until Saturday. It was already going, and she leaned to the right. Friday I left at 4:30 and didn't know anything about it until Saturday. They said that she was leaning on one side of the bed. I went to the room and seen what was going on with the bed to see if I could fix the situation. She was leaning to the right. That is an air mattress, when you use the dermaflow mattress it is designed to keep the resident in the center of the mattress so that they don't fall, it prevents them from rolling off of the bed. It looked like it was deflated, she was leaning to one side. She told one of the CNAs and the CNA brought it to my attention while I was over there. 4). Resident #98 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, an Admission MDS, dated [DATE], Resident #98 had a BIMS score of 08. The MDS documented that Resident #98's height was 68 inches (5 feet 8 inches tall). A Patient Transfer form from the Hospital, dated 01/11/24, documented that Resident #98 was 6 feet 5 inches tall (77 inches). An Admission Nursing Evaluation dated 01/11/24 (upon admission to the facility) documented that the resident was 68 inches tall. A Nutrition Evaluation dated 01/18/24 documented that Resident #98 was 68 inches tall. During an interview with Resident #98, on 04/03/24 at 9:07 AM, Resident #98 was in bed with the head of his bed raised and breakfast on the resident's over bed table. It was noted that Resident #98 had both feet pressed firmly against the foot board of the bed and legs bent at the knees and appeared to be uncomfortable in the bed in it's position. When asked about the observation, Resident #98 stated that the bed was not comfortable. Resident #98 stated, I am 6 foot 5 and I don't fit in this bed. During an interview, on 04/03/24 at 10:59 AM, with the Director of Environmental Services, the concern was brought to his attention. The Director of Environmental Services confirmed that the resident was on a standard air mattress and that he and his staff would provide a larger bed for the resident.

Based on observations, interviews and record reviews, the facility failed to provide nutrition via enteral tube feeding as ordered for 4 of 4 residents reviewed for tube feeding (Residents #100, 29, 67, 1). The findings included: 1) Resident #100 was admitted to the facility on [DATE] to 02/12/24 and most recently readmitted to the facility on [DATE] after being sent out to the hospital for pulling out her Peg tube. According to the resident's most recent full assessment, a 5-day Minimum Data Set (MDS), dated [DATE], Resident #100 had a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. Resident #100's diagnoses at the time of the MDS included: Hemiplegia following CVA affecting left non-dominant side, renal insufficiency, Diabetes, CVA, Malnutrition, Gastrostomy status, Dysphagia following cerebral infarction, Dysphagia. Resident #100's diet orders included: NPO (nothing by mouth) diet, 01/29/24. Enteral Feed - Resident on enteral feeding of Glucerna 1.5 via pump at the rate of 50ml/hr to start at 1400 until completion of 1000ml. Autoflush with H2O at 50ml/hr x 20 hours. - 01/29/24. Resident #100's Care plan for Tube feeding, dated 02/06/24, documented, Resident requires tube feeding related to Dysphagia The goals of the care plan included: o Resident will remain free of side effects or complications related to tube feeding through review date. Target date 05/30/24. o Resident will maintain adequate nutritional and hydration status through review date. Target Date: 05/30/2024. Interventions to the care plan included: o Follow physician orders regarding nutrition order and flushes. o NPO o RD to monitor/evaluate quarterly and PRN. o TURN OFF feeding during care when head of bed (HOB) is down On 04/01/24 at 9:49 AM Resident #100 was observed in bed with tube feeding (TF) initiated at 50 milliliters per hour (ml/hr). The date mark on the container documented that it was initiated on 04/01/24 at 00:05. At the time of the observation, there was approximately 950 ml remaining in the 1000 ml container of supplement. At a rate of 50 ml/hr, Resident #100 should have received 450 ml of the supplement in the 9 hours that the pump had been initiated. On 04/03/24 at 8:38 AM, Resident #100 was observed in bed with tube feeding initiated at 50 ml/hr. The date mark on the container of supplement documented that it was initiated on 04/02/24 at 6:30 PM. At the time of the observation, there was approximately 450 ml remaining in the 1000 ml container of the supplement. At a rate of 50 ml/hr, Resident #100 should have received 700 ml of the supplement in the 14 hours that the pump had been initiated. During an interview, on 04/04/24 at 7:23 AM, with Staff B, LPN and Staff C, RN, when asked about the feeding being stopped at any time during her shift, Staff B replied, not at all. I stopped it at around 2 AM and gave her medication and started it again and at 5. I stopped for medication and started again. Normally it if stops there is an alarm. I stopped for 10-15 minutes twice on my shift for her to be changed. Staff C stated that she did not stop the feeding during her shift (3-11). Staff C stated, the time on the bottle (date mark) is not right. When I started my shift there was one warning. It was a warning from the first shift, and I stopped it at around 2 PM for bowling. When she came back, I resumed the one that she had. On the second shift, I hung the other one at around 19:00 (7:00 PM). Sometimes when the CNA change her, they stop it. I did not stop it during my second shift, I did not stop the feeding for any reason. I have to stop her for medications for 10-15 minutes depending on how her pain is. Review of Resident #100's electronic health records revealed no documentation to justify not having met the order for tube feeding. 2). Resident #29 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, a Quarterly MDS, dated [DATE], Resident #29 had a BIMS score of 10, indicating moderate cognitive impairment. Resident #29's diagnoses at the time of the MDS included: Anemia, Hyponatremia, Anxiety disorder, Depression, Dysphagia. Resident #29's care plan for nutrition, initiated on 07/20/23 with a revision date of 08/28/23, documented, Resident is at risk for alteration in nutrition/hydration related to mechanically altered diet, PEG feeding, poor p.o. intake, depression, anxiety. The goal of the care plan was documented as, The resident will tolerate current diet and tube feeding & flushes order through next review. Initated 07/20/23 with a revision date of 03/27/24 and a target date of 06/18/24. Interventions to the care plan included: Honor preferences. Monitor tolerance to tube feeding. Provide tube feeding & flushes per MD order. RD to evaluate and make diet change recommendations PRN (as needed). Resident 29's diet orders included: Diet orders included: Regular diet, Pureed texture, Thin consistency - 07/20/23. Enteral feed - Resident on enteral feeding of Jevity 1.5 via pump at the rate of 50ml/hr to start at 2230 and stop at 0830 (500ml) Autoflush with H2O at 60ml/hr. On 04/02/24 8:36 AM resident noted not to be in her room with the tube feeding at the resident's bedside. The date mark on 1000 ml container of Jevity 1.5 documented initiated on 04/01/24 at 10:30 PM with approximately 650 ml remaining. At a rate of 50 ml/hr, resident should have received 500 ml of the supplement in the 10 hours since being initiated. On 04/03/24 at 8:52 AM, Resident #29 was observed in the common area of the pod eating breakfast independently with TF still attached and initiated at 50 ml/hr. At the time of the observation, there was approximately 600 ml remaining of the 1000 ml container. The date mark on container documented initiated on 04/02/24 at 21:00 (9:00 PM - an hour and a half earlier than the order dictated). At a rate of 50 ml/hr, Resident #29 should have received 650 ml of the supplement. During an interview, on 04/04/24 at 7:17 AM, with Staff D, LPN, when asked about the tube feeding order for Resident #29, Staff D replied, the previous shift started at 10:30 PM and she goes until 8:30 AM. Staff D confirmed observation of 1000 ml container, and stated, when they clean her, they stop and start again. It takes10-15 to clean and change her every 2 hours. Review of the resident's records revealed no documentation to justify not providing tube feeding as ordered. On 04/04/24 at 8:32 AM, with the Registered Dietitian (RD), the Administrator and the Director of Nursing (DON), when asked about the order for Resident #29, the RD stated that the tube feeding should be from 10:30 PM to 8:30 AM until 500 ml of the supplement has been infused. 39167 3) Record review revealed Resident #67 was admitted to the facility on [DATE] and 02/28/24 with diagnoses including: Cerebral vascular accident, hemiparesis (one side weakness), and Malnutrition. Review of the admission minimum data set (MDS) assessment, reference date 03/03/24, recorded a brief interview for mental status score of 06, which indicated Resident #67 was moderately cognitively impaired. This MDS recorded no mood and behavior issue. Review of physician order dated 03/04/24 for enteral feeding of Osmolite 1.5 at 70ml/hr x 20 hours or until 1400ml has infused. Diet order as of 02/29/24 was nothing by mouth (NPO). Review of nutrition assessment dated [DATE] recorded Resident #67 was at risk for malnutrition, her diet was NPO, enteral feeding was the sole source of nutrition at this time. Review of care plan completed 03/27/24 indicated Resident #67 required tube feeding for nutritional needs. She was at risk for alteration nutrition/hydration related to increased nutrient needs. Interventions included: Explain and reinforce to the resident the importance of maintaining the diet ordered. Provide, and serve diet as ordered. On 04/01/24 at 11:05 AM Resident #67 was noted lying in bed sleeping, the tube feeding was off, there was a bottle of osmolite formula hanging on the feeding pole, the bottle had 200 ml remaining. There was a basin on the bedside table, there were wet napkins inside the basin. On 04/02/24 at 8:45 AM Resident #67 was noted lying in bed, she was connected to the feeding tube, she was receiving feeding formula of Jevity 1.5 cal at 70 ml/hr. There was a basin on the bedside table, there were wet napkins inside the basin. An interview process was started with Resident #67, she conveyed she has been spitting up and she doesn't know what the cause may be. On 04/03/24 at 10:22 AM Resident #67 was noted lying in bed, she was receiving tube feeding of Osmolite 1.5 cal at 70ML/hr. There was a basin on the table, and wet napkins inside the basin. Resident #66 revealed she has been spitting up and her mouth tasted bitter, she reported to the nurse who said it may be due to the medications she's taking. On 04/04/24 at 10:04 AM an interview was held with the registered dietitian (RD), she voiced Resident #67's diet was Osmolite formula, to be on at 2 PM and off at 10 AM. The RD revealed Osmolite and Jevity are similar, but Osmolite is gentler in the stomach, as far as calorie wise and protein wise, they're pretty much the same. When asked, would she expect the nurses to use the formulars interchangeably, would nurses provide Osmolite one day and Jevity the next day, the RD stated the order says Osmolite. They must follow the order. The RD was asked if she was aware that the resident has been spitting up and she reported her mouth tasted bitter. The RD revealed that she was not aware. On 04/04/24 at 11:13 AM an interview was held with Staff Q, a license practical nurse ( LPN). An inquiry was made regarding which feeding formula Resident #67 received on 04/02/24. Staff Q revealed, around 11:00 AM when she checked Resident #67, she realized that the resident was receiving the wrong feeding formula (Jevity 1.5 cal instead of Osmolite 1.5 cal). She took it down, and hanged Osmolite but the feeding wasn't going to start until 2 PM. She voiced she usually checks the resident early in the morning when she comes in, but that day she didn't get a chance to check her until later. When inquired regarding Resident #67's had been spitting up. Staff Q divulged a certified nursing assistant had informed her the resident was spitting up, but she doesn't know why she was spitting up. On 04/04/24 at 11:24 AM an interview was held with Staff R, a certified nursing assistant (CNA), she voiced that she had informed the attending nurse (Staff Q) regarding Resident #67 had been spitting up. Staff R stated, it is like every minute her mouth is filled up. On 04/04/24 at 1:19 PM an additional interview was held with Staff Q; an inquiry was made whether she notified the registered dietitian or the speech therapist that the resident was spitting up. She stated no. 25404 4) Review of the record revealed Resident #1 was admitted to the facility on [DATE] and moved to her current room on 03/28/24 after a short hospitalization . Review of the current Quarterly MDS assessment dated [DATE] documented the resident was fed entirely via a tube. Review of the current order dated 03/20/24 documented Resident #1 was to receive Jevity 1.5 calorie at 50 milliliters (ml) per hour, continuously for 20 hours. This order also documented an auto water flush of 35 ml per hour for 20 hours was to be administered. The order was updated on 04/04/24, after surveyor intervention, to read the Jevity was to run until 1000 ml (a full container) was infused. On 04/01/24 at 4:03 PM, the tube feeding pump did not appear to be running. Staff I, Registered Nurse (RN), entered the room. When asked if the tube feeding was running, the nurse went to the pump, appeared to have difficulty, and stated she was going to get help. The RN returned, stated it had been running earlier, but it had suddenly stopped. (Photographic Evidence Obtained). Staff V, RN, came into the room and set the feeding pump. When asked the rates of administration for the feeding and water flush, both RNs stated they were the same at 50 ml per hour. This was observed by the surveyor. During an observation on 04/02/24 at 9:04 AM, the water flush remained at 50 ml per hour, instead of the ordered 35 ml per hour (Photographic Evidence Obtained). On 04/03/24 at 2:39 PM, Staff I, RN, changed the tube feeding canister and tubing setup, and started the feeding pump. When she was finished, Staff I was asked to show the surveyor the settings for both the feeding and the water flush, and they were both noted to be running at 50 ml per hour. Observation of the water flush bag revealed a label that documented the water flush was to run at 35 ml per hour. Both Staff I, RN, and the wound care nurse agreed, and the rate for the water flush was changed to 35 ml per hour. An observation on 04/04/24 at 11:28 AM revealed the tube feeding pump was off, the tube feeding tube was still hooked to Resident #1, and there was 300 ml of formula left in the container. The current orders were reviewed and documented the tube feeding was to continue until all 1000 ml were administered. During an interview on 04/04/24 at 11:40 AM, when asked the status of the tube feeding, Staff J, Licensed Practical Nurse (LPN), stated she had turned it off at 10 AM, because, that is what the orders says. The LPN stated, but I saw the order to administer the 1000 ml and wasn't sure what to do. The LPN agreed the full 1000 ml container was not provided to Resident #1.

Based on observation, record review, interview, and policy review, the facility failed to ensure competent nursing staff during care for 2 of 8 sampled residents observed. Staff failed to ensure an order for the use of oxygen and failed to replace an empty water bottle for the oxygen of Resident #1; failed to ensure proper order of care for the wound and tube feeding for Resident #1, failed to ensure competency for setting the tube feeding pump for Resident #1, and failed to properly administer medications through the PEG tube (feeding tube surgically placed in the stomach) for Resident #23. The findings included: 1) Review of the policy Oxygen Administration revised 12/2023 documented, General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or other device per physicians' orders and/or facility protocol. Observations on 04/01/24 at 4:03 PM, on 04/02/24 at 9:04 AM and 2:05 PM, and on 04/03/24 at 10:58 AM, all revealed Resident #1 wearing humidified oxygen via nasal cannula. Review of the record revealed Resident #1 was admitted to the facility on [DATE], and moved to her current room on 03/28/24, after a short hospital stay. Review of the current orders lacked any oxygen administration order. An observation on 04/03/24 at 2:39 PM revealed the continued oxygen administration, but the water container that provided the humidified oxygen was empty. On 04/04/24 at 11:28 AM, the water bottle for the humidified oxygen was empty. A current care plan initated on 04/10/23 documented Resident #1 required oxygen therapy related to ineffective gas exchange. During an interview on 04/04/24 at 11:40 AM, when asked what she looks for when a resident is on oxygen, Staff J, Licensed Practical Nurse (LPN), explained she monitors lung sounds and oxygen levels, ensures the tubing is changed, and looks at the water bottle when humidified oxygen is used. Staff J volunteered she noticed during her 7 AM rounds this morning, that two of her residents needed new water bottles for their oxygen, as they were both empty. When asked which residents, Staff J named Resident #1, and further stated she hadn't had a chance to get them yet. During a side-by-side review of the record, Staff J was unable to locate a current order for the resident's oxygen use, and stated the resident needs the oxygen as her oxygen saturation was 94% this morning on 3 liters of oxygen. 2) A request was made on 04/03/24 in the morning to observe wound care. Staff I, Registered Nurse (RN) stated she would be doing wound care and changing the tube feeding set about 2:15 PM. The surveyor requested to observe both procedures. On 04/03/24 at 2:39 PM, wound care was provided by Staff I, RN, accompanied by the wound care nurse. When asked who usually provided the wound care, the wound care nurse explained she does the weekly rounds with the wound care physician and does care for the surgical wounds, but the direct care nurses complete the care for the long term residents and other wounds that are not surgical. The wound care nurse was asked to allow Staff I, RN, to complete the care without cueing, unless she felt it necessary, as the wound care nurse normally is not with the direct care nurses during wound care. Staff I, RN set up supplies to change the tube feeding set and to provide wound care. Both nurses donned gloves and gowns upon entering the room. Staff I, RN, opted to start with the wound care to the resident's sacral wound. The wound care nurse needed to cue Staff I during the cleaning of the wound, cued her to change gloves after cleaning the wound, and cued her during the process of applying the gentamicin ointment. Staff I then removed her gloves, washed her hands, and applied new gloves, but did not change her gown. Staff I primed the tubing for the feeding, and hooked it up to the resident's PEG tube, her contaminated gown touching the bed and tube feeding equipment. The wound care nurse also cued Staff I to flush the feeding tube. Upon completion, when an incorrect water flush rate was identified by the surveyor, Staff I, was unable to reprogram the pump and needed the wound care nurse to complete the change. Staff I had been observed on 04/01/24 at 4:03 PM having difficulty with the feeding tube machine and needed to ask another nurse to set up the pump to administer the feeding and water flush. When asked the order in which procedures are to be done for residents, specifically clean and dirty procedures, the wound care nurse stated the clean procedure should be completed first, followed by the dirty procedure. The wound care nurse agreed Staff I should have changed the tube feeding set prior to doing the wound care, or change her gown as needed between procedures if done out of appropriate order. 3) Review of the policy Administering Medications through an Enteral Tube revised November 2018 documented, 12. Administer medication by gravity flow. a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clamp and deliver medication slowly. c. Begin flush before the tubing drains completely. 14. When the last of the medication begins to drain from the tubing, flush with 15 ml (milliliters) warm purified water (or prescribed amount). 15. Quickly clamp the tubing when the flush is complete. Remove syringe. A medication pass observation for Resident #23 was made on 04/03/24 beginning at 4:54 PM, with Staff K, Registered Nurse (RN). The RN prepared 10 ml of liquid colace, along with two 10 ml water flushes for before and after administration. The amount was verified by the RN. Upon entering the room, Staff K checked for residual by pulling back on the syringe that he attached to the PEG. There was none. The RN removed the plunger of the syringe, attached the syringe back onto the PEG and poured 10 ml of water into the tube followed by pushing 30 ml of air through the tube. The RN then removed the syringe, took out the plunger, reattached the syringe and administered the medication. The RN then pushed 30 to 60 ml of air through the tube. The RN followed the same procedure for the last 10 ml water flush. During the administration of the water and the medication, the fluid were observed running out the opened side port of the PEG tube. A pink stain, the color of the medication, was noted on the towel below the PEG. The RN did not notice the water and medication coming out of the PEG tube or the pink stain on the towel. When brought to his attention, the RN stated he would do it again. Staff K obtained another dose of the colace along with two 10 ml water flushes, and administered the water and medication in the same manner, providing 30 to 60 ml of air between each step. When asked why he was pushing air into the resident's tube, Staff K stated, Because you are here. I saw it go down.

Based on observation, interview and record review, the facility failed to follow the shower schedule for Resident #19 to ensure he received his 2 showers per week. And the facility failed to ensure a certified nursing assistant communicated Resident #92's desire for outside activities to the Activity Director. The findings included: 1) Clinical record review revealed Resident #19 was admitted to the facility on [DATE] and 01/20/24, with diagnoses that included anxiety disorder, and depression. Review of the quarterly minimum data set (MDS) assessment, reference date 03/12/24, revealed a brief interview for mental (BIMS) status score of 15, which indicated Resident #19 was cognitively intact. This MDS recorded no mood or behavior issue. Further review of this MDS, under section GG for functional abilities and goals, it was documented Resident #19 had impairment on both lower extremities (related to double amputation of his lower extremities). This MDS also documented Resident #19 was dependent with activities of daily living (ADL) care included: toileting, hygiene, Shower/bath, lower body dressing, and chair/bed-to-chair transfer. Review of the comprehensive care plan completed 03/22/24 indicated Resident #19 had an ADL self-care deficit related to chronic medical condition of bilateral below the knee amputation (BKA). Intervention included: Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, and personal/oral hygiene. Review of February, March and April 2024 progress notes lacked documented evidence of providing showers and/or refusal. On 04/01/24 at 11:17 AM Resident #19 was observed lying in bed, an interview was held with him, he stated that he doesn't get the care he requires, the staff doesn't get him out of bed. He doesn't receive shower as he should, he was supposed to receive shower twice a week, and it doesn't happen, certified nursing assistants said they don't have enough help. On 04/02/24 at approximately 9:00 AM Resident #19 was observed lying in bed. On 04/03/24 at 10:00 AM Resident #19 was noted lying in bed. At 10:28 AM an interview was held with Resident #19 an inquiry was made regarding whether he had a shower this week. He voiced that his scheduled showers are on Tuesdays and Fridays, he hadn't received his shower on Tuesday (4/2/24), the staff didn't get him up as they have lost his Hoyer lift pad. Resident #19 revealed he wanted to get up. On 04/04/24 at 08:52 AM Resident #19 was noted lying in bed. During that time an interview was conducted with the resident, an inquiry was made regarding whether staff got him up and out of bed this week. Resident #19 conveyed that he hasn't gotten up, because they had lost his Hoyer lift pad, they've just brought it back to him today. On 04/04/24 at 1:55 PM an interview was held with the director of nursing (DON), she revealed that the resident's shower schedule was on Tuesdays and Fridays on the 3-11 shift and as needed; he received showers on 03/08/24, 03/15/24, 03/18/24, and 03/29/24. When asked for additional documented evidence of the shower. The DON revealed she was going to obtain the bin that had the shower records. The DON carefully searched the bin and voiced that she didn't find any additional documented shower for March and April 2024 for Resident #19. The DON further revealed Resident #19 should have received a shower on 04/02/24, there was no documented evidence of shower. She added the last documented shower was on 03/29/24. During the interview process the DON was made aware of concern related to Resident #19 hasn't gotten up for 3 days during the survey process due to his Hoyer pad not being available, it was found in another resident room at the North unit. The DON advised that they'd found the Hoyer pad in another resident' room and they took it to the laundry. 25404 2) Review of the record revealed Resident #92 was admitted to the facility on [DATE]. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the Admission MDS dated [DATE] documented it was very important for the resident to go outside. During an interview on 04/01/24 at 12:48 PM, Resident #92 stated she would like to go outside. Resident #92 stated she had asked the Certified Nursing Assistants (CNAs) to go outside, and they told her there were not permitted to take her out. Resident #92 stated she has asked staff, but has to wait for her friend to come and take her outside. When asked if the activity staff or any other staff have offered to take her outside, the resident stated none have offered. During an interview on 04/04/24 at 12:20 PM, the Activity Director stated if the CNAs would have told her the resident wanted to go outside, she or her staff would have taken her out. During a supplemental interview on 04/04/24 at 12:44 PM, in the presence of the Activity Director, when asked again about going outside, Resident #92 stated the CNAs tell her they don't have time to take her outside as they are too busy.

Based on record review and interview, the Facility failed to provide appropriate beneficiary notices for 3 of 3 sampled residents reviewed for Beneficiary Protection Notification (Residents #58, #110, and #89). The findings included: On 04/02/24 at 10:20 AM, the Administrator was provided a sample list of 3 residents who had been, or still were, residents in the facility and had been discharged from Medicare Part A services. A SNF Beneficiary Protection Notification (BPN) Review Worksheet (Form CMS-20052) was provided to be completed for each resident. On 04/02/24, the following documentation was provided by the Administrator: 1) Resident #58's BPN Review worksheet showed Resident's last covered day of Part A Services was on 12/05/23. The facility had initiated the discharge from Part A Services when benefit days were not exhausted. Based on record review, this resident remained in the facility. The facility provided Resident #58 with a NOMNC (CMS Form 10123) on 12/05/23. Based on regulation, The NOMNC ( Form CMS 10123), is given by the facility to all Medicare beneficiaries at least two (2) days before the end of a Medicare covered Part A stay. Resident #58 received his NOMNC on the day his Part A services were ending. Also, due to the fact that this resident chose to remain in the facility, he should have also been provided with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS Form 10055), but he never received this notice. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial responsibility for those services. 2) Resident #110's BPN Review worksheet showed Resident's last covered day of Part A Services was on 02/19/24. The facility had initiated the discharge from Part A Services when benefit days were not exhausted. Based on record review, this resident remained in the facility. The facility provided Resident #110 with a NOMNC (CMS Form 10123) on 02/19/24. Resident #110 was not provided a copy of the NOMNC least two days before the end of a Medicare covered Part A stay. Resident #110 received his NOMNC on the day his Part A services were ending. Also, due to the fact that this resident chose to remain in the facility, he should have been provided with a SNF ABN (CMS Form 10055), which he did not receive. 3) For Resident #89, no completed BPN worksheet or copy of the Resident's NOMNC was provided to this surveyor for review. However, documentation was provided showing that at the end of Resident #89's Part A services, the Resident's representative requested an expedited appeal of the decision to discharge the Medicare beneficiary. An Expedited Appeal Documentation Request was sent to the Facility's Social Services Director on 02/24/24 requesting specific documentation for the appeal (copy of the Notice of Medicare Non-Coverage, copy of the Detailed Explanation of Non-Coverage, and copy of specific items in the beneficiary's medical record from the last 7 days). The form stated, Failure to submit the information requested above could affect the decision of the Medicare QIO regarding the appeal of the termination of coverage notice. The Appeal was rejected on 03/08/24 due to the BFCC-QIO [Beneficiary and Family Centered Care Quality Improvement Organization] received insufficient medical records or other necessary documents within the required time frame. On 04/03/24 at 2:30 PM, the Administrator stated that a new Social Services Director was just recently hired and was not here at the time the notices for Residents #58, #110, and #89 were provided, so she would not have any further information to provide. The Administrator was unaware that a second beneficiary notice, SNF ABN (CMS Form 10055), was required when a resident was discharged from Part A services with benefit days remaining and chose to remain in the facility.

Based on interview, record review, and policy review, the facility failed to ensure 1 of 4 sampled residents, Resident #2, was free from verbal abuse and neglect. Staff A, Registered Nurse (RN), verbally abused Resident #2 on 01/14/23 at about 1:00 AM, as witnessed by four staff (Staff D, Registered Nurse (RN); Staff G, RN; Staff H, Licensed Practical Nurse (LPN); and Staff I, Certified Nursing Assistant (CNA)), and overheard by the Director of Nursing via phone. The facility also neglected to provide ordered pain medications for approximately 13 hours as per staff interviews (staff verbalized Resident #2 was admitted [DATE] at 12:30 PM and staff verbally said she received pain medication on 01/14/23 at about 2:00 AM but not documented) or approximately 17 hours as per documentation (the record documented Resident #2 was admitted on [DATE] at 3:00 PM and received pain medication on 01/14/23 at 8:35 AM). The findings included: Review of the policy, titled, Patient Protection - Abuse, Neglect, Mistreatment and Misappropriation Prevention, dated 10/2021, documented, Overview: . The most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to violent, abusive, humiliating, exploitive or neglectful behavior. Definitions: . Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect . (a) The facility must (1) Not use verbal, mental, sexual, or physical abuse. Review of the record revealed Resident #2 was admitted to the facility on [DATE] at 2:58 PM, as per the 'Quick A/D/T' (Admission / Discharge / Transfer) documentation. The resident's diagnoses included cancer and palliative care. The resident was discharged to a hospital in-house hospice on the afternoon of 01/14/23. A progress note on 01/13/23 at 3:16 PM by Staff B, Licensed Practical Nurse (LPN), documented the resident was admitted via a wheelchair, accompanied by family members. This note revealed the oncoming nurse was made aware. The Referral Communication Form for Resident #2 documented the resident was being admitted from home. An Admission Evaluation by Staff C, LPN, initiated on 01/13/23 at 2:57 PM, and completed on 01/14/23 between the times of 1:12 PM and 2:25 PM, documented Resident #2 was admitted accompanied by paramedics. The surveyor confirmed the resident was admitted from home. This evaluation documented the orders were verified with the Medical Practitioner on 01/13/23 at 12:00 AM (midnight), a time prior to admission. The Drug Regimen review of this evaluation documented there were no issues identified and to continue with discharge medications as provided by home-hospice. The admission evaluation's vital signs were documented on a piece of paper as being within normal limits (WNL). Vital signs were automatically generated onto the Admission Evaluation form with the most recent value documented in the electronic medical record as being WNL. The documented vital signs on this Admission Evaluation were also dated 01/14/23 between the times of 1:12 PM and 2:25 PM. On this admission evaluation, initiated on 01/13/23 at 2:57 PM and completed on 01/14/23, Resident #2's pain was assessed to be at 9 on a scale of 0 to 10, with a goal pain level of 3. Review of the Medication Administration Record (MAR) of 01/14/23 prior to approximately 1:00 AM, documented the pain level as 0 (zero). The MAR on 01/14/23 for day shift (7 AM - 3 PM) also documented the pain level as 0. Review of the physician orders revealed six different scheduled and as needed (PRN) medications for pain to include Methadone every 12 hours, Oxycodone every 3 hours as needed, Lyrica every 12 hours as needed, Morphine solution every hour as needed, Meloxicam once daily, and a Tylenol Suppository every 8 hours as needed. Review of the corresponding January 2023 Medication Administration Record (MAR) documented the first provision of pain medication was on 01/14/23 at 8:35 AM, which was approximately 17 hours after the documented admission. During an interview on 02/28/23 at 12:09 PM, Staff C, LPN and the day nurse who completed the documented Admission Evaluation for Resident #2, described the admission process to include a review of the admission paperwork prior to the arrival of the resident, completing a rapid COVID test to ensure proper room placement, introductions and orientation to the room, obtaining vital signs, and completion of a head-to-toe assessment, which the nurse indicated could be completed in about 10 minutes. The LPN stated she would then go to the computer and do the Quick A/D/T, review the orders and medications with the physician or nurse practitioner, along with the resident or family, enter the orders, and then complete the assessment in the computer. When asked the process if there were pain medications, the LPN stated the prescription should be immediately faxed over to the pharmacy to 'get that going'. The LPN clarified that she also fills out an authorization to remove the medication from the Omnicell (an automated medication dispensing system), along with making a call to the pharmacy. During this continued interview, Staff C, LPN, was asked to look up Resident #2 in the electronic record. Upon review, the LPN stated she did not recall the resident, but determined she was assisting Staff B, who was new at the time, with the admission. When asked about her assessment of a pain level of 9, the LPN reviewed the record and was unable to provide any evidence Resident #2 was provided medication and / or what happened to treat the resident's voiced pain. The LPN explained that sometimes one nurse would do the assessment, and another would take care of the orders. The LPN confirmed a resident who was admitted with a pain level of 9 should have had some provision of medication and / or let the oncoming nurse know if it was at shift change. During an interview on 02/28/23 at 3:07 PM, the current HR (Human Resource) Director, who was the Admissions Coordinator at the time of the event, explained Resident #2 was scheduled to arrive at the facility on 01/13/23 at 8:00 AM, but arrived while he was at lunch around noon. The HR Director explained there was some confusion related to the rooms, so the spouse of Resident #2 insisted on waiting in the lobby until the HR Director was available. The HR Director stated he spoke with the resident and family upon his return from lunch, and assisted them to the room. The HR Director stated Resident #2 would have been to the room by 12:15 or 12:30 PM. This would indicate Resident #2 failed to receive any pain medications for approximately 13 hours as per staff interviews. Review of the orders and paper admission records revealed the following: The order for Methadone 10 mg (milligrams) every 12 hours for pain was created in the electronic record on 01/13/23 at 6:42 PM by Staff D, RN (Registered Nurse), to start on 01/13/23 at 9 PM. The order was updated by Staff E, RN on 01/13/23 at 11:33 PM to start on 01/14/23 at 9 PM, and then by the Director of Nursing (DON) on 01/14/23 at 10:40 AM to start on 01/14/23 at 9 AM. The paper chart revealed a hard copy prescription for the Methadone as ordered, with a fax time stamp of 01/13/23 at 5:30 PM. The order for Oxycodone 5 mg every 3 hours for pain was created on 01/14/23 at 10:34 AM by the DON, to start as of 01/13/23 at 7 PM. The paper chart revealed a hard copy prescription for the Oxycodone as ordered, with a fax time stamp of 01/13/23 at 5:29 PM. The order for the Lyrica 150 mg every 12 hours as needed for nerve pain was created by Staff D, RN on 01/13/23 at 7:03 PM, and updated by Staff F, LPN, on 01/13/23 at 11:28 PM to start on 01/14/23 at 9 AM. The paper chart revealed a hard copy prescription for the Lyrica as ordered, with a fax time stamp of 01/13/23 at 5:29 PM and a second time-stamped 01/13/23 at 6:22 PM. The paper chart also contained a Fax Message from Omnicare pharmacy to the facility, with a time stamp of 01/14/23 at 7:28 PM that the Lyrica was not in the E-kit (emergency medication kit). The record lacked any other documentation related to this medication. The order for the Morphine solution to be given every hour as needed was created by Staff D, RN on 01/13/23 at 6:56 PM, with no documented changes or updates. The paper chart revealed a hard copy prescription for the Morphine Solution as ordered, with a fax time stamp of 01/13/23 at 6:22 PM. The order for the Mobic 15 mg once daily for pain was created by Staff D, RN on 01/13/23 at 6:42 PM, with no documented changes or updates. The paper chart revealed a hard copy prescription for the Mobic as ordered, with a fax time stamp of 01/13/23 at 5:30 PM. The order for the Tylenol Suppository 650 mg every 8 hours as needed for pain was created by Staff D, RN on 01/13/23 at 18:42 (6:42 PM), with no documented changes or updates. The paper chart revealed a hard copy prescription for the Tylenol Suppository as ordered, with a fax time stamp of 01/13/23 at 5:32 PM. Review of Resident #2's medication list provided by the Hospice provider, documented all of the above pain medications with no discrepancies identified. The faxed time-stamp documented 01/13/23 at 4:48 PM. During an interview on 02/28/23 at 1:57 PM, when asked about the lack of provision of medication for Resident #2, the Director of Nursing (DON) stated there was some back and forth with getting the physical scripts from the physician. The DON stated the medication list the resident came in with was not the same as the medication requisition from the physician. The DON was only able to locate and provide one medication list from the Hospice provider in the paper chart of admission documents. The DON located the pain medication prescriptions and authorizations filled out by the facility staff, but none had been sent back from the pharmacy as authorized. The DON also stated the pain medications were not available in the Omnicell. When asked what the nurse should do if a medication was not available in the Omnicell, the DON stated the nurse should reach out to physician and see if it could be changed to a medication that was available at the facility. The DON agreed there was no evidence of this in the resident's record, and agreed the admission was not handled appropriately. When asked if the facility reported the failure to provide pain medications to Resident #2 in a timely manner as neglect, the DON stated he thought it was reported as abuse. Review of the mentioned abuse report documented an allegation of abuse by Staff A, RN on 01/14/23 at 1:00 AM. This report documented, On 1/4/2023 [incorrect date] at 1am Resident [name of resident] requested anxiolytic [anxiety medication, which was also incorrect information] medication from nurse [name of Staff A]. [Name of Staff A] went on break and after returning to floor became verbal [sig] abusive to nurse [name of Staff G] and resident. This report further described the DON overheard an argument between the nurses while speaking with the resident on the phone. This report further documented the evidence showed Staff A, RN, was yelling and abusive toward another staff member, thus Resident #2 was not abused or neglected by the action of Staff A. Review of the written statement by Staff G, witness RN, incorrectly dated 01/04/23, did indicate Staff A was verbally abusive toward him. A supplemental written statement by Staff G dated 01/18/23 documented he was at the nurse's station when Resident #2 came out of her room asking for a pain pill. This statement stated Staff D asked Staff A, the resident's direct care RN, to call the pharmacy for the pain pill, when Staff A responded, the patient needed to stop whining, at which time the two nurses started arguing. Review of a witness statement by Staff H, LPN, dated 01/18/23 described a verbal altercation between Staff A and Staff D, that included Staff A saying in front of the nurses and Resident #2, I did tell the patient she was whining all day. This witness statement documented Resident #2 stated she did not want Staff A to be her nurse and that she needed to be fired. Review of a witness statement from Staff I, Certified Nursing Assistant (CNA) dated 01/18/23 documented a verbal argument between Staff A and Staff D, to include numerous swear words, that the resident was whining all night, and that Staff A stated she was not going to do anything, all of which was in front of Resident #2. The investigation lacked any written statement from Staff D, the nurse who was the main victim of Staff A's verbal abuse, besides Resident #2. During an interview on 02/28/23 at approximately 3:30 PM, the NHA (Nursing Home Administrator) was informed the investigation lacked a witness statement from Staff D, the second night shift nurse on the unit, and that at least one of the statements that was included in the investigation contained information that the resident was present during the nurse's altercation and that comments were directed at Resident #2. When asked why it wasn't substantiated, the NHA stated she was told the altercation only involved the nurses, not the resident. When asked if she reviews the investigation, the NHA stated the team reviews them during morning meetings. During a phone interview on 03/01/23 at 8:24 AM, Staff D, night RN, explained Staff A, the second night nurse on the unit, had gone on break when Resident #2 came to nurse's station, said she was in pain, and stated that she was supposed to get IV (intravenous) morphine. Staff D stated she explained to the resident they did not have IV morphine in the Omnicell, but they did have other medications available. Staff D explained to Resident #2 that they could call the pharmacy and get authorization to pull the medication for her. Staff D stated the resident responded that was good because her nurse (Staff A) told her they could not get any medications until the next day. Staff D explained when Staff A returned from break, she told Staff A that Resident #2 was in pain and was asking for medications. Staff D stated that Staff A said, I already heard about her, and she is trouble and she won't get anything for pain. Staff D stated she explained to Staff A that she could not talk like that, and Staff A began yelling and cursing, in front of Resident #2. Staff D stated she called the DON because Staff A was 'out of control. When asked if Resident #2 was present during the altercation, Staff D stated the resident was right there at nurse's station during the entire event. Staff D explained Resident #2 as alert and oriented, not giving any of the staff a hard time, but that she was just in pain and wanted her medications. Staff D further stated the DON came into the facility and took over for Staff A, and Staff D thought they were able to get Resident #2 medications by about 2:00 AM. Review of the record lacked any documented evidence of the provision of any type of pain medication until 01/14/23 at 8:35 AM. During the continued phone interview, when asked if Staff A's yelling and cursing was directed at her or the resident, Staff D stated it was directed at both the nurses and the resident. Staff D stated Staff A looked right at Resident #2 and stated, I already told you, you are not getting anything until tomorrow.

Based on interview and record review, the facility failed to implement positioning equipment for 1 of 3 sampled residents (Resident #40). Resident #40 was care planned for the intervention of wedge pillows on each side for positioning and bed boundaries, which were not in place on 11/12/19 when assisted to bed. Resident #40 was found out of bed on the floor on 11/12/19 with a subsequent left [MEDICAL CONDITION]. The facility also failed to ensure a thorough investigation. The findings included: During a phone interview on 02/27/20 at 10:18 AM, the daughter of Resident #40 confirmed her mother returned to the facility after having fallen out of bed and sustaining a [MEDICAL CONDITION] in November of 2019. When asked if she knew what happened, the daughter stated an aide forgot to put the wedges in the bed, and she (Resident #40) fell and broke her hip. The daughter explained because of the resident's age, they decided not to do the surgery, and the surgeon said it would heal. The daughter explained that before the incident, the facility staff would get her mother up out of bed and into a wheel chair so they could go outside. The daughter voiced her mother has had a real set back and decline since the event, and has been put on Hospice because of it. When asked if the facility utilized a low bed prior to the incident, the daughter stated, not always explaining at times when she visited the bed would be to the floor, and at other times it would not be. The daughter explained Resident #40 was on bed rest for weeks after the incident, and just recently has been up in a recliner type chair. Review of the record revealed Resident #40 was admitted to the facility on [DATE], was hosptalized on [DATE] after being found on the floor next to the bed with a subsequent left [MEDICAL CONDITION], and re-admitted to the facility on [DATE]. Further review revealed the resident was admitted to Hospice services on [DATE]. An order to discontinue bed rest was received on 01/31/20, eleven weeks after the fall. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented Resident #40 had a fall with a major injury. Review of the Significant Change MDS dated [DATE] documented Resident #40 has a Brief Interview for Mental Status (BI[CONDITION]) score of 03, on a 0 to 15 scale, indicating the resident as severely cognitively impaired. This MDS documented the resident needed assistance of one or two persons for all Activities of Daily Living ADLs. The MDS prior to the fall dated 0[DATE] documented Resident #40 needed the extensive assistance of one or two persons for her ADLs. Review of the progress notes revealed the following: On 11/12/19 at 11:00 PM, Staff N, a Licensed Practical Nurse (LPN), found Resident #40 laying on the floor next to her bed with no observation of pain or injuries. An assessment was completed by the nurse, and the physician and family were notified. On 11/13/19 at 7:43 AM, Staff E, an LPN, documented the CNA (Certified Nursing Assistant) identified around 2 AM that the left hip of the Resident #40 was swollen, and the resident complained of pain. The physician has been notified, an x-ray ordered, and the technician to arrive shortly. On 11/13/19 at 11:00 AM, Staff F, a Registered Nurse (RN)/Unit Manager, notified the physician of the x-ray results and received an order to send the resident to the ER (emergency room ) for further evaluation. On 11/13/19 at 11:58 AM, Staff F documented the resident was transferred to the hospital. Review of the current care plan dated 11/21/19 documented Resident #40 is at risk for further falls due to poor sitting balance, impaired cognition, and history of falls with fractured left hip. A resolved intervention, that was initiated on 09/21/18, documented to implement use of preventative device - wedge pillows on each side for positioning and bed boundaries. This intervention was resolved upon readmissin on 11/20/19 to the facility. A wider air mattress with built in side cushions was provided to the resident on 11/21/19. The facility was asked to locate and provide evidence of their investigation for the fall event of 11/12/19. The Director of Nursing (DON) provided their investigation, which included the following: Left hip x-ray completed on 11/13/19 at 9:35 AM and reported to the facility on [DATE] at 10:11 AM with finding of acute left [MEDICAL CONDITION]. Written statement dated 11/12/19 from Staff O, the Certified Nursing Assistant (CNA), who put Resident #40 to bed. This statement makes no mention of the wedge pillows. Phone interview dated 11/19/19 from Staff L, the CNA, who identified a change in the resident's hip. This aide stated the protective wedges were not in the bed. Written statement dated 11/12/19 from Staff N, the direct care LPN at the time of the fall, lacked any information regarding the assistive devices. Phone interview dated 11/19/19 from Staff P, the CNA who found the resident on the floor, lacked any information regarding the assistive devices. Phone interview dated 11/19/19 from Staff E, the direct care LPN who was told of the change in the resident's hip by the CNA, lacked any information regarding the assistive devices. A print out of the progress notes. The investigation provided by the DON lacked any Investigation Report of the findings or conclusion of their investigation. During an interview on 02/26/20 at 3:45 PM, the DON was asked about the incident for Resident #40 on 11/12/19. The DON explained Resident #40 was found lying beside her bed. The DON stated they interviewed the nurse and CNA who had cared for the resident, and nurse who came on for the next shift. The DON explained the CNA provided ADL care about 8 PM, and went to another resident. Another CNA passed by the room and saw Resident #40 on floor about 10:30 PM and notified nurse. The nurse did an assessment, notified the physician, the daughter and himself (DON). A report to the next nurse was done, and the 11 PM to 7 AM nurse did an assessment with no concerns. At about 1 or 2 AM, the CNA went in to provide care and noticed swelling, notified the nurse, who called the physician, and ordered x-rays. Results revealed a [MEDICAL CONDITION]. The resident was transferred to the hospital and the family was notified. Because of the resident's age and comorbidities, surgery not done. The DON was asked how they determined it was not an adverse event. The DON explained they asked the CNA and staff about the position of the bed prior to the event. The DON explained that during the morning meeting, the Administrator (who is not the current administrator) would pull up the orders and care plans on the big screen (monitor in the conference room) for review. When asked if there was any evidence of that review and the findings, the DON stated there was not. The DON stated that at the time of the incident, it was just his second or so day here, and the previous administrator did this investigation. During an interview on 02/27/20 at 12:09 PM, Staff O, the CNA who put Resident #40 to bed on 11/12/19, confirmed she was the CNA caring for Resident #40 on the night of the incident. The CNA stated she did not get report that evening from the off-going CNA, and had not worked with the resident before. The CNA stated she just started working that evening and put the resident to bed, without looking at the resident's care plans. The CNA stated the wedge pillows were not on the bed or even near the bed, so she didn't see any when she put her to bed. The CNA stated she did see the wedge pillows on her care plan after the event. During an interview on 02/27/20 at 12:13 PM, the DON again confirmed they did not have any evidence that an investigation was done except for staff interviews, had no evidence that the care plans were reviewed, and had no evidence if the facility determined it was or was not an adverse event. On 02/27/20 after 3 PM, the Consultant Nurse provided the Investigation Report, which the previous Administrator was able to locate. The surveyor was also provided a Performance Improvement Plan (PIP) related to reviewing the plan of care for adaptive equipment. (Refer to citation at F[AGE]5). Review of the Investigation Report documented the incident date as 11/12/19 with the date of the investigation as 11/21/19. The report was prepared by the previous Administrator but was not dated. This report documented the timeline of critical events to include the CNA putting Resident #40 to bed on 11/12/19 at 6 PM without bed wedge pillows, and the resident found with swelling in the hip on 11/13/19 at 2 AM without notification to the physician. The conclusion documented on this Investigation Report was that Resident #40 fell due to precautions not being in place, and that staff were educated on following the Kardex (care plan). Review of an additional interview by facility staff completed on 11/20/19, and later provided to the surveyor as part of their investigation, documented Staff O, the CNA who put Resident #40 to bed on the evening of the incident, lowered her bed to the floor because I know that she is a patient who twists and turns frequently. I did not place any wedges on the side of the patient because I did another patient I had to rush to and then I would return and place the wedges on. Approximately 8:30 (PM) I was notified by another CNA that the patient was found on the ground.