Every finding on record at Regal Heights Healthcare & Rehab Center

Based on interviews, record reviews, and review of the facility's policies, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for three of four residents (R58, R123, and R172) reviewed for accidents. The facility failed to ensure staff consistently followed care plans requiring two-person assistance during bed mobility, toileting, and showering, resulting in residents being left or cared for by a single staff member during high-risk activities.This deficient practice resulted in actual harm for Resident R58, who sustained a head laceration requiring emergency department evaluation and sutures after falling from the bed during care when a single staff member attempted to provide care without the required two-person assist.Additionally, Resident R123, who required two-person assistance at all times, sustained a fall from a shower bed with a head injury when care was provided by one staff member without required assistance, and Resident R172, who also required two-person assistance, experienced a fall from bed during care when left with one staff member, requiring hospital evaluation to rule out injury.Findings include: 1. Review of the Face Sheet located in the Profile tab of the electronic medical record (EMR) revealed R58 was admitted to the facility on [DATE] with diagnosis of multiple sclerosis, cerebrovascular disease, and unspecified convulsions. Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/15/25, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Review of R58's Care Plan, found under the Care Plan tab of the EMR, dated 11/13/25, revealed R58's current functional performance required the assistance of two-persons for bed mobility. Review of the document titled, Documentation Survey Report v2 for the month of 12/25, on page three of 24, revealed that R58 had an intervention/task of bed mobility – assist of two staff. Review of the Progress Note found under the Prog Note tab of EMR, dated 12/01/25 at 6:01AM, indicated R58 had an unwitnessed fall on Monday 12/01/25 at 5:42AM, from the bed during care. He is on the left side of his bed, face down. There is blood coming from his head, but unable to determine exact location of bleeding. He is moaning & has garbled speech. Staff did not move him from his position. Called 911.Power of Attorney and Nurse Practioner (NP) notified. Further review of the Progress Notes found under the Prog Notes tab of the EMR, dated 12/01/25 at 7:47AM, indicated, Certified Nurse Assistant (CNA) 21 reported to nurse that resident rolled and slip out of bed when she was giving care. This nurse found resident lying on his face bleeding, was not able to talk at the moment V/S [vital signs] were completed, . Review of the Facility Reported Incident revealed that on 12/01/25 at 5:42 AM, the CNA provided incontinent care by herself, the CNA turned the resident on his left side and turned her back on the resident to reach for a sheet and R58 slid off the bed, was found on the floor, on the left side of the bed in between the CNA and the bed. R58 sustained a head laceration which required him to be evaluated in the emergency department and returned to the facility with stitches on his head (measuring 3.2 centimeters x 2.7 centimeters). Review of the document titled, CNA Fall Report Form, dated 12/01/25, located in the facility reported incident paper packet, CNA 21 stated, .Was providing care, I went to roll him towards myself and I turned back to grab something and slipped right between me and the bed. Review of the document titled, Occupational Therapy Discharge Summary for the dates of service 01/05/26 through 02/20/26, stated, .Discharge recommendations: patient continues to require total assistance with activities of daily living (ADLs), bed mobility, and transfers with mechanical lift assist of two staff members. During an interview on 05/21/26 at 4:18PM, Licensed Practical Nurse (LPN) 4 stated, .Certified Nursing Aide (CNA) 21 called and said that the resident fell off the bed, so I went in the room and the CNA told me that she turned him towards her. CNA21 said she could not hold the resident because he slipped from her hands. He fell between her and the bed. I saw the supervisor call CNA21 and said that she was told to write a statement and was told to leave. The resident fell off the bed and busted his head. They talked to CNA21. They did in service, everybody at that time had to sign the in service. During an interview on 05/21/26 at 4:02 PM, R58 stated, .There was only one aide helping me get cleaned up, she turned me, she then turned her back and I slid out of the bed, it damaged my head, and she turned me to the left side of the bed and she lost her grab to me and that's when my head went down first and caused damage to my head. There are supposed to be two people to do it, it still happens that only one person helps me get changed. There are no men that help me get changed, only girls and it still happens that only one girl helps me get changed to this day. Sometimes they get another person to help out but it's not all the time. I get changed two to three times a day, usually in the morning and at night. During an interview on 05/22/26 at 11:39 AM, the Director of Nursing (DON) stated, .for residents that are care planned for assist times two with bed mobility, there must always be two staff. We have done training on paired care specifically due to false allegations. I don't recall doing education for assist times two with bed mobility and transfers lately, but these trainings are done during new hire orientation. 2. Review of R172's admission Record located under the Profile tab of EMR revealed the resident was admitted on [DATE], with diagnoses of Alzheimer's disease, dementia, malignant neoplasm of prostate, contracture of muscle-left hand, blindness-one eye, and low vision other eye. R172 was discharged to the hospital on [DATE]. Review of R172's quarterly MDS, with an ARD of 09/09/25, located under the MDS tab of the EMR revealed R172 had a Brief Interview for Mental Status score of zero out of 15, which indicated R172 was severely cognitively impaired. The assessment documented R172 was dependent on staff or required maximal assistance for all activities of daily living. Review of R172's Care Plan located under the Care Plan tab of the EMR and updated 08/19/25 revealed R172 had impaired verbal communication and visual function, was incontinent of bladder and bowel, required the assistance of two staff for bed mobility and toileting, and had a low air loss mattress due to wounds. R172's Kardex was unavailable for review as the resident was no longer at the facility. Review of R172's Progress Notes located under the Prog Notes tab of the EMR dated 09/28/25, revealed Writer was called to resident's room by nurse to assess resident. Writer walked in resident room and observed resident on floor lying on his back. CNA giving care stated that while she was giving the resident care the resident fell off of his bed. Writer assessed resident no bruises and no injuries noted. V/S [vital signs] recorded and within normal ref [reference] range. POA [Power of Attorney] and MD [physician] on-call notified. MD agreed to send resident to hospital to rule out head injury. Review of R172's Hospital Records, located in the EMR under the Misc [Miscellaneous] tab dated 09/28/25, revealed documentation that R172 had no injuries. Review of the facility provided investigative documentation, dated 10/03/25, revealed, Resident is an [AGE] year old male here for continued care and follows with hospice services. Nursing staff report patient with a witnessed fall on 09/28/25 and was sent to the emergency room for evaluation. Resident is seen today resting in bed in no acute distress. Resident with no visible signs of injury and his neurological status is at baseline. He was evaluated in the emergency room and per discharge orders patient CT [cat scan] scan head neck pelvis were negative for acute injury and chest x-ray was also negative. Resident with witnessed fall out of bed. Resident had been changed and treatment applied by nurse and CNA. Nurse had left room and CNA went to secure brief and turned resident in order to grab brief from underneath resident when resident moved his leg with heel bool on rotated over other leg and resident rolled out of bed onto fall mat. Review of a verbal statement by CNA1, provided by the facility, dated 09/29/25, revealed [CNA1] stated [Licensed Practical Nurse (LPN) 1] and I were in the room performing care. [LPN1] was changing his wound and I had finished ADL [activities of daily living] care. I asked [LNP1] to help me pull up the side of resident's brief and turn him to the middle of the bed. [LPN1] did help me and he left the room. I continued to straighten up the draw sheet and attach his brief turning him slightly. Resident had heel boots on so I positioned his legs in order to fasten the brief when the resident moved his legs with boots on and fell out of bed onto his floor mat. First the boot went over the side then resident just slid out of bed and even though I was holding him I could not stop him from falling. I immediately got [LPN1] and the Supervisor was called. Review of a written statement by LPN1, provided by the facility, dated 09/28/25, revealed This writer informed the CNA that the dressing on the patient needed to be changed and that when she was going to clean him up to come get me. This writer went in to help and change the dressing. After treatment was completed, this writer asked if she was ok from here and she said yes. This writer proceeded to exit the room. Approximately ten minutes later the CNA called for me in the room. In the room upon arrival, patient was on the fall mat laying on his back. This writer informed the supervisor and the patient's nurse for the shift about the fall. During an interview on 05/22/26 at 10:39 AM, CNA1 stated The nurse and I were washing him up and the nurse did his wound care. The nurse left the room when wound care was finished. I finished attaching his brief and rolled him side-to-side. When I rolled him away from me, he rolled off the bed, onto the fall mat on the floor. I didn't realize he was on an air mattress. I'm not quite sure if he required two staff for care. He didn't have any bed rails. He was total dependent. After the incident, I was suspended pending investigation and allowed to return to work. I would check the chart to find out if the resident required two staff. There is a section that states two staff, when going into the computer. During an interview on 05/22/26 at 11:49 AM, the DON stated If a resident is a two person assist, I would expect both staff to be at bedside. The DON stated staff should check the Kardex to determine the level of care needed. 3. Review of R123's admission Record, located under the Profile tab in the EMR revealed R123 was admitted to the facility on [DATE] with diagnoses of neuromyelitis optica (autoimmune condition causing vision loss, paralysis, nerve pain and quadriplegia) and quadriplegia (loss of motor function and sensation in all four limbs). Review of the annual MDS, with an ARD of 10/21/25 and located under the MDS tab of the EMR, revealed R123 had a BIMS score of 15 out of 15, indicating intact cognition. The MDS indicated R123 had bilateral impairment in both upper and lower extremities and required the use of a mechanical lift. The MDS also indicated R123 was dependent for showering/bathing and for rolling left and right. Review of the Care Plan, dated 11/03/25 and located under the Care Plan tab in the EMR, revealed, Unable to do own ADLs [activities of daily living] without assistance R/T [related to] weakness and quadriplegia. Date Initiated: 11/19/2024. BED MOBILITY: assist of 2. Date Initiated: 11/19/2024. Current Functional Performance. Date Initiated: 06/29/2025. Functional Status will Maintain or Progress Towards Personal Goal During Stay. Date Initiated: 06/29/2025. Showers twice a week using shower bed & 2 Staff. 2 Staff to remain present during task. Date Initiated: 11/04/2025. Functional ability - Bed mobility Assist x 2. Date Initiated: 10/29/2025. Review of the Order Summary Report, dated 11/03/25 and located under the Orders tab in the EMR, revealed an order dated 10/16/25 indicating, 2 person care at all times. Review of R123'sProgress Notes, dated 11/03/25 at 9:52 AM and located under the Progress Notes tab in the EMR, revealed Fall Note. Resident reported on floor in shower room, found face down by charge nurse upon her arrival. Resident alert and able to communicate. Resident noted with laceration to forehead. Resident assessed by DON and NP [name]. NP [name] gave verbal order to send resident to hospital ER [emergency room] for Evaluation. Another nursing note dated 11/03/25 indicated, LATE ENTRY. Fall Details: Date/Time of Fall: 11/03/2025 9:10 AM Fall. was witnessed. Who witnessed fall: Assigned CNA. Other fall location: Shower room. Did an injury occur as a result of the fall: Yes. Injury details: Abrasion to forehead. Scale: Mechanical Lift. Review of the facility reportable documentation provided by the Administrator revealed, Resident stated that the Aide had begun his shower and when she rolled him over to wash his back and the shower rail gave way and resident rolled out of shower bed onto the floor. CNA states went to give resident shower and placed the shower bed against the wall of shower stall entrance. CNA states she locked the wheels and rails of the shower bed. CNA states she rolled the resident over when the shower rail gave way and resident rolled out of shower bed onto the floor. Resident sustained a fall from the shower bed during his shower. Upon investigation and interview with CNA it was determined that the CNA started care by herself. Resident is a two person assist with all care. During an interview on 05/21/26 at 12:15 PM, R123 confirmed he fell in the shower in November of 2025. R123 stated when CNA22 turned him, the rail broke and I fell and hit my head. R123 stated since the fall, Sometimes other CNA's have showered him by themselves using the shower bed. R123 stated CNA5 did it alone once since the fall. R123 stated CNA5 called out to the other Aides who were in the hall talking and no one would come help him. During an interview on 05/22/26 at 11:44 AM, the DON stated, If they're assist times two, it takes two. She stated if a resident is a two person assist and one staff is turning the resident, they should not turn them away from themselves, but towards themselves. The DON stated, If they can turn themselves independently, it can be one staff, but if they can't turn themselves independently, it should be two. She stated, I think that the shower bed is always two people. During a phone interview on 05/22/26 at 12:46 PM, CNA22 she confirmed she was showering R123 on 11/03/25 when he fell. CNA22 stated, I was a float that day and I asked for help. She stated she provided care for R123 before that day and most of the time she did it by herself because she could not get other staff to help. CNA22 stated when she took R123 in on the shower bed, she called out the door for help but no one came. She stated, When I went to roll him, the pin in the side rail maybe didn't latch on. CNA22 also stated R123 fell off the shower bed on the floor and hit his head. During an interview on 05/22/26 at 3:17 PM, LPN8, stated, That day (11/03/25), I worked as a CNA on that unit. LPN8 stated when using a shower bed to shower a resident it should be Always two. LPN8 stated, I have provided care with him (R123) in bed by myself, yes, because I know how to position him. If I needed to turn him the other way I always pull him close to me, so when I turn him over away from me. If he falls forward it will be on the bed. LPN8 stated it was Two supposed to to provide care for R123 in bed. LPN8 CNA23 and CNA24 also provided care to R123 in the bed by themselves. Regarding R123's fall from the shower bed, she stated, [R123's name] was on the floor. He was face down on the floor in a little pool of blood. It was a sight to see. LPN8 stated, What I got from it, she (CNA22) was in there by herself in the shower room and thought it was a good idea to turn him to the side, and I don't know why she thought the rail would hold him up. During an interview on 05/23/26 at 10:53 AM, the Director of Rehabilitation (DOR) stated R123 Has been a two person assist [assistance] for bed mobility since admission and all other therapy evaluations after admission indicate remains at baseline which means he is still a two person assist. During an interview on 05/23/26 at 2:09 PM, CNA5 stated he was working the day R123 fell in the shower in November 2025. CNA5 stated he heard the girl who had him. screaming hysterically, Help me! He fell! CNA5 stated R123 Was on the floor and he was facedown and blood was on his head. When asked if he has ever given R123 a shower on the shower bed by himself, CNA5 stated, Ya. It's hard to find people so most people don't want to help. I asked everybody to come and help me, but nobody would come. When asked how he knew if a resident was a one or two person assist for a bed bath, CNA5 stated, It's in the Kardex. If it says two-person bed mobility, then it's two people. Air mattresses require two-person. During an interview on 05/23/26 at 2:45 PM, the Assistant Director of Nursing (ADON) stated she remembered when R123 fell in November of 2025. The ADON stated, He fell out of the shower bed. It was just that CNA. When I got there, he was on the floor. bleeding from the forehead. The expectation at that time. it was just like there was an assumption or understanding that if it was two-person bed mobility then it would be two in the shower bed. When asked if CNA5 told her she couldn't get help that day, she stated, I don't remember any details. Review of the Facility Action Plan Checklist And AD HOC [specific committee] QAPI [quality assessment and performance improvement], dated 11/03/25 revealed, ln depth review of How incident Occurred: Resident. with a BIMS of 15 [cognitively intact]. Resident has a history of requiring the use of a mechanical lift for transfers and 2 person assist for all care. Per the assigned CNA, she was showering [R123's name] alone when he is a 2 person assist at all times. She confirmed that she was alone in the shower room with the resident. The Task Kardex says resident is to be a two Person Assist. The resident continues to require two staff assistance for all care. Education to 100% of Nursing Staff was initiated on 11/3/25. b. lf Resident's bed mobility status is 2 Assist- this requires two staff to assist with showers during the entire task. d. Residents are never to be turned away from you when providing care, they must always be turned towards you. e. lf task in POC states 2 Person Assist; Do not attempt to provide care alone. f, Shower Rails are for Spatial Awareness Only & is not to be used as an enabler for Mobility/Turning or Repositioning . g. lf You can not find assistance; a second person- Do not complete the task until a second Person is found. During an interview with the Administrator on 05/23/26 at 7:40 PM, she stated the facility did not have policies and procedures regarding bed mobility, transfers, or shower beds. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting dated 05/26, that on page one of two, stated, Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal, and oral hygiene and on page two of two item #7 stated, A resident's ability to perform ADLs is measured using clinical tools, including the MDS. Functional decline and improvement are evaluated using the following MDS definitions: Dependent two-person assist – if a resident is evaluated dependent with a two-person assist of staff to perform ADL's (bed mobility, toileting, or transfer); these ADL must not be completed without a second staff member. If another nurse aide is not available to assist, notify the nurse or nursing supervisor. The nurse or nursing supervisor will assist with necessary/immediate ADL care.

Based on observation and interview, the facility failed to maintain the vents on the hood above the stove and fryer in a safe and sanitary condition. This placed all 160 residents who received food from the kitchen, out of a total census of 165 residents, at risk of injury from fire in the hood or spread of food-borne illness.Findings include: Review of the facility's Diet Type Report, provided on paper and dated 05/23/26, revealed there were five residents who did not consume any food orally. During initial tour of the kitchen on 05/19/26 at 9:55 AM, the vents in the hood above the stove and fryer were observed with caked on dark brown grease and debris. The Assistant Food Service Director (AFSD) stated they were cleaned every few months by a contracted company and were not cleaned by the dietary staff. During a subsequent observation of the kitchen on 05/21/26 at 12:04 PM, the vents in the hood above the stove and fryer were again observed with caked on dark brown grease and debris. During an interview on 05/21/26 at 1:43 PM, the Food Service Manager (FSM) agreed the vents were very dirty and needed to be cleaned. He stated a contract company came in to clean the vents but did not know the frequency. During an interview on 05/23/26 at 11:36 AM, the Maintenance Director (MD) stated he was not involved in cleaning the hood vents and a contracted company came every six months to clean them. He stated when it was brought to his attention, he cleaned the vents the best he could, and it would take another washing to get them thoroughly clean. The MD stated that going forward, cleaning the hood vents would be part of the monthly cleaning schedule. A policy addressing cleaning of the hood vents was requested but was not provided prior to facility exit.

Based on record review, interview and policy review, the facility failed to protect the residents' right to be free of physical and/or sexual abuse for three of 13 residents (Resident (R)82, R140 and R23). R82 reviewed for abuse out of a total sample of 56. Resident (R)82 experienced physical abuse by R153, R140 experience sexual abuse by R48 and R23 experienced verbal abuse Certified Nurse Assistant (CNA) 28.The Findings Include:1. Review of R153's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and depression. Review of R153's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 05/08/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated severely impaired cognition. Review of R153's Care Plan, initiated on 06/16/25 and located under the Care Plan tab of the EMR, revealed . The resident will not exhibit physical abuse more than twice per week for 90 days. Further review revealed the care plan was not updated after the December 2025 or March 2026 incident. Additionally, R153 was care planned prior to this for being verbally aggressive towards others and but there had been no updates since 2024. Review of R153's Nurses note, written on 06/14/25 by Registered Nurse (RN) 7 and located under the Notes tab of the EMR, revealed . Supervisor called to the unit following an altercation between R153 and her roommate R82. R153 was witnessed hitting her roommate while the roommate was laying down in bed. Staff immediately intervened. R153 was noted to be cursing at staff members but denied reasoning behind her actions. She was able to calm down. Room changes implemented. Staff reported R153 was calm moments prior when she approached staff at the desk and asked for a cup of water which was given to her. It was later noted that R153 had thrown the water on her roommate while she slept. Resident assessed, now calm. Review of R82's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and depression. Review of R82's significant change MDS, with an ARD of 03/31/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. Review of R82's Nurses note, written on 06/14/25 by RN7 and located under the Notes tab of the EMR, revealed . R82 was noted being struck by roommate R153, while she slept in bed. Staff immediately intervened. R82 was initially concerned about roommates R153's behavior and kept stating I don't understand what I did to her. Denied pain. Small scratch to top of left hand noted. Area cleansed with NSS. No other injuries were noted. Nurse offered resident PRN medications and room change implemented. During an interview on 05/21/26 at 1:08 PM Licensed Practical Nurse (LPN) 21 stated R153 can be very unpredictable and will lash out with no warning. On 06/14/25 she was working when there was an incident with R153's roommate R82 at the time. She remembers R82 screaming after staff found R153 standing over R82 hitting her. During an interview on 05/21/26 at 3:47 PM RN7 stated she was the nurse manager working at the time of the incident that occurred on 06/14/25 between R153 and R82. She remembers staff coming to ger her after they observed R153 standing over R82 and hitting while she slept and the residents were immediately separated. 2. Review of R48's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, and major depressive disorder. Review of R48's quarterly MDS, with an ARD of 05/07/26 and located under the MDS tab of the EMR, revealed a BIMS score of six out of 15, which indicated severely impaired cognition. Review of R48's Care Plan, initiated on 04/29/17 and located under the Care Plan tab of the EMR, revealed . The resident will have a decrease in behavior of making sexual comments or touching others. Further review revealed the care plan had not been updated with new interventions since 2017. Review of R140's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia. During an interview on 05/22/26 at 9:22 LPN25 said R48 will touches, grab and will violate women. He was unable to see but he would feel out. She said there was an incident when R48 grabbing R140's breasts and they were separated. She said it was documented in either progress notes or on the MAR, and the family was notified but she was unsure if it was reported to management. `3. Review of R23's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included anxiety and depression. Review of R23's quarterly MDS, with an ARD of 05/11/26 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. Review of the facility's 5 Day Follow Up, dated 01/22/26, revealed that a verbal exchange was witnessed by nursing staff. Further review revealed CNA28 was terminated after the incident. Review of statement written on 01/14/26 by LPN31 revealed she witnessed a verbal exchange between CNA28 and R23 that LPN31 described as escalated exchange of words after he asked for some ice. LPN31 further wrote that she witnessed CNA23 go behind R23 and yanked him to get him from the nurse's desk area and resident grabbed onto the nurse's desk resisting the move. An attempted phone interview was conducted on 05/22/26 at 12:28 with LPN31 but was unsuccessful. During an interview on 05/19/26 at 1:05 PM R23 stated CNA28 came into his room and threw his covers back and was rude to him when he told her he was independent and did not need any ADL or incontinent care. He stated that CNA28 said something rude to him and left his room. He stated a few minutes later that her went to the nurse's station to request some ice and was waiting for the nurse when CNA28 told him she would get the ice but he declined. CNA28 at that time became upset and came behind him and grabbed his wheelchair and pulled him back so hard that he had to grab ahold of the nurse's station. During an interview on 05/22/26 at 11:28 AM the Director of Nursing (DON) said all residents should feel safe and be kept safe and free from any resident-to-resident abuse. She stated she was unaware of R153 attacking R82 or R48 sexually fondling R140 or any other female residents. During an interview on 05/22/26 at 11:58 AM the Administrator stated she was unaware of any current issues with R48 or R153. She stated it was the facility's responsibility to ensure all residents were safe and free from any type of sexual fondling or physical aggression. She further stated she was unable to recall if she was aware of the incident that occurred on 06/14/25 with R153 and R82 or that staff observed R48 sexually fondling R140 or any other residents. Review of the facility's policy titled, Abuse Investigation and Reporting, dated July 2017, revealed, The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented .

Based on interview, record review, and review of facility policy, the facility failed to: 1.) report incidents and/or allegations of resident to resident physical and/or sexual abuse to the Administrator within two hours for three of 17 sampled residents (Resident (R) 82, R136, and R55) reviewed for abuse out of a total sample of 56, and 2.) report injuries of unknown origin to the State Survey Agency (SSA) for one of four residents (R34) reviewed for accidents out of a total sample of 56. This had the potential to allow for continued abuse.Findings Include:1. Review of R153's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and depression. Review of R153's quarterly Minimum Data Set (MDS),with an assessment reference date (ARD) of 05/08/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated severely impaired cognition. a. Review of R82's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and depression. Review of R82's significant change MDS, with an ARD of 03/31/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. Review of R153's Nurses note, written on 06/14/25 by Registered Nurse (RN) 7 and located under the Notes tab of the EMR, revealed, . Supervisor called to the unit following an altercation between [R153] and her roommate [R82]. [R153] was witnessed hitting her roommate while the roommate was laying down in bed. Staff immediately intervened. [R153] was noted to be cursing at staff members but denied reasoning behind her actions. She was able to calm down. Room changes implemented. Staff reported [R153] was calm moments prior when she approached staff at the desk and asked for a cup of water which was given to her. It was later noted that [R153] had thrown the water on her roommate while she slept. Resident assessed, now calm . During an interview on 05/21/26 at 1:08 PM, LPN21 stated on 06/14/25 she was working when there was an incident with R153's roommate at the time, R82. LPN21 stated she remembered R82 screaming after staff found R153 standing over R82 hitting her. LPN21 stated she reported it to the nurse supervisor. During an interview on 05/21/26 at 3:47 PM, RN7 stated she was the nurse manager working at the time of the incident that occurred on 06/14/25 between R153 and R82. RN7 stated she remembered staff coming to ger her after they observed R153 standing over R82 and hitting R82 while she slept, and the residents were immediately separated. RN7 stated she did not remember if she reported it but she should have. RN7 stated she thought she did but was unsure to whom it was reported. b. Review of R136's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and anxiety disorder. Review of R136's quarterly MDS, with an ARD of 12/09/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. Review of R136's Nurse's Note, dated 12/31/25 at 11:12 PM, written by LPN22, and located under the Notes tab of the EMR, revealed, . While doing oncoming rounds, upon exiting a resident's room, an aide came down the hall telling me [R136] reports to have been hit by her roommate, [R153]. Upon entering the room, this resident was seen lying in bed, when asked what took place, she states she attempted to pull the privacy curtain between both beds because the light on the other side of the room was too bright and bothering her, when her roommate started hitting her on her arm. Incident reported to RN supervisor . c. Review of R55's admission Record, located under the Profile tab of EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and major depressive disorder. Review of R55's quarterly MDS, with an ARD of 03/12/26 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. Review of R153's Nurse's Note, dated 3/17/26 at 2:07 PM, written by LPN24, and located under the Notes tab of the EMR, revealed, . [R153] hit roommate, [R55] in the chest. [R55] was moving the phone cord, and [R153] struck her in the chest. After, she started throwing things across the room. DON and Unit manager notified. During an interview on 05/22/26 at 9:03 AM, LPN24 stated R55 told her that she was trying to move the phone cord when R153 started yelling and hit R55 in the chest. LPN24 stated when she went into the room, R153 was still yelling and there were items that had been thrown on the floor. LPN24 stated she said the unit manager at the time had her write a progress note about the incident, but she did not report it. LPN24 stated she assumed the unit manger did. 2. a. Review of R48's admission Record, located under the Profile tab of EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, and major depressive disorder. Review of R48's quarterly MDS, with an ARD of 05/07/26 and located under the MDS tab of the EMR, revealed a BIMS score of six out of 15, which indicated R48 was severely cognitively impaired. b. Review of R140's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia. Review of R140's quarterly MDS, with an ARD of 03/25/25 and located under the MDS tab of the EMR, revealed a BIMS score of 04 out of 15, which indicated severe cognitive impairment. Review of R48's Medication Administration Record (MAR), for the period from August 2025 until May 2026 revealed a total of six documented incidents of sexual inappropriate behavior towards others. The last date documented occurred on 05/07/26. There was no documentation to show which residents had been affected by R48's sexual inappropriate behaviors. During an interview on 05/22/26 at 9:22, LPN25 stated there was an incident when R48 was in his wheelchair and she heard a female resident screaming and she observed R48 feeling on the resident's breasts. LPN25 stated she could not remember who the resident was and she did not report it. LPN25 stated she assumed other staff that observed it reported it. LPN25 stated she did remember observing R48 grabbing R140's breasts, and the residents were separated. LPN25 stated the incident was documented in either progress notes or on the MAR, and the family was notified. She stated she was unsure if it was reported to management. Review of facility reportable log revealed none of the incidents involving R153 or R48 had been reported. During an interview on 05/22/26 at 10:15 AM, the Social Services Director (SSD) stated she was unaware of any incidents involving residents in the last year or longer and was confident if there had been any issues involving residents, she would have been made aware of it. The SSD stated she would expect staff to report any behaviors they observed and document on the MAR. The SSD stated she was unaware there were any documented sexual inappropriate behaviors that had been documented on the MAR or that staff had observed R48 fondling female residents. During an interview on 05/22/26 at 11:28 AM, the Director of Nursing (DON) stated staff should immediately report any physical aggression between residents or sexually inappropriate behaviors to their supervisor. The DON stated when one or more staff were aware of the same incident, she would expect both staff to report the incident. During an interview on 05/22/26 at 11:58 AM, the Administrator stated she was unaware of any current issues with R48 or R153, and she confirmed that none of the incidents involving these resident-to-resident incidents of physical and sexual abuse had been reported. The Administrator stated it was the responsibility of the facility to follow their abuse protocol and ensure the safety of all residents. Review of the facility's policy titled, Abuse Investigation and Reporting, dated July 2017, revealed,. all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) . 3. Review of R34's admission Record, located under the Profile tab of the EMR, revealed R34 was admitted to the facility on [DATE] with diagnosis of dementia with behavioral disturbance, type 2 diabetes, and repeated falls. Review of R34's quarterly MDS, with an ARD of 02/23/26 and located under the MDS tab of the EMR, revealed a BIMS score of zero out of 15, which indicated that her cognitive function was severely impaired. Review of R34's Care Plan, initiated on 05/21/26 and located under the Care Plan tab of the EMR, revealed R34 was dependent on staff for leisure involvement and required prompting and encouragement to engage. It also revealed R34 had dementia, constant re-direction was needed, had a very short attention span in groups, and strolled around the unit. Review of the incident report dated 01/26/26 at 5:30 AM, reported by RN3, revealed R34 was noted with a bruise of unknown origin to her right shin. R34 was noted with a gray bruise to the right shin measuring 6.0 centimeters (cm) by 4.0 cm with a maroon-red line through the center of the gray bruise. R34 was unable to state the reason for the bruise. Review of the document titled, CNA Statement, dated 01/26/26, revealed that R34 was asleep in bed prior to finding the bruise of unknown origin. The document was not signed by any staff member. Review of the incident report dated 11/06/25 at 8:00 PM, reported by LPN12, revealed during activities of daily living (ADL) care, CNA 16 noticed bruises to R34's right breast and left upper arm. R34 was also noted with a contusion to her left great toenail. Review of the document titled, Wound Notification, dated 11/06/25 revealed that LPN12 assessed R34 and found a bruise on the right outer breast and left arm measuring a length of 4.2 cm by width of 3.2 cm. The bruises were noted to be of unknown origin. Review of the document titled Staff Statement, dated 11/06/25 by LPN12, stated During ADL care, staff noticed bruises to resident's right breast and left upper arm. Resident had no idea what had happened to her breast or to her arm. Her breast was noted to be purple in nature and left upper arm seems to be purple also. Resident grimaced when breast was touched and stated, it hurts. During an interview on 05/21/26 at 3:49 PM, the Administrator stated the facility found no documented evidence that R34's injuries of unknown origin had been reported to the SSA. Review of the facility policy titled, Investigating Resident Injuries, on page one of two, stated, . All resident injuries are investigated and on page one of two under item seven, stated, If the nursing and medical assessment determines an injury of unknown source the investigation will follow the protocols set forth in our facility's established abuse investigation guidelines.

Based on interview, record review, document review, and policy review, the facility failed to investigate: 1.) incidents of resident to resident physical and/or sexual abuse for three of 17 sampled residents (Resident (R) 82, R136, and R55) reviewed for abuse out of a total sample of 56 after R153 physically assaulted R82, R136, and R155; 2.) injuries of unknown origin for one of three residents (R34) reviewed for accidents out of a total sample of 56; and 3.) a potential incident of neglect for one of three residents (R172) reviewed for accidents out of a total ample of 56. These failures placed residents at continued risk of abuse and neglect.Findings Include: 1. Review of R153's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and depression. Review of R153's quarterly Minimum Data Set (MDS),with an assessment reference date (ARD) of 05/08/26 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated severely impaired cognition. a. Review of R82's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and depression. Review of R82's significant change MDS, with an ARD of 03/31/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. Review of R153's Nurses note, written on 06/14/25 and located under the Notes tab of the EMR, revealed, . Supervisor called to the unit following an altercation between [R153] and her roommate [R82]. [R153] was witnessed hitting her roommate while the roommate was laying down in bed. Staff immediately intervened. [R153] was noted to be cursing at staff members but denied reasoning behind her actions. She was able to calm down. Room changes implemented. Staff reported [R153] was calm moments prior when she approached staff at the desk and asked for a cup of water which was given to her. It was later noted that [R153] had thrown the water on her roommate while she slept. Resident assessed, now calm . b. Review of R136's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia and anxiety disorder. Review of R136's quarterly MDS, with an ARD of 12/09/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. Review of R136's Nurse's Note, dated 12/31/25 at 11:12 PM and located under the Notes tab of the EMR, revealed, . While doing oncoming rounds, upon exiting a resident's room, an aide came down the hall telling me [R136] reports to have been hit by her roommate, [R153]. Upon entering the room, this resident was seen lying in bed, when asked what took place, she states she attempted to pull the privacy curtain between both beds because the light on the other side of the room was too bright and bothering her, when her roommate started hitting her on her arm. Incident reported to RN supervisor . c. Review of R55's admission Record, located under the Profile tab of EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and major depressive disorder. Review of R55's quarterly MDS, with an ARD of 03/12/26 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. Review of R153's Nurse's Note, dated 3/17/26 at 2:07 PM and located under the Notes tab of the EMR, revealed, . [R153] hit roommate, [R55] in the chest. [R55] was moving the phone cord, and [R153] struck her in the chest. After, she started throwing things across the room. DON and Unit manager notified. 2. a. Review of R48's admission Record, located under the Profile tab of EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, and major depressive disorder. Review of R48's quarterly MDS, with an ARD of 05/07/26 and located under the MDS tab of the EMR, revealed a BIMS score of six out of 15, which indicated R48 was severely cognitively impaired. b. Review of R140's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia. Review of R140's quarterly MDS, with an ARD of 03/25/25 and located under the MDS tab of the EMR, revealed a BIMS score of 04 out of 15, which indicated severe cognitive impairment. Review of R48's Medication Administration Record (MAR), for the period from August 2025 until May 2026 revealed a total of six documented incidents of sexual inappropriate behavior towards others. The last date documented occurred on 05/07/26. There was no documentation to show which residents had been affected by R48's sexual inappropriate behaviors. During an interview on 05/22/26 at 9:22, Licensed Practical Nurse (LPN) 25 stated she did remember observing R48 grabbing R140's breasts, and the residents were separated. LPN25 stated the incident was documented in either progress notes or on the MAR, and the family was notified. During an interview on 05/22/26 at 11:28 AM, the Director of Nursing (DON) stated any incident of a resident sexually groping another resident or physical assaults would immediately initiate an investigation, and staff should ensure that the residents involved along with all other residents were safe. She stated staff should have monitored the aggressor resident's behaviors and taken statements from anyone in the general area and continued monitoring until they had completed the investigation and decided if abuse occurred. During an interview on 05/22/26 at 11:58 AM, the Administrator was asked to provide the investigative files for the incidents of physical and sexual abuse. She confirmed that none of the incidents involving these resident-to-resident incidents of physical and sexual abuse had been investigated. The Administrator stated it was the responsibility of the facility to follow their abuse protocol and ensure the safety of all residents. Review of the facility's policy titled, Abuse Investigation and Reporting, dated July 2017, revealed,. all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be . thoroughly investigated by facility management . The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented . Review of the facility policy titled, Investigating Resident Injuries, on page one of two, stated, . All resident injuries are investigated and on page one of two under item seven, stated, If the nursing and medical assessment determines an injury of unknown source the investigation will follow the protocols set forth in our facility's established abuse investigation guidelines. 3. Review of R172's quarterly MDS with an ARD of 09/09/25, located under the MDS tab of the EMR, revealed R172 had a BIMS score of zero out of 15, which indicated he was severely cognitively impaired. Review of R172's Progress Notes located under the Prog Notes tab of the EMR dated 09/28/25 at 11:35 AM, revealed the following documentation, Writer was called to resident's room by nurse to assess resident. Writer walked in resident room and observed resident on floor lying on his back. CNA giving care stated that while she was giving the resident care the resident fell off of his bed. Writer assessed resident no bruises and no injuries noted. V/S [vital signs] recorded and within normal ref [reference] range. POA [power of attorney] and MD [medical doctor] on-call notified. MD agreed to send resident to hospital to rule out head injury. Review of R172's hospital records, dated 09/28/25, provided by the facility, revealed R172 had imaging studies and had no injuries. Review of the intake form, provided by the facility and submitted to the State Agency (SA), regarding a fall without injury for R172, revealed the report was submitted to the SA on 09/28/25 at 1:28 PM. Review of the facility's investigative documentation, provided by the facility, dated 10/03/25, and submitted to the SA, indicated the conclusion, Resident is an [AGE] year old male here for continued care and follows with hospice services. Nursing staff report patient with a witnessed fall on 9/28/2025 and was sent to the emergency room for evaluation. Resident is seen today resting in bed in no acute distress. Resident with no visible signs of injury and his neurological status is at baseline. He was evaluated in the emergency room and per discharge orders patient CT [cat scan] scan head neck pelvis were negative for acute injury and chest x-ray was also negative. Resident with witnessed fall out of bed. Resident had been changed and treatment applied by nurse and CNA. Nurse had left room and CNA went to secure brief and turned resident in order to grab brief from underneath resident when resident moved his leg with heel boot on rotated over other leg [the CNA crossed one leg over the other one when turning the resident] and resident rolled out of bed onto fall mat. The investigation did not include the names of the CNA and nurse that cared for R172. The investigation did not include review of R172's care plan that identified R172 required the assistance of two staff for bed mobility and toileting and had a low air loss mattress. During an interview on 05/22/26 at 1:16 PM, the Director of Nursing (DON) reviewed the facility investigation and stated, I did not work here at the time of this incident. I am responsible for investigating incidents. The names of the staff involved should have been included in the investigation. The care plan should have been reviewed to identify that two people were required for repositioning and care. Neglect is not providing care that you know someone is supposed to have. This could be neglect. This was not a thorough investigation. Staff were not identified. Staff were not documented as suspended. It should tell the whole story. There was no perpetrator identified. If two people were required, then two people should have been providing care the entire time. The plan of care should have been reviewed. Review of the facility's undated policy titled, Abuse Investigating and Reporting, indicated The individual conducting the investigation will, as a minimum: . review the resident's medical record to determine events leading up to the incident . Reporting. Notices will include, as appropriate: . the names of all persons involved in the alleged incident, and what immediate action was taken by the facility.

Based on observation, interview, and policy review, the facility failed to serve perishable cold foods at appropriate temperatures for palatability and food safety for 94 residents who received regular or mechanical soft texture diets out of a total census of 165 residents. This failure had the potential to increase dissatisfaction with meals or spread of foodborne illness.Findings include: Review of the facility's Diet Type Report, provided on paper and dated 05/23/26, revealed there were 86 residents who received a regular texture diet and eight residents who received a mechanical soft diet. During meal service observations in the kitchen on 05/21/26 beginning at 12:04 PM, the bowls of lettuce salad and fruit cocktail were observed in trays that were not on ice or cooled in any way. These salads and bowls of fruit cocktail were served to residents receiving regular and mechanical texture diets. During a test tray observation in H Hall on 05/21/26 at 1:28 PM, the food cart was brought to the hall and staff began serving. The last tray was served at 1:40 PM; at this time, a test tray was evaluated. The salad, fruit cocktail, and pureed fruit cocktail tasted warm to the palate. The temperature of the salad was 72 degrees Fahrenheit (F), and the fruit cocktail was 62 degrees F. During a concurrent interview on 05/21/26 at 1:43 PM, the Assistant Food Service Director (AFSD) stated the salads and fruit cocktail were kept on the tray line on top of a pallet, not cooled in any way. Dietary Aide (DA) 1 added that they used to have cold boxes for keeping cold food items cold, but they no longer used them. The Food Service Manager (FSM) stated he expected cold foods to be held and served at 40 degrees F or below and the facility would devise a system for keeping foods cold on the tray line. Review of the policy titled, Food: Preparation, dated February 2026 revealed, All foods will be held at appropriate temperatures . less than 41 [degrees] F for cold food holding.

Based on observations, record reviews, interviews, and policy reviews, the facility failed to ensure 1.) Ensure linens and resident care items were maintained and transported in a clean and sanitary manner to prevent potential cross contamination and disease transmission for residents 2.) Failed to wear appropriate Personal Protective Equipment (PPE) in rooms with Droplet, Contact, and Enhanced Barrier Precautions (EBP) 3.) Failed to use appropriate hand hygiene and 4.) Failed to change soiled gloves after providing peri-care and getting a resident dressed. These deficient practices had the potential to affect all residents receiving incontinent care and linen services, to increase the risk for cross contamination and the spread of infections throughout the facility. Findings include:1. During an observation on 05/22/26 at 6:41 AM, Certified Nurse Aide (CNA) 25 was observed pushing an overbed table down the hallway in and out of resident rooms A32, A31, and A30. The overbed table contained wipes, peri-care cleanser, towels, and briefs. During the observation, a laundry staff member told CNA25 they could not have those items in the hallway while pushing them room-to-room. CNA25 stated she was using the items and could not place them back onto the clean cart. During an interview on 05/22/26 at 7:08 AM, the Director of Nursing (DON) stated the wipes and peri-care cleanser should be dedicated to one resident only and should not be transported on an overbed table in and out of rooms for use among multiple residents. During an interview on 05/23/26 at 11:32 AM, the Infection Preventionist (IP) stated linens should be removed from the linen cart and taken directly into the resident rooms, not taken in and out of multiple resident rooms. The IP stated staff should place linens into a plastic bag and take them directly into the resident room. The IP further stated CNAs were expected to use individualized linens and supplies during resident care to mitigate disease transmission. 2. Review of Resident (R) 81's admission Record, located under the Profile tab in the electronic medical record (EMR), indicated R81 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, end stage renal disease, dependence on renal dialysis, chronic atrial fibrillation, essential (primary) hypertension, and chronic kidney disease. Review of R81's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 05/14/26 and located under the MDS tab in the EMR, revealed R81 had a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R81 was severely cognitively impaired. The assessment also documented R81 had respiratory syncytial virus (RSV). Review of R81's Comprehensive Care Plan, located under the Care Plan tab of the EMR, revealed the care plan did not indicate R81 had a contagious virus or was on droplet precautions. During an observation 05/19/26 at 1:32 PM, CNA 20 entered R81's room and picked up R81's meal tray. CNA20 was not wearing a gown, gloves, or mask. CNA20 carried the tray with used dishes to the tray cart located in the hallway and placed the tray on the cart. A Droplet precautions sign was posted on the door that read, Everyone must: clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry or remove face protection before room exit. A Contact Precautions sign was also posted on the door that read, Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before exiting the room. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reuseable equipment before use on another person. During an interview on 05/19/26 at 1:50 PM, CNA20 stated I did enter [R81's] room. CNA20 was unaware of the precaution signs posted on the door until she read them and stated, I think it's just because she's on dialysis. Contact precautions should wear gown, and gloves during contact. Droplet precautions should have gown and mask on when entering room. I did not wear [a] gown, gloves, or mask when entering the room and should have. During an interview on 05/20/26 at 1:27 PM, the IP stated, The expectation of staff regarding contact precautions is staff should get dressed outside the room with gown and gloves every time they enter the room. The expectation of staff regarding droplet precautions is the same as contact precautions plus an N95 mask and face shield. Staff should not enter the room without wearing the required PPE. 3. Review of R84's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with a diagnosis of brain cancer and leukemia. Review of R84's Physician's Order, dated 03/25/26 and located under the Orders tab in the EMR, revealed an order for Contact Precautions as a prophylactic measure due to radiation treatments. During an observation on 05/19/26 at 11:07 AM, a sign posted on R84's room door directed staff to follow Contact Precautions and don a gown and gloves upon room entry. Licensed Practical Nurse (LPN) 19 entered R84's room without donning a gown or gloves, turned off the call light, and entered the bathroom where R84 was seated. He then exited the room without performing hand hygiene and found additional staff to help the resident. At 11:10 AM, LPN19 again entered R84's room without donning a gown. During an interview on 05/19/26 at 11:12 AM, LPN19 stated staff only needed to wear a gown and gloves if they were providing high-contact care to R84. LPN19 confirmed he did not put on a gown because he was not providing hands-on care. During an observation on 05/21/26 at 11:05 AM, a sign posted on R84's room door directed staff to follow Contact Precautions and don a gown and gloves upon room entry. Laundry Aide (LA) 1 was inside R84's room wearing only gloves and was emptying the trash can. She exited the room with the trash can, emptied it into a bag in the hall, then entered the room again and replaced the trash can. She then proceeded to wipe the room with cleaning solution. LA1 did not wear a gown during the observation. At this time, the IP approached LA1 to correct her, telling her she had to wear a gown while in the room. During an interview on 05/21/26 at 11:09 AM, LA1 stated she did not put a gown in R84's room and was told by a nurse that she did not need to wear a gown when in the room. During an observation on 05/22/26 at 5:20 AM, a sign posted on R84's room door directed staff to follow Contact Precautions and don a gown and gloves upon room entry. LPN20 entered R84's room without a gown or gloves and administered medications to the resident. During an interview on 05/22/26 at 5:22 AM, LPN20 stated she did not wear a gown or gloves because she thought R84's Contact Precautions had been discontinued. During an interview on 05/23/26 at 11:24 AM, the IP stated for R84, the staff needed to wear a gown and gloves every time they entered the room for contact precautions due to R84's radiation treatments. She stated Contact Precautions had not been discontinued. 4. Review of R5's admission Record, revealed she was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R5's Physician's Orders, dated 05/11/26 and located under the Orders tab in the EMR, revealed orders for droplet, and contact isolation due to diagnoses of respiratory syncytial virus (RSV) and COVID-19. During an observation on 05/20/26 at 9:05 AM, a sign posted on R5's room door indicated contact and droplet precautions were in place and directed staff to wear a gown, gloves, mask, and eye protection when entering the room. CNA26 and CNA27 entered R5's room without donning a gown, gloves, mask, or eye protection. CNA26 touched R5's bed and turned off the call light. CNA26 and CNA27 assisted R5's roommate with using the bathroom. During an interview on 05/20/26 at 9:10 AM, CNA26 stated she did not wear the appropriate PPE when entering R5's room because her roommate had been calling out for help and she wanted to get into the room quickly. She stated she should have donned a gown, gloves, mask, and eye protection before entering. During an interview on 05/20/26 9:12 AM, CNA27 stated she did not wear PPE because she was only assisting R5's roommate, and R5 was the only resident under precautions. During an interview on 05/23/26 at 11:24 AM, the IP stated staff needed to don PPE every time they entered R5's room, no matter with which resident they were working. 5. Review of R19's admission Record, located under the Profile tab of the EMR revealed he was admitted to the facility on [DATE] with a diagnosis of anoxic brain damage. Review of R19's EMR under the Orders tab revealed a physician's order, dated 02/26/26, for Enhanced Barrier Precautions due to use of a feeding tube. During an observation on 05/21/26 at 2:02 PM, R19's room door had a sign indicating EBP were in place and directed the staff to wear a gown and gloves for all high-contact activities. LPN9 entered R19's room to provide medications and water flushes through his feeding tube. LPN9 donned gloves but did not wear a gown as she checked the tube's placement and administered the medications and water flushes. During an interview on 05/21/26 at 2:59 PM, LPN9 stated she typically wore a gown in addition to gloves when administering medications through a feeding tube, but she forgot to do it this time. During an interview on 05/23/26 at 11:46 AM, the IP stated staff should be wearing gown and gloves during medication administration through a feeding tube. 6. a Review of R130's admission Record, located under the Profile tab of the EMR revealed R130 was admitted to the facility on [DATE] with diagnosis of vascular dementia, cerebral infarction, and atrial fibrillation. Review of R130's annual MDS, with an ARD of 12/29/25 and located under the MDS tab of the EMR, revealed a BIMS score of four out of 15, which indicated severely impaired cognition. Review of the document titled, Lab Results Report, with a printed date 05/22/26, revealed that R130's clostridium Difficile (C. Diff) results came back Positive for the C. Diff toxin. b. Review of R111's admission Record, located under the Profile tab of the EMR revealed R 111 was admitted to the facility on [DATE] with diagnosis of dementia, psychotic disturbance, and peripheral vascular disease. Review of R111's admission MDS, with an ARD of 04/08/26, and located under the MDS tab of the EMR, revealed a BIMS score of zero out of 15, which indicated severely impaired cognition. Review of R111's Progress Note, dated 05/23/26 at 8:07 AM, written by Registered Nurse (RN) 6 and located under the Progress Notes tab of the EMR, revealed, Resident's provider team was notified regarding recent C. diff result. The Nurse Practitioner called and ordered Vancomycin 150 milligrams tablet every six hours by mouth for ten days. c. Review of R123's admission Record, located under the Profile tab of the EMR revealed R130 was admitted to the facility on [DATE] with quadriplegia, hepatomegaly, and atelectasis. Review of R123's quarterly MDS, with an ARD of 05/07/26, and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated cognitively intact. During an observation on 05/19/26 at 12:28 PM, Laundry Aide (LA) 2 was standing by the nurses' station wearing gloves and was touching the nurses' station counter. LA2 proceeded to go into one of the rooms on the B hall, came back out to get the mop, with the same gloves on, then came back out of the room to grab a cleaning solution from the housekeeping cart still wearing the same gloves, then went back into the room to start mopping the floor. LA2 came back out with the same gloves on. During an observation on 05/22/26 at 3:39 PM, CNA7 was taking clean linens out of the A Hall linen cart and placed them under her arm, covered the clean linen cart, and proceeded to walk towards R123's room. While walking, CNA7 took the clean linens, hugged them, and entered R123's room and placed them on top of the chest of drawers. During an observation on 05/22/26 at 5:36 AM, CNA6 entered R130 and R111's room without donning on PPE. CNA6 came out of the room, with gloves on, took off the gloves and threw the gloves in the combo trash and linen hamper cart, and performed hand hygiene with hand sanitizer. During an interview on 05/22/26 at 5:47 AM, CNA6 stated, I was in R130's room, and I assisted her with incontinent care. She is negative for C. Diff; I was told that she was negative for it. I don't know why the Contact Precaution sign is still up on the door, I'm sorry that I don't know. During an interview on 05/22/26 at 3:42 PM, CNA7 stated, We are not supposed to keep the clean linens close to our clothes and we are supposed to put it in a fresh bag while taking it to the patient's room. I realized I put the clean linens against my clothes and that was not correct. 7. During an observation on 05/22/26 at 5:25 AM, CNA3 and CNA2 were observed providing a partial bed bath to R43. CNA3 had gloves on and was observed to bathe R43 including providing peri-care. CNA3 did not remove the gloves she had on while performing the peri-care. CNA3 then applied lotion to R43 and dressed her with the same gloves still on. During an interview on 05/22/25 at 5:25 AM with CNA3 as soon as she completed dressing R43, CNA3 confirmed she did not remove the gloves she wore while providing peri-care before applying lotion and clothing. CNA3 stated it was not ok to leave the same gloves on after providing peri-care. During an interview on 05/23/2026 at 11:39 AM, the IP stated, They should change the gloves after providing peri-care. 8. During an observation on 05/21/26 at 5:44 AM, revealed R50 had signage on the outside of door indicated EBP. LPN29 was administering medications to the residents in bed A with the gown only covering her arms and not pulled over her and secured in the back with the straps. LPN29 walked out of the room still wearing the gown and gloves and started walking down the hallway before realizing she was still donning gown and gloves. LPN29 walked back inside room A31 and removed the gown and gloves and walked out without sanitizing her hands. During an interview on 05/21/26 at 5:46 AM LPN29 stated she was aware that she was supposed to remove her gown and gloves and sanitize her hands prior to exiting the resident on EBP's room. She also stated she does not wear the gown completely due to it not being large but stated she has never reported that to staff because she does not work on the A unit that often. During an interview on 05/23/26 at 4:17 PM the IP said when staff are administering medications or any direct care to a resident on EBP they need to don a gown and gloves, and a facemask if there is any risk for splashes of bodily fluids. They should remove the gown, gloves and mask if worn and sanitize their hands prior to leaving the room. The IP said the items should be discarded in the trash inside the room. She also expected staff to completely wear the gown and have it secured with the two ties in the back. She stated it increases the risk of spreading infection if they are not wearing PPE appropriately. During an interview on 05/23/26 at 7:23 PM the Assistant Director of Nursing (ADON) stated nursing staff were expected to wear gown, and gloves at a bare minimum when providing direct care to any resident on EBP. Staff should also be removing the PPE (gown and gloves) prior to exiting the room and sanitizing their hands. The gown should also be secured fully on the body, with the ties and staff need to ask for help if they are unable to do that. She said if PPE was not working appropriately or not discarded it increases the risk of contamination. Review of the facility policy titled, Handwashing/Hand Hygiene, dated October 2023 revealed, . Indications for Hand Hygiene . Hand hygiene is indicated . after contact with blood, body fluids, or contaminated surfaces . (f). before moving from work on a soiled body site to a clean body site on the same resident . Review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions, dated September 2022, revealed, . Contact Precautions. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The policy did not include any information regarding Droplet Precautions.

Based on record review, interviews, and facility policy the facility failed to provide the resident/resident representative (RR) with a written notice of transfer in a language that could be understood and the address of the facility the resident was transferred to for two (Resident (R) 81 and R137) of ten residents reviewed for notice of transfer out of 56 total sampled residents. This failure had the potential for the residents and RR to be misinformed of the transfer out of the facility.Findings include: 1. Review of R81's undated admission Record located under the profile tab in the electronic medical record (EMR) indicated R81 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, end stage renal disease, dependence on renal dialysis, chronic atrial fibrillation, essential (primary) hypertension, and chronic kidney disease. Review of R81's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 07/31/25 revealed R81 was coded as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R81 was cognitively intact. Review of R81's Progress Notes located under the Prog Notes tab in the EMR revealed R81 had been transferred to the emergency room (ER) on 10/18/25 at 4:14 PM for slurred speech, nausea, and vomiting post dialysis. Review of R81's Notice of Transfer dated 10/18/25, located under the Documents tab of the EMR, revealed R81 was transferred to CCHS and did not state the address of the facility R81 was transferred to. 2. Review of R137's undated admission Record located under the profile tab in the EMR revealed R137 was admitted to the facility on [DATE] with diagnoses of dementia, depressive disorders, atrial fibrillation, impulse disorders, cerebral infarction, long term use of anticoagulants, and obsessive-compulsive disorder. Review of R137's quarterly MDS located under the MDS tab in the EMR with an ARD of 11/10/25 indicated R137 was coded as having a BIMS score of zero out of 15 which indicated R137 was severely cognitively impaired. The assessment also revealed R137 took an anticoagulant medication. Review of R137's Progress Notes located under the Prog Notes tab in the EMR revealed R317 had been transferred to the emergency room (ER) on 01/05/26 at 8:00 AM after hitting her head during a fall and being on anticoagulant medication. Review of R137's Notice of Transfer dated 01/05/26, located under the Documents tab of the EMR, stated R137 was transferred to CCHS and did not state the address of the facility R137 was transferred to. During an interview on 05/22/26 at 12:57 PM, the Director of Nursing (DON) reviewed R81's Notice of Transfer dated 10/18/25 and R137's Notice of Transfer dated 01/05/26 and stated, No, it does not include the address of the facility the resident was transferred to. The DON stated, The name of the facility should be spelled out. CCHS as an abbreviation of the receiving facility is not understood if the family didn't live here or know what that was. It is not in a language that the resident/RR could understand. It's important so the family knows where the resident was sent to. Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, revised October 2022, indicated Notice of Transfer or Discharge (Planned). The resident and representative are notified in writing of the following information: The specific reason for the transfer or discharge, . The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is being transferred or discharged . Notice of Transfer or Discharge (Emergent or Therapeutic Leave) . Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments.

Based on observations, record review, and interviews, the facility failed to develop and implement a comprehensive care plan that included instructions needed to provide effective and person-centered care for two (Resident (R) 81 and R58)) of 44 sampled residents. Failure to develop and implement a comprehensive person-centered care plan could place residents at risk for unmet care needs.Findings include: 1. Review of R81's undated admission Record, located under the Profile tab in the electronic medical record (EMR), indicated R81 was originally admitted to the facility on [DATE] with diagnoses of diabetes mellitus, end stage renal disease, dependence on renal dialysis, chronic atrial fibrillation, essential (primary) hypertension, and chronic kidney disease. Review of R81's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 02/16/26, indicated R81 was coded as having a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R81 was severely cognitively impaired. Review of R81's Progress Notes, located under the Prog Notes tab of the EMR, dated 04/02/26, revealed R81 was sent to the emergency room for cough, congestion, wheezing, nausea, vomiting, and elevated blood pressure. Review of R81's Medical Diagnosis screen located in the EMR, revealed a diagnosis of Respiratory Syncytial Virus (RSV) dated 04/05/26. Review of R81's Hospital discharge records dated 04/15/26 and located under the Misc tab of the EMR, revealed a diagnosis of RSV. Review of R81's Physician Note, located under the Prog Notes tab of the EMR dated 05/11/26, revealed [R81] was evaluated for infection, and was determined to still be shedding RSV . During an observation on 05/19/26 at 1:32 PM, R81's room had Droplet Precautions and Contact Precautions signs on the door. Review of R81's Comprehensive Care Plan, located under the Care Plan tab of the EMR, revealed the care plan did not indicate R81 had a contagious virus or was on droplet precautions. During an interview on 05/20/26 at 1:27 PM, the Infection Preventionist (IP) nurse stated, I determine what precautions residents are placed on. [R81] had RSV and was on droplet precautions. During a follow-up interview on 05/22/26 at 5:03 PM, the IP nurse stated, I was just recently assigned to update care plans regarding infection control issues, previously it was the unit manager. RSV and droplet precautions should be included on the care plan. [R81] was not care planned for RSV and droplet precautions. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . and which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; . and reflects currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: . when the resident has been readmitted to the facility from a hospital stay. 2.Review of R58's admission Record, located under the Profile tab of the EMR revealed R58 was admitted to the facility on [DATE] with diagnosis of multiple sclerosis, cerebrovascular disease, and unspecified convulsions. Review of R58's quarterly MDS, with an ARD of 03/25/26 and located under the MDS tab of the EMR, revealed a BIMS score of eight out of 15, which indicated the resident's cognitive function was moderately impaired. Review of R58's Care Plan, dated 11/13/25 and located under the Care Plan tab of the EMR, revealed R58's current functional performance required the assistance of two-persons for bed mobility. Review of the document titled, Documentation Survey Report v2, for the month of 12/25 and located under the Reports tab of the EMR on page three of 24, revealed that R58 had an intervention/task of bed mobility – assist of two staff. Review of the document titled, Occupational Therapy Discharge Summary, for the dates of service 01/05/26 through 02/20/26, provided by the Director of Rehab, indicated, .Discharge recommendations: patient continues to require total assistance with activities of daily living (ADLs), bed mobility, and transfers with mechanical lift assist of two staff members. Review of Facility Reported Incident (FRI) revealed that on 12/01/25 at 5:42 AM, the certified nurse aide (CNA) provided incontinent care by herself, when R58 was care planned for assist x 2 for bed mobility. The CNA turned the resident on his left side and turned her back on the resident to reach for a sheet and R58 slid off the bed. R58 was found on the floor, on the left side of the bed in between the CNA and the bed. R58 sustained a head laceration which required him to be evaluated in the emergency department and returned to the facility with stitches on his head (measuring 3.2 centimeters x 2.7 centimeters). During an interview on 05/21/26 at 4:02 PM, R58 stated, There was only one aide helping me get cleaned up, she turned me, then turned her back and I slid out of the bed, it damaged my head, and she turned me to the left side of the bed and she lost her grab to me and that's when my head went down first and caused damage to my head. There are supposed to be two people to do it, it still happens that only one person helps me get changed. There are no men that help me get changed, only girls and it still happens that only one girl helps me get changed to this day. Sometimes they get another person to help but it's not all the time. I get changed two to three times a day, usually in the morning and at night. During an interview on 5/21/26 at 4:18 PM, Licensed Practical Nurse (LPN) 4 stated, .It's been a while now, but I would initially do my rounds. The CNA called and said that the resident fell off the bed, so I went in there and the CNA told me that she turned him towards her. She said she could not hold the resident because he slipped from her hands. He fell between her and the bed. I saw the supervisor call the CNA and said that she was told to write a statement and was told to leave. The resident fell off the bed and busted his head. They talked to the CNA. They did in-service, everybody at that time had to sign the in service. During an interview on 05/22/26 at 11:39 AM, the Director of Nursing (DON) stated, For residents that are care planned for assist times two with bed mobility, there must always be two staff. We have done training on paired care specifically due to false allegations. I don't recall doing education for assist times two with bed mobility and transfers lately, but these trainings are done during new hire orientation. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, on page one of two, revealed, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. and on page two of two, under item nine, Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on observation, record review, interview, and policy review, the facility failed to ensure an ongoing program of activities to meet the needs of one of two residents (Resident (R) 45) reviewed for activities out of a total sample of 56. This failure had potential to cause boredom and lead to increased anxiety or depression.Findings include: Review of R45's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] and had diagnoses including anoxic brain damage, epilepsy, chronic respiratory failure with tracheostomy, and quadriplegia. Review of R45's annual MDS with an ARD of 01/29/26 and located under the MDS tab of the EMR, revealed she was interested in reading, music, animal visits, news/current events, religious activities, and her favorite activities. Review of R45's Care Plan dated 02/18/26 and located under the Care Plan tab of the EMR revealed, Requires 1:1 [one-to-one] room visits for socilization [sic] and stimulation . Activity staff will provide 1:1 visits at bedside a minimum of 3x per week for minimum of 15 minutes per session . Offer favorite music to listen too for independent activity in room . Offer to turn TV on and to favorite channel to help fill alone time . Provide resident a variety of activities to promote choice and independence in leisure participation. Review of R45's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/28/26 and located under the MDS tab of the EMR, revealed she was rarely/never able to make herself understood. R45 was assessed with severely impaired cognition. She was dependent on staff for all activities of daily living and mobility. During an observation in R45's room on 05/19/26 at 11:22 AM, R45 was lying in bed with her eyes open. When questioned, she did not make eye contact or respond in any way. There was a TV in the room over her bed, though it was not turned on. There was no radio or music in her room. Her roommate's TV was not on and there was no sound other than the oxygen machine in the room. During periodic observations on 05/19/26 in R45's room from 1:05 PM to 4:37 PM, R45 was lying in bed with her eyes open. The TV was not on and there was no music or sound in the room. Her roommate's TV was not on. During periodic observations in R45's room on 05/20/26 from 9:18 AM to 10:18 AM, R45 was lying in bed with her eyes closed. The TV was not on and there was no music or sound in the room. Her roommate's TV was not on. During periodic observations in R45's room on 05/20/26 from 1:29 PM to 5:05 PM, R45 was lying in bed with her eyes open. The TV was not on and there was no music or sound in the room. Her roommate's TV was not on. During periodic observations in R45's room on 05/21/26 from 9:00 AM to 11:17 AM, R45 was lying in bed with her eyes open. The TV was not on and there was no music or sound in the room. Her roommate's TV was not on. During observation in R45's room on 05/21/26 at 3:03 PM, R45 was lying in bed with her eyes open. The TV was not on and there was no music or sound in the room. Her roommate's TV was not on. During an interview on 05/22/26 at 4:28 PM, the Activity Director (AD) stated R45 received one-to-one visits from activity staff for 15 minutes at least three times week, where she was provided with audiobooks, music, or sensory stimulation and received meet and greet visits daily. The AD stated R45 would benefit from having music or TV on in her room throughout the day during her alone time and he did not know why the TV was not on in her room. The AD stated even the sound from her roommate's TV would be beneficial and the TV should be turned on daily. Review of the policy titled, Individual Activities and Room Visit Program dated June 2018 revealed, Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities . For those residents whose condition or situation prevents participation in group activities, . the activities program provides individualized activities consistent with the overall goals of an effective activities program . Individualized activities offered are reflective of the resident's activity interests, as identified in the activity assessment, progress notes, and the resident's comprehensive care plan.

Based on record review and interviews, the facility failed to perform tracheostomy (trach) care as ordered by the physician for one of two residents (Resident (R) 4) reviewed for tracheostomy care out of a total sample of 56. Specifically, nursing staff failed to change the resident's Heat and Moisture (HME) device for the tracheostomy. This deficient practice could result in the trach becoming occluded, infection, or other respiratory emergency.Findings include: Review of R4's admission Record located under the Profile tab in the electronic medical record (EMR) indicated R4 was originally admitted to the facility on [DATE] with diagnoses of intracranial injury with loss of consciousness, tracheostomy, quadriplegia, acute respiratory failure with hypoxia, traumatic brain injury, epilepsy, and dysphagia. Review of R4's Care Plan located under the Care Plan tab of the EMR, dated 03/02/25, revealed R4 had a tracheostomy. It was recorded that trach care was to include ensuring trach ties were secure at all times, trach site was to be kept clean and dry every shift, suction as necessary, enhanced barrier precautions, and extra trach tube and obturator were to be kept at bedside. Review of R4's Physician Order dated 09/10/25 and located under the Orders tab of the EMR revealed, . Change HME every 24 hours and as needed for saturation, clogging, or visibly soiled . Review of R4's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 09/30/25 indicated R4 was assessed by staff with severe cognitive impairment. The assessment also indicated R4 had a tracheostomy, required tracheostomy care, and was dependent on staff for all activities of daily living. Review of R4's Medication/Treatment Administration (MAR/TAR) record located under the Orders tab of the EMR, dated 10/04/25 and 10/05/25, revealed documented evidence that LPN16 signed R4's HME had been changed as ordered by the physician. Review of the facility's investigative documentation, provided by the facility, dated 10/05/25, revealed that on 10/05/25, R4's family member brought a care concern to staff regarding R4's trach care. An investigation was conducted, and the conclusion was, [LPN 16] charted that the HME was changed, however it was not. When interviewed [LPN16] stated the reason I did not change the HME was because I thought it was the trach collar and I did not change the trach collar because it was not visibly soiled or wet. Staff member was educated and received a discipline. During an interview on 05/22/26 at 9:49 AM, LPN16 stated The HME goes on the trach. I forgot to change it for two days. I clicked it off in the computer and forgot to go back and replace the HME. I just made a mistake . I did not go back and correct the documentation. During an interview on 05/22/26 at 4:22 PM, the Director of Nursing (DON) stated, I expect nurses to complete trach care as ordered. Review of the facility's policy titled, Tracheostomy Care, revised November 2023, indicated . Procedures Guidelines. Preparation and Assessment. Check physician order.

Based on interview, record review, and policy review, the facility failed to: 1.) ensure ongoing communication occurred between the facility and the dialysis center for one of two residents (Resident (R) 81) reviewed for dialysis out of a total sample of 56, and 2.) ensure there was a physician order in place for one of two residents (R6) reviewed for dialysis treatments out of a total sample of 56. These deficient practices could result in residents who are on dialysis not receiving the needed care or services.Findings include:1. Review of R81's undated admission Record, located under the Profile tab in the electronic medical record (EMR), indicated R81 was originally admitted to the facility on [DATE] with diagnoses of diabetes mellitus, end stage renal disease, dependence on renal dialysis, chronic atrial fibrillation, essential (primary) hypertension, and chronic kidney disease. Review of R81's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/31/25 and located under the MDS tab in the EMR, indicated R81 was coded as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R81 was cognitively intact. The assessment also indicated R81 received dialysis. Review of R81's Physician's Orders, dated October 2025 located under the Orders tab in the EMR, revealed R81 receives dialysis on Tuesday, Thursday, and Saturday each week. Review of R81's Progress Notes, located under the Progress Notes tab in the EMR, revealed documentation that R81 left for dialysis on 10/18/25 at 6:00 AM and returned from dialysis on 10/18/25 at 1:15 PM. Review of R81's Misc, tab in the EMR, revealed there was no Dialysis Treatment Summary (used to document communication between the facility and the dialysis center) for 10/18/25. Review of R81's Progress Notes, located under the Prog Notes tab in the EMR reflected R81 had been transferred to the emergency room (ER) on 10/18/25 at 4:14 PM for slurred speech, nausea, and vomiting post dialysis. When the facility was asked for the Dialysis Treatment Summary for 10/18/25, the facility provided notes from the dialysis center dated 10/18/25 with a fax date/time of 5/21/26 at 8:10 AM. During an interview on 05/22/26 at 12:38 PM, the Director of Nurses (DON) reviewed R81's EMR and stated, [R81] went to dialysis on 10/18/25. After she returned, she was sent to the hospital. I do not find a communication from dialysis for 10/18/25. It's important to receive communication from the dialysis facility to know how much fluid was removed, the resident's response to dialysis, blood pressure issues, and pre/post weights. 2. Review of R6's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of R6's admission MDS, with an ARD of 02/28/26 and located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R6 was not cognitively impaired. R6 was documented as receiving hemodialysis. Review of R6's Care Plan, dated 05/25/22 and located under the Care Plan tab of the EMR, revealed R6 was care planned for a diagnosis of end stage renal disease and received dialysis. Further review revealed R6 attended dialysis on Tuesday, Thursday, and Saturday. Review of R6's Physician Orders, dated 05/23/26 and located under the Orders tab in the EMR, revealed no current order for dialysis treatment. Review of R6's Dialysis Treatment Report, forms dated March 2025 through May 2026 revealed two days were missing in March, April, and in May. There was no additional documentation from the dialysis center for that time. Further review revealed the dates missing in March were 03/19/26 and 03/21/26, in April were 04/11/26 and 04/23/26, and in May were 05/02/26, and 05/12/26. Review of R6's Medication Administration Record (MAR), for the period for pre and post dialysis weights for the months of March, April, and May 2026 revealed R6 went to dialysis on 03/19/26 and 03/31/26, 04/11/26 and 04/23/26, 05/02/26 and 05/12/26. During an interview on 05/23/26 at 7:23 PM the Assistant Director of Nursing (ADON) stated nursing staff were expected to capture communication between the center and the facility each time a resident received dialysis services. She stated nurses would document on the communication for review, the nurse practitioner (NP) would review it, and it was uploaded. She stated the NP would probably not notice when there were missing communication forms. She also stated there should be an order for a resident to receive dialysis. Review of the facility's contract titled, SNF Outpatient Dialysis Services Agreement, dated 06/23/11, indicated, Interchange of information. The Nursing Facility shall provide for the interchange of information useful or necessary for the care of the ESRD Residents. Obligations of the ESRD Dialysis Unit and or Company. To provide to the Nursing Facility information on all aspects of the management of the ESRD Resident's care related to the provision of services, including directions on management of medical and non-medicalemergencies, including, but not limited to, bleeding, infection, and care of dialysis access site. Mutual Obligations. Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the nursing facility and ESRD Dialysis unit. Review of the facility's undated policy titled, End-Stage Renal Disease, Care of a Resident with, revealed . Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: how fie care plan will be developed and implemented; how information will be exchanged between the facilities; .

Based on interview and record reviews, the facility failed to: 1.) ensure seven of nine nurses reviewed for tracheostomy (trach) care competency (Licensed Practical Nurse (LPN) 16, LPN10, LPN15, LPN17, LPN18 and Registered Nurse (RN) 4 and RN6) were competent in providing trach care that included Heat and Moisture Exchanger (HME) devices; and 2.) the competency of overall trach care for two of nine nursing staff reviewed for trach care (LPN1 and LPN14). This had the potential to affect two of two residents residing in the facility with tracheostomies and could result in the residents not receiving appropriate care which could result in respiratory emergencies. Cross Reference: F695 Findings include: 1. Review of R4's admission Record located under the Profile tab in the electronic medical record (EMR) indicated R4 was originally admitted to the facility on [DATE] with diagnoses of intracranial injury with loss of consciousness, tracheostomy, quadriplegia, acute respiratory failure with hypoxia, traumatic brain injury, epilepsy, and dysphagia. Review of R4's Physician Order dated 09/10/25 and located under the Orders tab of the EMR revealed, . Change HME every 24 hours and as needed for saturation, clogging, or visibly soiled . Review of the facility's investigative documentation, provided by the facility, dated 10/05/25, revealed that on 10/05/25, R4's family member brought a care concern to staff regarding R4's trach care. An investigation was conducted, and the conclusion was, [LPN 16] charted that the HME was changed [on 10/04/25 and 10/05/25] however it was not. When interviewed [LPN16] stated the reason I did not change the HME was because I thought it was the trach collar and I did not change the trach collar because it was not visibly soiled or wet. Staff member was educated and received a discipline. Review of LPN16's Tracheostomy Care Competency Checklist dated 08/14/25 and provided by the facility, revealed LPN16 had been assessed to be competent in providing trach care; however, the competency check did not include competency in the use of HME devices. During an interview on 05/22/26 at 9:49 AM, LPN16 stated he now knew what an HME was and that it attached to the trach. LPN16 stated he had been trained at the facility in the use of HME devices following the incidents on 10/04/25 and 10/05/25 where he had not changed the HME. 2. Review of Tracheostomy Care Competency Checklist for LPN15, RN4, LPN10, RN6, LPN17, and LPN18 revealed the nurses were assessed for competency in providing trach care on the following dates: LPN15 - 11/19/25RN 4 - 03/14/25LPN10 - 08/15/25RN6 - 03/14/25LPN17 - 08/12/25LPN18 - 03/14/25 Further review of the nurses' trach care competency verifications revealed no documented evidence the nurses' competency related to the use of HME devices was assessed. During an interview on 05/22/26 at 10:35 AM, LPN15 stated I do not know what an HME is. I have only cared for one resident with a trach and had another nurse with me since I'm new. I don't have any trachs on the hall that I work. I do not recall any training or education regarding caring for residents with trachs. 3. Review of Employee Staff List, provided by the facility, revealed LPN1 was hired on 07/23/24 and LPN14 was hired on 01/23/24. Review of Tracheostomy Care Competency Checklists for the facility's nursing staff revealed no documented evidence LPN1 and LPN14 had been assessed for competency related to tracheostomy care. During an interview on 05/22/26 12:05 PM, LPN1 stated, I do not provide care for residents with trachs. I have not had any training on trach care. During an interview on 05/22/26 at 4:22 PM, the Director of Nursing (DON) stated I have only worked here a couple of months. All nurses should be trained to care for residents with a trach. To ensure competency, I would take them to the bedside and have them demonstrate the care and complete a competency checklist. HMEs are not listed on the Trach care competency checklist and should be. Review of the facility's Facility Assessment Tool, reviewed 04/14/26, revealed, List any special equipment needed . Trach . Special Treatments and Conditions . Tracheostomy. Average number of residents = 2. Care provided . Tracheostomy Care . Competencies include: . Trach Care . Staff Training, education, and competencies. [Facility name] nursing staff and contract nursing staff complete core competencies associated with the provision of care in the SNF [skilled nursing facility] and LTC [long term care] setting. Examples include but are not limited to: . Tracheostomy Care and Emergency Tracheostomy Care .

Based on observations and staff interviews, the facility failed to ensure that one of the medication carts on Unit A Hall was secure when staff were not present. This had the potential to affect all residents who were walking by the cart. Findings include:An observation on 05/21/26 at 5:28 AM and again at 9:34 AM revealed a medication cart sitting in the hallway between room A26 and A25 was not locked and the computer screen was open with resident medical information visible due to the screen not being locked. There were several residents in the area along with other staff that walked by. During an interview on 05/21/26 at 5:32 AM, Licensed Practical Nurse (LPN) 29 walked up and stated she knew it was unlocked. She stated that she does not normally work on Unit A Hall but stated she was aware she should lock her cart anytime she walked away from it. During an interview on 05/21/26 at 9:34 AM, LPN30 walked up and stated he knew the cart should be locked, but he was concerned that a resident who was a fall risk needed assistance and he walked away quickly without thinking of locking the cart first. He stated that he was usually always good at making sure to lock his cart and the screen before walking away. He said this was a mistake on his part. During an interview on 05/23/26 at 7:23 PM, the Assistant Director of Nursing (ADON) stated nursing staff were expected to lock their medication carts and computer screen anytime they walked away. She said the medication carts should be locked at all times, along with the screen and there should never be any resident information visible on the screen. She stated all medications need to be secured because there could be potential side effects for any medication that a resident takes when they are not prescribed.

Based on interview, record review and review of other documentation as indicated, it was determined that for one (R70) out of six residents reviewed for abuse, the facility failed to assure that a physical restraint was used to treat R70's medical symptoms and was not being used for staff convenience. Findings include: R70, a resident with dementia, had two gowns on during the evening shift of 3/31/25. The first gown was on in the correct position. The second gown was oversized and the gown material was gathered and tied in a knot below R70's knees and behind her neck to prevent R70 from exposing herself. R70's oversized gown was not untied and R70 remained in the same position through the evening and night shifts without opportunities for repositioning, incontinence care or release of the knotted oversized gown for mobility. The inability to reposition or straighten one's legs would result in psychosocial harm to a reasonable person. Due to the facility's corrective measures completed on 4/10/25, the facility was notified that R70's incident was a harm past non-compliance. The facility policy titled, Use of Restraints (2001) documented, Policy Statement . Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the preventions of falls . Policy Interpretation and Implementation . 1. 'Physical Restraints - . any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom or restricts normal access to one's body . Cross refer F677 Review of R70's clinical records revealed: 9/24/19 - R70 was admitted to the facility with diagnoses including dementia, bipolar, anxiety and insomnia. 9/25/19 (revised 6/1/22) - R70 had a care plan for potential for falls related to poor safety awareness with interventions including, but not limited to, allowing R70 to sit in doorway of room when up when possible to experience increased stimulus from other people in the hallway. 9/25/19 (revised 5/1/20) - R70's ADL care plan stated, [R70] was unable to do own ADLs (Activities of Daily Living) without assist related to cognitive loss and interventions included . assist resident to pick out own clothes. 10/21/19 - R70 had a care plan for repetitive statements related to anxiety and memory loss. Interventions included: assessing for unmet needs. 10/21/19 - R70 had a care plan for making sexual comments and/or touches others inappropriately. Interventions included getting involved in activities of choice. 5/7/20 - R70 was care planned for removing clothes over and over in inappropriate places related to cognitive level. Interventions for R70 included approaching in a calm manner and not being judgmental. 8/9/22 - R70 had impaired verbal communication care plan developed related to cognitive loss. R70's interventions included anticipating R70's needs and approaching R70 in a gentle, calm, friendly, relaxed manner with a smile on the face. 9/27/23 - R70 was care planned for alteration in thought process related to progressive dementia with interventions including allowing R70's choices when appropriate and assisting resident to activities of choice. 2/21/25 - R70's quarterly MDS (Minimum Data Sets) assessment indicated that R70's cognition was severely impaired with short and long term memory problems and had verbal behavioral symptoms occurring 1- 3 days during the review period. R70 was dependent with toileting hygiene and upper/lower body dressing. In addition, R70 was dependent with the following mobility performance: roll left and right, sit to lying to, lying to sitting on side of bed and sit to stand. R70 was always incontinent of urine and bowel. 3/31/25 - R70's CNA Kardex Report for Activities indicated that R70 required assistance in developing/providing a program of activities that was meaningful and of interest including to encourage and provide opportunities for exercises and physical activity. 4/1/25 7:30 AM - A nurse progress note by E13 (LPN) documented, CNA [E14] reported this morning that the resident's gown was tied up very tightly on the patient. Upon assessment the gown was bunched up and tied up very tightly by the neck and left thigh. It took a considerable amount of force in order to untie the knots, to the point where the gown was torn some . patient [R70] could not lay down straight when I observed how she was laying. 4/1/25 11:57 AM - A facility incident report submitted to the State reporting agency documented that on 4/1/25 at 7:30 AM, . Resident observed in bed with two gowns. One fitted appropriately, second gown oversized and tied incorrectly. 4/1/25 12:01 PM - A skin evaluation note by E13 documented, . [R70] had gown tied too tightly (sic) no injuries to skin, no red marks, no skin tears present . 4/1/25 - A written statement by E18 (7-3 shift RN, UM) documented, Made aware by 7-3 charge nurse [E13] . [R70] was observed in bed with two gowns on. The first gown was on in the correct position. The second gown was oversized and placed on over the first knotted at the right [left when clarified] thigh. [R70] was unable to straighten herself out and was observed in a semi fetal position . 4/1/25 - A documented phone interview of E12 (11-7 LPN) by E18 revealed that she was made aware of [R70] having on two gowns and gowns being knotted in passing by the day shift nurse as she was leaving. [E12] stated that she did not notice during her shift. 4/1/25 - A documented statement by E14 (CNA) revealed that E14 came in to provide care to R70 who was observed in a semi fetal position with two gowns on, one knotted at the right thigh. E14 immediately notified the nurse [E13]. 4/1/25 - In a joint phone interview with E2 (DON) and E18, E10, the CNA assigned to provide care to R70 in the evening shift (3-11), confirmed Yes and that she put two gowns on R70. E10 stated that while R70 was out to bed, R70 kept lifting her gown up in the hallway. Because R70 kept exposing herself, E10 obtained a second gown and put on R70 and tied the gown just below R70's knees to keep her from exposing herself. 4/1/25 - In a separate statement documentation, a clarification phone interview by E2 and E37 (Admin/Office) revealed that E10 was not aware that putting on two gowns and preventing resident from lifting up the gown by criss-crossing it at the bottom is considered a form of restraint. 4/1/25 - A documented phone interview by E18 with E11, the CNA assigned to provide care to R70 during the night shift (11-7 on 3/31/25 going into 4/1/25) revealed that E11 did not put two gowns on R70. E11 stated that she was unaware if R70 had on two gowns while providing care and from what she can recall the gown was not tied at all during her time of providing care for R70. 4/8/25 - The facility's 5 Day follow up summary documented, . [R70] with a past history of dementia, bipolar disorder, anxiety and insomnia . with severe cognitive impairment . note (sic) occasional impulsivity with poor safety awareness and mild agitation . In an attempt to limit resident exposing herself and protect her dignity an oversized gown was placed on resident incorrectly. The gown was oversized and the gown material was gathered and tied in a knot below her knees and behind her neck. [R70] was able to move freely in her gown but was unable to pull up gown exposing herself. During movement in her sleep resident pulled her legs up and they got caught in (sic) gown. 4/10/25 - A psych physician assistant follow up note by P1 (PA) documented, . Chief Complaint/Nature of Presenting Problem: F/u (follow up) dementia, recent med adjustment, recent worsening mood lability/compulsions . Seen today at request of facility staff due to report of recent increased agitation and restlessness over the past week . restless and engaging in repetitive movements globally and appears mildly irritable . 5/20/25 9:00 AM - In an interview, P1 stated that he saw R70 and had read the nurse's notes about the inappropriate way of tying the oversized gown on R70. P1 stated that it was not the right way to address R70s' increasing behavior of raising her gown exposing herself and that R70 has intermittent clothing removal, repetitive behaviors. P1 stated, . [R70] has severe cognitive impairment and from the psychosocial point, there was no indication of harm. 5/20/25 1:25 PM - In an interview, E27 (PT) stated, . [R70] was pretty mobile . can move and walk at least 40 feet and she has been on the restorative nursing program for ambulation and range of motion when discharged from Physical Therapy caseload in February 2025 . 5/20/25 1:37 PM - During an interview, E13 (7-3 LPN) stated that he was the primary nurse for R70 on 4/1/25. Responding to E14's (CNA) call, he went to R70's room. E11 further stated, . I saw [R70] almost on her left side in a fetal position. E14 pulled down the outer gown but the knot around the neck was tied very tight that E14 had to use a pair of scissors to cut it off. I also untied the knot in the bottom of her gown. The hem or bottom of the gown was below the knee and tied around the legs, with the knot on the left side of R70's leg. The knot was tied very tight that it took an amount of time and strength for me to untie the knot. 5/20/25 1:50 PM - During interview, E14 stated, . I went to R70's room on 4/1/25 around 7:30 AM. I saw her gown tied up in a knot and she was in a fetal position. It did not looked right to me so I called [E13]. R70 had on 2 gowns. 1 smaller gown she had on underneath with snaps on the shoulders . The inner gown had ties tied very tightly on her back. She had another oversized gown over the smaller gown. The top part of the outer gown was loose enough to be gathered around the neck and formed a knot. The knot on the right side of the neck was very tight I had to use a pair of scissors to cut it. I checked her incontinence brief and she was soaked in urine and was very soiled. 5/20/25 3:30 PM - In a follow up interview, E13 demonstrated to Surveyor how R70 was found with the double gowns. The following were observed with the Surveyor as the model resident for demonstration purpose: The top part of the outer gown was gathered and tied in a knot on the right side of the model's neck. The lower hem or bottom of the model's outer gown was wrapped around the model's legs and tied in a knot on the left side of the leg. Both knots on the right side of the model's neck and on the left side of the leg were tied so tight that it was very difficult to untie them. 5/22/25 5:00 PM - Findings were discussed with E1 (NHA) and E2 (DON). 5/22/25 5:15 PM - E1 submitted to the Surveyor documentation of the abatement/corrective action plan with correction completed 4/10/25 at 1:00 PM. Corrective Actions: 4/1/25 - R70's gowns were removed and skin check was performed with no noted areas of concern. - Investigation was initiated and statements were obtained. - Staff directly involved were interviewed and suspended pending investigation. - Incident reported to Division of Healthcare Quality (DHCQ) - Through investigation and interviews it was found that in an attempt to limit [R70] from exposing herself and to protect her dignity, an oversized gown was placed on [R70] incorrectly. The oversized gown gathered and tied in a knot below her knees and behind her neck. [R70] was able to move freely in her gown but was unable to pull up her gown to expose herself. During movement in her sleep it appears [R70] pulled her legs up and they got caught in the gown causing her to be unable to straighten out her legs. This is how she [R70] was found during routine rounding on 4/1/25 7-3 shift. - No other residents were found with gowns tied. - Facility reviewed incident during high risk meeting with Medical Director present. Discussed with Medical Director the events reported and staff statements obtained at that time. - Facility reviewed incident with the Corporate Regional Nurse. 4/10/25 - Facility initiated nursing staff education to promote resident dignity, proper use of a gown and reporting anything found to be out of the ordinary. All nursing staff will be educated prior to next scheduled shift. - Facility initiated audits of residents who are dependent on staff for care to ensure dignity is being observed an gowns are being used properly. - Audits will continue three times a week until 100% successful audits over three consecutive evaluations, then continue monitoring once a week until 100% successful over three consecutive evaluations. Audits will continue another month after that time, if 100% success is noted then compliance is achieved. Results of the audits and evaluations will be brought to the QAPI steering committee for further evaluation or recommendation. - CNAs [E10] and [E11] were terminated for inconsiderate care of a resident. No immediate action required related to facility correction and no further occurrences after the incident on 4/1/25. This was verified by interviews with staff about promoting resident dignity and abuse with use of physical restraints, education, spot inspection for residents wearing gowns and inspection of the facility abuse incident reports. 5/22/25 5:00 PM - Findings were discussed with E1 (NHA) and E2 (DON). 5/23/25 2:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference.

Based on observation and interview, it was determined that for two (R136 and R163) out of four residents reviewed for dignity, the facility failed to ensure that staff treat each resident with respect and dignity. Findings include: 1. 5/16/25 9:00 AM - During a medication pass observation, E16 (LPN) was seen administering medications to R163 who was lying in bed, via PEG/feeding tube (a tube that is passed into a patient's stomach through the abdominal wall). R163's bedroom door was left opened and she was visible from the hallway by visitors and staff walking by. R163's bed curtain was not pulled out to cover her and provide privacy. 5/16/25 9:20 AM - Finding was discussed with E16 who confirmed that she should have shut the door or pulled the curtain for privacy as a way to treat R163 with dignity and respect while administering her medications. 5/22/25 5:00 PM - Finding was discussed with E1 (NHA) and E2 (DON). 2. Review of R136's clinical record revealed: 12/1/23 - R136 was admitted to the facility with diagnosis of dementia. Observations of R136 during the survey include: - 5/14/25 4:32 PM - R136 was sitting on a blue-colored sling in her wheelchair in the B-Wing dining/activity room. - 5/20/25 11:40 AM - R136 was sitting on a blue-colored sling in her wheelchair outside the Social Worker's office after having participated in an activity. - 5/20/25 1:02 PM - R136 was sitting on a blue-colored sling in her wheelchair and seated at the table in the B-Wing dining room while lunch was being served. 5/20/25 1:13 PM - During an interview, E39 (LPN/UM) confirmed that the resident's sling is not to remain under the resident when sitting in the wheelchair during the day. The facility failed to provide R136, a dependent resident, with dignity as evidenced by multiple observations where a blue sling, used for mechanical lift transfers, was left under her while she sat in her wheelchair. 5/23/25 2:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (ADON).

Based on record review and interview, it was determined for one (R95) out of three residents reviewed for participation in care planning, the facility failed to ensure the correct resident representative was invited to participate in R95's care planning conferences. Findings include: Review of R95's clinical record revealed: 11/19/20 - A durable power of attorney (DPOA) financial only document appointing P6 was signed and notarized by R95. 7/1/21 - R95 was admitted to the facility for long-term care. 7/8/21 - The facility's form entitled Preferred Intensity of Medical Care and Treatment was signed by F3 (R95's family member). 7/1/24 8:29 AM - A care conference review documented the following: - R95 had severe cognitive impairment. - R95's resident representative was P6 (R95's DPOA-financial only). P6 was invited, but did not attend. The documented stated, No RSVP. - Does Resident and or Resident/Representative agree with Plan of Care established? YES. - Under the social work section, it was documented that . Nursing reported fall on 6/12/24 and [R95] was sent to the hospital. [F3, family member] was informed . - Code Status Reviewed? Yes, No changes required. 9/19/24 6:17 PM - A care conference review documented the following: - R95 had severe cognitive impairment. - R95's resident representative was P6 (DPOA-financial only). P6 was invited, but did not attend. The documented stated, No RSVP. - Does Resident and or Resident/Representative agree with Plan of Care established? YES. - Code Status Reviewed? Yes, No changes required. 12/16/24 10:56 AM - A care conference review documented the following: - R95 had cognitive impairment. - R95's resident representative was P6 (DPOA-financial only). P6 was invited, but did not attend. The documented stated, No RSVP. - Does Resident and or Resident/Representative agree with Plan of Care established? YES. - Code Status Reviewed? Yes, No changes required. 3/7/25 10:43 AM - A care conference review documented the following: - R95 had cognitive impairment. - R95's resident representative was P6 (DPOA-financial only). P6 was invited, but did not attend. The documented stated, No RSVP. - Does Resident and or Resident/Representative agree with Plan of Care established? YES. - Code Status Reviewed? Yes, No changes required. 5/22/25 at 4:41 PM - During an interview, E20 (BOM) confirmed that R95's profile had P6 (DPOA-financial) incorrectly listed as the facility's first point of contact/resident representative. As a result, R95's care conference invitation letters were incorrectly and repeatedly sent to P6 and not to F3 (R95's family member). The facility failed to ensure that the correct Resident Representative, F3, was able to excerise the resident's rights on behalf of R95 with respect to medical care and treatment. 5/23/25 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (ADON).

Based on record review and interview, it was determined that for one (R87) out of four (4) residents reviewed for personal property, the facility failed to provide the family with a written explanation of why R87 moved rooms at the facility's request on 1/23/25. Findings include: 2/23/22 - R87 was admitted to the facility on the C wing with diagnoses including, but was not limited to, dementia. 2/23/22 - 1/23/25, R87 resided on the C wing of the facility. 1/23/25 - R87's room was changed, and she was moved to the A wing of the facility. 5/15/25 2:56 PM - During an interview, F1 (R87's husband) stated, They (the facility staff) told me on a Thursday around 11:30 AM that they were going to move my wife's room. It was [E20] (admission office) who told me. When I asked why, my wife has been on C wing for 3 years, we went to the office (admissions) and . the DON (E2) came in and said it was because she (R87) was hollering. But she has been hollering for years. I had built relationships with the staff on C wing, and they knew my wife. By 2 PM, a lady with a clipboard came in (my wife's room) and they started moving her. I thought it would happen in a few days. I did not get any paperwork or sign anything . 5/15/25 3:30 PM - A review of R87's progress notes revealed no documentation regarding the 1/23/25 room change. 5/16/25 10:30 AM - A review of the Notice of Room Change document provided by the facility regarding R87's move did not demonstrate the required explanation in writing of why the move was required. 5/23/25 2:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (ADON).

Based on interview and record review, it was determined that for one (R167) out of six (6) residents reviewed for abuse, the facility failed to ensure that R167 was protected from verbal abuse. Findings include: Review of R167's clinical records revealed: 11/12/24 - R167 was admitted to the facility with diagnoses including end stage renal failure, heart failure and morbid obesity. 2/11/25 - R167's quarterly MDS documented a BIMS score of 15, indicating a cognitively intact status. The MDS also documented that R167 was independent with activities of daily living. 4/2/25 8:00 PM - The facility's investigation documented that R167 wanted to take a shower but there were used towels on the bathroom floor. He requested that the bathroom be cleaned. E6 (CNA) told R167, If you don't think I am doing my job, then speak to the supervisor. Approximately one hour later, E6 overheard R167 telling his significant other on the phone about the dirty towels in the shower. E6 stated, Why are you still talking about it? It was a mistake. E6 began to yell profanities at him. Both E6 and R167 then yelled profanities towards each other. This event was witnessed on the phone video by R167's significant other. 4/3/25 9:21 AM - A facility report to the Division documented, Staff member [E6] CNA got into a verbal confrontation with resident [R167]. Staff member was suspended pending outcome of investigation. 5/19/25 11:13 AM - During an interview E6 stated, He started cursing and snapping at me, so I cursed back at him. The Surveyor asked E6 whether she had received any training at the facility on abuse, dementia, and resident rights. E6 stated, We had a lot of training. But it was not like he [R167] had dementia or anything. E6 was terminated from employment at the facility. The facility failed to protect R167 from verbal abuse from a staff member. 5/23/25 2:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (ADON).

Based on record review and interview, it was determined that for two (R6 and R22) of six residents reviewed for abuse, the facility failed to report an allegation of abuse within two hours. Findings include: 1. Review fo R22's clinical record revealed: 5/3/25 8:30 AM - A facility incident report documented, . [R22] presents wit (sic) 2 bruises on the the inner side of the left arm above the elbow. Main bruise is 13.0 x 10.5 and smaller bruise above it is 2.5 x 3.0. [R22] did not know how it occurred. . RCA (Root Cause Analysis) Summary: . bruises appear that they may have been caused by a hand that may have been facilitating a transfer . [R22] also noted to have been transported to the dentist by family on 4/30/25 .also noted to be on aspirin therapy . 5/20/25 3:00 PM - Review of the state incident report database lacked evidence that the facility reported the incident to the state incident reporting center. 5/22/25 - A written statement by E2 (DON) documented, I have observed family both daughter and son, have difficulty putting him in car. They seem to have most difficulty with getting him out of his wheelchair when putting him into car. When the son has him alone, he often will hold on to his upper arms and or wrap his arms around him to assist him into and out of the car . 5/22/25 5:00 PM - Finding was discussed with E1 (NHA) and E2 (DON). 2. Review of R6's clinical record revealed: 3/27/23 - R6 was admitted to the facility with diagnoses including. but was not limited to bipolar disorder. 4/2/25 - R6 was hospitalized with a mental status change and was diagnosed with a urinary tract infection (UTI). 4/12/25 - R6 returned to the facility from the hospital. 5/20/25 10:10 AM - A review of R6's hospital records revealed documentation of R6's allegation to hospital staff regarding this alleged incident and the hospital's subsequent report to the state agency. 5/20/25 11:35 AM - A review of the facility personnel lists revealed no staff by the name of [name] work at the facility. A review of the staff assignments on the day of the alleged incident revealed there were no Caucasian staff providing care on that wing on that date. 5/20/25 1:52 PM - During an interview, E1 (NHA) stated, We did not know about the allegation when she was at the hospital. She has made multiple allegations (prior to the 4/2/25 hospitalization) and the story changed several times. 5/21/25 11:09 AM - During an interview, E36 (RNAC) stated, I was the one that [R6] reported the alleged abuse to. I was doing a pain assessment for her quarterly MDS in late March. Her roommate [R126] was there shaking her head the entire time saying 'No, that did not happen.' I reported it to leadership within two hours. I thought it was reported to the state agency because there was a big investigation. 5/21/25 12:04 PM - During an interview, E2 (DON) stated, We investigated it twice. We did not think it was anything and we knew [hospital] had reported it so I did not report it. 5/23/25 2:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (ADON).

Based on record review, interview and review of other related documents, it was determined that for one (R10) out of nine residents reviewed for accidents, the facility failed to provide R10 adequate supervision and assistance to prevent burns. This resulted in harm to R10 as he sustained second-degree burns over 15-20 % of his body surface area. This is being brought forward as past non-compliance with an alleged date of compliance of 10/13/24. Findings include: 2/18/19 - R10 was admitted to the facility with diagnoses, including but not limited to, Alzheimer's disease. 3/1/22 - R10's care plan documented, [R10] has impaired verbal communication R/T (related to) cognitive loss . Interventions: . Assess resident's non-verbal behaviors, such as facial expressions, body language, grimacing and increased restlessness . Face resident when communicating . 9/5/24 2:48 PM -E17 (Psych NP) documented in R10's EMR in a Psychiatric Periodic Evaluation note, XXX[AGE] year old male .[R10] is noted with severe cognitive impairment and non-verbal throughout . Mental Status Evaluation - Sensorium: alert, Orientation: person, Speech: non-verbal, Affect: dull, . 9/13/24 -R10's MDS revealed a BIMS score of 0, which is reflective of severe cognitive impairment. 10/3/24 5:05 PM - E19 (LPN) documented in R10's EMR in a health status note, Called to shower room by assigned CNA [E20], same [E20] stated 'after giving resident shower and drying him off, he noticed that resident skin (sic) became very red.' This nurse [E19] noticed redness and skin peeling on resident (sic) face, neck, forehead, chest and upper upper (sic) left shoulder, this writer immediately called supervisor on duty. Resident taken to his room. No s/s (signs/symptoms) of pain noted. Vs (vital signs) obtained 133/57, 78, 97.6, 20, 96%. NP [E16] made aware. New order obtained to send resident to ER (emergency room ) for evaluation, apply (sic) cold towels and wash rags to affected area, responsible party wife [F1] made aware. resident left facility @ 5:38 PM via 911 on stretcher. 10/3/24 5:33 PM - In R10's prehospital care report, C2 (EMT) documented, At 5:33 PM, the patient [R10] was found lying in bed alert, but mental status was unable to be performed due to patient being nonverbal at baseline . Skin- red with multiple burns. Nurse reported to EMS crew that the patient's skin was red and peeling. Upon further assessment, it was noted that the patient had multiple first-degree burns on his body along with second -degree burns. The first first-degree burns were all over his body to include the chest, abdomen and head. The second-degree burns were again found in multiple areas differentiating in size with some blisters noted both open and closed. The nurse stated that the pt (patient) came out of the shower this way, and that the aid (sic) took him into the shower to clean him up and when he got out of the shower and back in bed they noted his skin red all over with some areas peeling and blistering. She stated the water must have been to (sic) hot .The nurse was unable to tell us how this happened other than it happened in the shower when the aid (sic) took him to give a shower, and she was unable to say if he [R10] was left in there unattended or not. As baseline this patient is a full care patient and is unable to care for himself, is nonverbal and unable to follow direct commands at baseline .Med report was called to [hospital] to request forensic nurse and trauma eval (evaluation) . 10/3/24 approx. 5:35 PM - Per the facility's abateman plan, At approximately 5:35 PM, [E4, Maintenance director] checked the temperature of the hot water. [E4] noted the temperature to be above 120 degrees and attempted an adjustment first and the temperature did not change. [E4] then immediately shut off the hot water to the building. 10/3/24 6:12 PM - C4 (hospital FNE RN) documented on R10's hospital forensic examination, pt (patient) nonverbal at baseline, unable to provide any details of events. Per wife [F1], pt with hx (history) (sic) dementia, non-ambulatory and totally dependent on facility staff for care. Areas of second degrees burns with blistering notable on exam. Unknown duration of thermal exposure. The hospital FNE nurse documented R10's burns with photographs and written descriptions as follows. DSC_0001 (face picture) was described as generalized superficial burn to head/face. DSC_0002 (left ear/cheek picture) was described as partial thickness burn with area of blisters and measured a 5 cm X 4 cm area of superficial partial thickness burn to L (left) cheek. DSC_0003 and DSC_0004 (right ear/cheek picture) were described as 2 cm X 2 cm area of superficial partial thickness burn. DSC_0005 and DSC_0006 (top of head pictures) were described as area of redness. DSC_0007, DSC_0008, DSC_0009, DSC_0010, DSC_0012, DSC_0018 (left clavicle/chest/neck pictures) were described as superficial burn generalized to neck, chest and abdomen with sparing noted to skin folds, area of 2 cm X 3 cm partial thickness burn to L chest. DSC_0011 (right inner upper arm picture) was described as superficial burn. DSC_0013, DSC_0014, DSC_0016, DSC_0019, DSC_0020, DSC_0021 (bilateral shoulders/back pictures) were described as generalized superficial burn to upper back with 4 cm X 4 Cm area of partial thickness burn to upper L back and 4 cm X 2 cm partial thickness burn to R (right) upper back. DSC_0017 and DSC_0023 (nose pictures) were described as circular partial thickness burn. DSC_0015, DSC_0022 (right/left ears pictures) were described as superficial burns behind R ear and L ear. 10/3/24 6:43 PM - In the ED (Emergency Department) Teaching Physician Record, C1 (hospital emergency room physician) documented, [AGE] year old male arriving per EMS for evaluation of second -degree burns. Patient has a history of CVA (stroke), is bedbound at baseline, nonverbal at baseline, and all his ADLs (activities of daily living) are provided by nursing home staff. Per nursing home, patient was found in the shower with reddened skin to face, chest and shoulders and upper back .roughly 15 to 20% surface area burns . However, secondary burns are very mild in nature and do not suspect he would require transfer to burn center at this time . 10/4/24 6:30 AM - E21 (LPN) documented in R10's EMR, Late entry. Resident [R10] arrived back to facility from hospital at 4:17 AM via stretcher, vital signs WNL (within normal limits) 126/73, O2 98%, HR 101, temp 97.4. Residents (sic) show no nonverbal signs of pain or discomfort, was able to take meds as needed without any issues, no new skin issues outside burns to face and shoulders. Orders to not remove bandage until follow-up with [physician] at the burn center in 1-2 days. Resident is in room resting in bed, with call bell in reach, bed in lowest position. 2/6/25 2:39 PM - During an interview, E19 (LPN) stated, There were two CNAs who showered [R10]. [E20 (CNA)] was orienting [E22 (CNA)], who was a new hire. They were with him the hole time. I was not in the shower room during the shower. I was called into the shower room to perform a skin check. His [R10] skin was red in the face and even his arm. His chest and shoulder was peeling . [R10] was in a reclining shower chair with the seat having a hole so the water drained. I think the water was malfunctioning, going hot then cold. 2/7/25 10:38 AM - During a telephone interview, F1 stated, . I never said it was intentional .maybe negligent but not intentional . My husband is able to move his head back and forth and he does very occasionally moan or groan but you don't know why he is doing it. He would not be able to groan when hot water hit him. 2/7/25 11:25 AM - During a telephone interview, E20 (CNA) stated, . It was me and another aide [E22] that I was orienting. She [E22] was there the whole time. I checked the temperature of the water twice once with my gloved hand and then on my bare wrist. The water was fine when we started the shower. We started with his head to wash his hair. He was in a reclining shampoo chair so we could tilt him back and just wash his head first. He uses a special shampoo. So I wet his hair, then I put the shower head the grab bar and the wall spraying the wall, while I lathered up his hair. I washed the shampoo out of his hair. I don't remember if I checked the water temp again before washing the shampoo out. I noticed the redness when I was drying him. So I sent [E22] to get the nurse to do a skin check. Once he was back in bed, [E19 LPN] was busy putting cool towels on him so I left the room. 2/7/25 12:49 PM - During an interview, E4 (Maintenance Director) stated, We don't know the actual temperature of the hot water when the mixing valve was defective, because the thermometer on the thermostat only goes to 120 degrees. All I can say is it was greater than 120 degrees. E4 also clarified that the temperatures were in degrees Fahrenheit. The facility did the following as a result of this incident: - 10/3/24 at approximately 5:15 PM - E2 (DON) put all showers/baths on hold within the facility. - 10/3/24 at 5:35 PM- E4 (Maintenance Director) checked the hot water temperature and once confirmed it was out of range, E4 shut down the hot water supply in the facility. - 10/3/24 6:00 PM - E4 replaced the problematic mixing valve to the hot water heating system. - 10/3/24 during 3 - 11 PM shift, E2 (DON) started educating the direct care staff regarding testing the water temperature prior to patient care and the risk factors of the elderly for receiving burns. Education of the entire direct staff continued until 10/13/24, when all staff had been educated. - 10/4 24 at 12:01 PM - E5 (Corporate facilities manager) and [plumbing contractor] technician were on site to check the operation of the facility water mixing valve. No issues were found with the water temperature. The old mixing valve cartridge was examined and found to have sediment stuck in the valve body/spring, which affected its function. This service call lasted 3 hours. -10/4/24 2 PM - A risk management meeting was conducted with the Medical Director regarding this incident. - The facility installed water temperature safety gauges on all shower heads in the facility that notify the resident and the care provider by the color of gauge light whether the water temperature is in a safe temperature range. - Additionally, E1 (NHA) and E4 (maintenance director) monitored the facility's water temperature daily on all units for 2 consecutive weeks, then weekly for 3 weeks and then monthly to confirm 100% compliance with the water temperatures being less than 110 degrees F. - These audit logs were presented at the QAPI steering committee meetings. The date of abatement completion was 10/13/24 at 3:30 PM. The surveyor confirmed these interventions were completed during the survey with review of trainings logs,document review and interview. 2/10/25 2:23 PM - Findings were reviewed during exit conference with E1 (NHA), E2 (DON), E6 (ADON), E9 (Corporate Risk Manager) and E8 (Corporate IP/SP).

3. Review of R165's clinical record revealed: 11/17/16 - R165 was admitted to the facility with diagnoses including, but not limited to, dementia and heart failure. 1/5/23 - R165's medical record documented E52's (MD) order: Transfer Status: assist of 2, Bed Mobility: assist of 1, Ambulation 1 person assist with RW (rolling walker) with wheelchair following. 11/22/23 4:30 AM- R165 fell from an elevated bed while receiving incontinence care by E53 (former CNA). 11/22/23 7:07 AM - E54 (Emergency Department MD) documented in the ED (Emergency Department) Physician Record, . History of Present Illness . patient's bed was elevated and they [staff] were changing her when she was rolled and unfortunately fell out of the bed . Secondary Survey- Head: hematoma to the right parietal region . CT (computed tomography) scan chest/abdomen/pelvis shows evidence of acute displaced rib fractures on the right side including ribs 4,6,7 and 9. Also has progressive loss of height of L3 (lumbar vertebrae 3) when compared to prior imaging . Trauma evaluated the patient and will admit to their service . 11/25/23 12:53 PM - R165 was discharged back to the facility after a three day admission following her fall with resultant right rib fractures. 4/26/24 7:36 AM - During an interview, E25 (RN) stated, I was called and told R165 had fallen. I went to her room and found her sitting on her butt with her legs in a V shape kind of in the air . I thought she [R165] hurt her right hip because she complained of pain when I palpated her right hip area but she ended up having right rib fractures . 4/26/24 11:07 AM - During a telephone interview, E53 (former CNA) stated, I was changing her [R165] and she had poop all over. I was turning her away from me towards the door . there was no scoop mattress or side rail. There was another CNA on the floor but she was a one person assist for bed mobility. She rolled out of the bed and onto the floor. I went and got the nurse. They sent her to the hospital. 4/30/24 1:25 PM - During an interview, E1 (NHA) stated that the facility immediately started to educate the staff on the proper method of turning and repositioning residents that morning of the incident. She said that she would provide the documentation of the facility's efforts to correct this situation. 4/30/24 - Review of all documentation of the corrective action plan completed on 11/28/23 included: - Timely reporting to State Agency; - Education regarding bed mobility for all nursing staff providing direct care to residents; - Initiated competencies on turning and repositioning residents; - Initiated a perimeter mattress on R165's bed upon her return from the hospital; - Facility investigation of the incident; and - Observations of bed mobility care with audits that documented compliance. This was verified by the Surveyor with observations of resident repositioning as well as multiple staff interviews about the content of the turning and repositioning inservice/education. 4. Review of R12's clinical record revealed: Eliquis (Apixiban) is an anticoagulant medication used to prevent serious blood clots from forming due to a certain irregular heartbeat (Atrial fibrillation). Source: Drugs.com 2024 1/24/14 - R12 was admitted to the facility with diagnoses including, but not limited to, dementia and atrial fibrillation. 10/26/22 - E55 (NP) ordered, Eliquis tablet 2.5 mg (milligram) - give one tablet by mouth two times a day for A fib (Atrial fibrillation). 7/19/23 - R12's medical record documented E52 (MD) ordering: Updated Transfer Status: transfer and bed mobility- assist of 1, Ambulation with PT (Physical therapy) only. 11/17/23 - R12's quarterly Minimum Data Set (MDS) assessment documented her Brief Inventory of Mental Status (BIMS) score of three, which reflected severe cognitive impairment. 12/25/23 2:45 PM - A progress note documented that while receiving care by E56 (CNA), R12 was rolled to her side and her head struck the windowsill. 12/25/23 4:06 PM - E57 (DO) documented in the ED (Emergency Department) Physician Record, . patient was at her skilled nursing facility, nursing staff was rolling her in bed. Her bed is up against a wall/window, and they accidentally rolled her against the windowsill when she hit her head. She developed a large hematoma over her left forehead . 12/25/23 8:32 PM - R12 discharged from the ED back to the facility. 4/30/24 12:07 PM - During an interview, E14 (LPN) stated that R12 no longer was able to interact with the staff in a meaningful way. She just grunts and makes noises. 4/30/24 1:25 PM - During an interview, E1 (NHA) stated that the facility recognized immediately that this incident involved staff rolling a resident in an inappropriate manner and began to re-educate the staff. 4/30/23 - Review of all documentation of the corrective action plan completed on 1/1/24 included: - Timely reporting to State Agency; - Additional education regarding bed mobility for all nursing staff providing direct care to residents; - Facility investigation of the incident; and - Observations of bed mobility care with audits that documented compliance. This was verified by the Surveyor with observations of resident repositioning as well as multiple staff interviews about the content of the turning and repositioning inservice/education. The Surveyor also reviewed the competency sheets for the bedside staff, which involved observations by management. Based on interview and review of clinical records and other documentation as indicated, it was determined that for five (R12, R63, R165, R169 and R170) out of nine residents reviewed for accidents, the facility failed to ensure that the residents' environment were free from accident hazards and the residents received adequate supervision. - R170 eloped on 8/16/23 at approximately 6:40 AM and was found outside the facility. Due to the facility's corrective measures completed on 8/31/23, the facility was notified that R170's elopement was an Immediate Jeopardy (IJ) past non-compliance. - R169 was able to retrieve a pair of sharp utility scissors from a treatment cart on 11/21/23 at 10:45 AM. Due to the facility's corrective measures completed on 11/28/23, the facility was notified that R169's incident was an Immediate Jeopardy past non-compliance. - R165 fell from an elevated bed while receiving incontinence care on 11/22/23 and sustained multiple right rib fractures and a back fracture. Due to the facility's corrective measures completed on 11/28/23, the facility was notified that R165's incident was a harm past non-compliance. - R12 was rolled into the windowsill during care with resultant facial hematoma on 12/25/23. Due to the facility's corrective measures completed on 1/1/24, the facility was notified that R12's incident was a harm past non-compliance. - R63 was served a hot tea beverage on 11/30/23 with breakfast at an inappropriate temperature as she sustained a first degree burn to her stomach and second degree burn to her upper right thigh. Additionally, the facility failed to ensure that E35 (LPN), the assigned nurse, followed the facility's policy and procedure when R63 had a change of condition (burns). Due to the facility's corrective measures completed on 12/5/23, the facility was notified that R63's incident was a harm past non-compliance. Findings include: 1. Review of R170's record revealed: The facility's Wandering and Elopements Policy, revised April 2024, Policy Interpretation and Implementation . A wandering/elopement assessment is completed as well as an obtained wandering/elopement hx (history) if able. Review of R170's clinical record revealed the presence of the following progress notes and physician's orders from the previous facility that R170 was in prior to his 8/9/23 facility admission. The documents indicated that R170 had been a resident of the previous facility from 8/2/23 - 8/9/23. The notes and orders were scanned into the facility's Emr (electronic medical record) on 8/9/23 by E6 (AD): - A Physician Order Summary Report that included an 8/2/23 order for R170 to have a Wanderguard; to check placement and function every shift. - An 8/2/23 Elopement Risk assessment that scored R170 at 2, at risk for elopement, related to his history of elopement at home, wandering in the facility and his verbal desire to return to his home. - An 8/2/23 nursing progress note which revealed that R170's elopement risk was a 2, and that R170 had a Wanderguard placed on his right ankle. - An 8/3/23 physician progress note that documented that R170 was under elopement precautions. 8/9/23 2:00 PM - R170 was admitted to the facility with diagnoses including dementia, mood disturbance and anxiety. The facility's new resident admission process included an assessment for a facility elopement risk and R170 was assessed as zero risk of elopement. A 3:09 PM progress note was written by E33 (LPN) revealed that R170 was admitted to the facility after being at another nursing home in the same city. 8/16/23 9:20 AM - A progress note was written by E24 (RN) that R170 eloped to parking lot . on 8/16/23 at 6:50 AM secondary to wandering related to advanced dementia. 4/25/23 9:30 AM - During an interview, E2 (DON) stated that R170 was able to elope from the facility through a locked window in the dining room, and that the resident apparently pushed the window until he broke the window locks, raised the window, removed the screen and then climbed out the window. R170 landed on a grassy area and walked to a cement path area which was on the side of the parking lot, which was next to a vehicular traffic road. A staff member who was arriving to work saw the resident on the pathway. 4/25/23 10:45 AM - During an interview, E16 (CNA) stated that on 8/16/23 when she was arriving to work at approximately 6:45 AM that she saw R170 walking on the walking pathway at the side of the facility. E16 stated that she did not know the resident so she wasn't sure if he was a facility resident and that she came in the building and asked E25 (RN) for assistance to verify the identity of R170. E16 stated that R170 was frustrated at the time and he wanted to go home. 4/30/24 10:30 AM - During an interview, E2 (DON) confirmed the presence of the previous facility's documents related to R170 previous facility stay and which had been scanned into the facility Emr on 8/9/23 by E6 (AD). E2 confirmed that R170 had a physician order for a Wanderguard, elopement precautions and the progress notes that described R170's elopement precautions, and all of which had previously been scanned into the facility's Emr. E2 stated that she was unaware of the elopement precautions that previous facility had R170 under. 4/30/23 1:42 PM - E1 (NHA) submitted to the Surveyor documentation of the corrective action plan with correction completed 8/31/23 at 7:00 AM. Immediate actions taken: - R170 was immediately moved to the facility's secured dementia unit, with one-to-one supervision and with a Wanderguard in place. - Facility wide Elopement Assessments accuracy was verified by E29 (ADON) 8/16/23. - Elopement Drills were conducted on 8/16/23, 8/17/23 and 8/30/23. - QAPI ad hoc meeting to review the elopement was held on 8/18/23. - Maintenance conducted a sweep of all windows to ensure the window locks were in place. - All staff elopement education began on 8/16/23 and was completed 8/31/23. - All resident name bracelets were audited to ensure that the bracelets were on the residents. - The elopement book that contained the residents identified as an elopement risk was reviewed and updated. Ongoing Actions: - QAPI review of the elopement incident at the September and October 2023 meetings. - All new admissions will have notes reviewed and elopement assessments checked by the ADON/designee. - Elopement book was audited weekly and then monthly for three months after the 8/16/23 elopement. Ongoing, E2 will review and update the elopement book with changes. 4/30/24 1:42 PM - Received from E1 the corrective action plan that was fully corrected, signed, dated and timed for 8/31/23 at 7:00 AM. 5/1/24 8:00 AM - An Immediate Jeopardy past non-compliance was called and reviewed with the facility leadership, including E1 (NHA), E2 (DON) and E28 (CRM). No immediate action required related to facility correction and no further occurrences after the incident on 8/16/23. This was verified by interviews with staff about elopement education, spot inspection for window locks and inspection of the elopement book. 2. Review of R169's clinical record revealed: The facility's policy on Security of Medication/Treatment Cart (revised June 2023) documented, The medication/treatment cart shall be secured during medication/treatment passes . 1. The nurse must secure the . cart during the medication/treatment pass to prevent unauthorized entry . 3 . The cart must be locked before the nurse enters the resident's room. 4 . carts must be securely locked at all times when out of the nurse's view. 5. When the . cart is not being used, it must be locked. 11/2/23 - R169 was admitted to the facility with a wound on the right lower extremity. 11/3/23 - A care plan was initiated for R169's agitation with verbal abuse exhibiting behaviors of cursing and use of derogatory language towards staff. 11/6/23 - R169 was also care planned for alteration in thought process related to episodes of confusion and anxiety. 11/6/23 9:28 PM - A nurse's progress note documented, Resident [R169] making suicidal statements to son. Resident stated that he wants to find a gun and 'end it all' . Son does not want resident sent to hospital. On call provider notified - provider made aware of son's wish to not send him. Provider ordered q (every) 15 (sic) checks until tomorrow, stat (immediately) psych consultation Q (every) 15 minute checks initiated. 11/7/23 - R169's admission MDS assessment revealed an intact cognition, having fluctuating behaviors of difficulty focusing attention and easily distractible with verbal behavioral symptoms directed towards others. R169 required supervision or hand touch assistance with mobility. 11/8/23 - R169 was hospitalized on [DATE] and was readmitted to the facility with new diagnoses including, but not limited to, depression and anxiety disorder. 11/16/23 - R169's physician's order for lorazepam (for anxiety) 0.5 mg (milligram), 1 tablet by mouth every 12 hours as needed for 14 days was changed to every 8 hours as needed for 14 days. 11/21/23 10:45 AM - A facility incident submitted to the State Incident Reporting Center documented that, Resident while in his wheelchair approached wound cart took out a pair of scissors and told staff he was going to hurt himself. He then began to cut at the bandage on his lower leg. When staff approached him to take away scissors he began to swing them around stating to staff he would harm himself. Scissors were successfully removed from his person. Wound team had used the cart during wound rounds. Resident sent to (hospital) for evaluation and behavior. 11/21/23 11:05 AM - A nurse's progress note revealed, Resident became combative with staff physically and verbally . Resident then went into the wound care cart, grabbed scissors and attempted to harm himself. Resident then smacked a nurse on her leg twice and attempted to bite unit clerk. NP (Nurse Practitioner) made aware . pick up resident to take (hospital). 11/21/23 - A written statement by E8 (Wound Nurse/UM) documented, During wound rounds on 11/21/23, I went to treatment cart to obtain scissors, and found none. I obtained a pair of bandage shears from the lower cart nurse (sic) and proceeded to complete dressing changes for residents seen on wound rounds. After rounds completed I returned supplies to treatment cart and thought I locked cart, I did not . 11/21/23 - A written statement by E9 (LPN) documented, I was sitting at the nursing station starting to chart. I heard the treatment cart doors opening and closing. I got up and stated, '[R169] please stop opening those.' As I got closer to him I noticed [R169] had a pair of scissors from the treatment cart he had started cutting his leg bandage off. I immediately intervened and I tried to get the scissors from him. When I tried the first time he threw his hands back and almost hit me in the head with the sharp end of the scissors. I lightly held his wrists with my palms so he couldn't hurt me or himself. I yelled for E10 (Unit Clerk) to come help me and take the scissors away from him. As E10 came over (sic) [R169] stated 'he wanted to die'. Once [R169] was safe and away from the scissors and the treatment cart, I had him sit next to me at the nurses station. [R169] proceeded to be disruptive and violent. He started to hit me in the legs and tried to grab my computer. We removed him for my safety and place (sic) him where he couldn't hurt me or anyone else or himself. 11/21/23 - A written statement by E10 (Unit Clerk) documented, I was sitting at my desk when me and the nurse heard the resident [R169] slamming the drawers open & (and) close on the wound cart, the nurse got up and went over and he had scissors in his hand. She went to grab them because he was cutting his wound bandage and said he was going to hurt himself (sic) as she went to grab he would not let her and was swinging the scissors. I came over to help her and I was able to get the scissors. Afterwards he was very rude to the staff he wouldn't stay calm he tried to hit the nurse multiple times as she had him sit with her, he said, 'Ima (sic) get serious now' and then grabbed at her computer trying to knock it down (sic) he was calm for just a minute then rolled over by the wound cart again and the key attached to the oxygen tank near the wound cart he grabbed and had it around his hand pulling . I tried to get it from me (sic) and on multiple occasions he tried to bite me saying 'I'm going to bite you stop!' I called over the unit manager for help . 4/25/24 1:00 PM - In an interview, E10 confirmed that she removed the scissors away from R169, who was very agitated at that time. E10 further stated, He tried to bite me as I took the scissor away. I don't know what type of scissors it was but the ends were sharp . He was sent out to the hospital after that incident and he did not return anymore. 4/26/24 11:30 AM - A spot check of the five treatment carts, four oxygen carts and nine medication carts across the five units revealed all carts were locked. 4/26/24 3:20 PM through 3:34 PM - An interview with the following nursing staff E11, E12, E13, E8, E14 and E15 revealed that staff were educated to keep all of the medication and treatment carts locked at all times when not in use and in view. 4/26/24 3:36 PM - In a separate interview, E8 (RN/Wound Nurse) clarified that she used a regular utility scissor and not a bandage scissor. E8 stated, There was no bandage scissor on the treatment cart. I used a regular scissor and that was the same scissor that [R169) took out from the drawer. 4/29/23 10:54 AM - E1 (NHA) submitted to the Surveyor an acceptable documentation of a signed and dated corrective action plan that was fully corrected on 11/28/23. The facility's corrective actions at the time of the incident included: - Investigation found that the treatment cart was left unlocked and resident was able to open it and obtain a pair of non-safety scissors. - Scissors were removed and the resident was unharmed. The resident was sent out for psychosocial evaluation. - Staff education immediately initiated on 11/21/23 along with auditing of treatment carts being locked. Safety scissors were placed in all treatment carts. - Completed education as of 11/28/23. - Audits documented compliance as of 11/28/23. - Facility was in substantial compliance as of 11/28/23. - The facility continued to audit and maintained compliance. 4/29/24 2:54 PM - An IJ was called and reviewed with the facility leadership, including E1 (NHA), E2 (DON) and E28 (CRM). During this conference, both E1 and E2 confirmed that there had been no other incidents of residents opening unlocked medication and treatment carts after the 11/21/23 incident. No immediate action required related to no further occurrences after the incident on 11/21/23 and past non-compliance. This was verified by spot inspection of medication/treatment carts, review of facility documents and interview with facility staff and residents. 5. Review of R63's clinical record revealed: 3/23/23 - R63 was admitted to the facility with hemiplegia and hemiparesis following a stroke affecting the right dominant side. 9/20/23 - R63's quarterly MDS assessment documented that she was cognitively intact and required supervision and setup help only for eating. 12/1/23 - A physician's note documented that R63 was seen and evaluated for .spilled tea to right thigh and lower abdomen . Right thigh with intact blister, + (positive) erythema (redness), mild swelling, no tenderness or drainage. Right lower abdomen with mild erythema, no blisters, swelling or open wound . Burn of abdominal wall, first degree . Burn of thigh, second degree . Monitor for signs of pain or discomfort, or infection. Apply Silvadene cream . Tylenol . for pain . Peripheral neuropathy. Discussed with patient concerns with drinking hot beverages and she is unable to feel when she dropped hot liquids. Reiterated with patient the need to have a two handle cup for all hot beverages and this includes any beverages that family or friends may bring in from the outside . 12/1/23 - The facility's investigation documented the following timeline: - at 10 AM, E2 (DON) was notified by NP of R63's burn/blisters from a hot water spill. NP and Wound Nurse assessed resident and treatment ordered. - at 10:30 AM, R63 stated during an interview that on 11/30/23 she spilled the hot water from her breakfast tray onto herself. She stated that when she picked up the cup that her hand gave out and it spilled. Resident admitted that she did not tell any staff members of the incident. During care on 12/1/23 at approximately 6am resident said that the C.N.A. [E37] discovered the blisters to her right thigh while she was getting her up. Additional interviews on 12/1/23 revealed: - Nurse [E38] from 12/2/23 7-3 shift was interviewed and stated that the burn/blister area on the resident was passed along to her during shift to shift report to have the NP assess the resident. Stated that the 11-7 nurse had contacted the family regarding the findings. - Nurse [E35] from 11/30/23 11-7 shift was called and multiple messages left to return urgently. Supervisor for 11-7 shift was not made aware of the resident having a blister on her right upper thigh area. Update: nurse returned DON call later that day 12/1/23. Nurse stated after aide notified her of changes to residents skin she assessed and notified MD/NP and emergency contact. Emergency contact told the nurse that her mother spilled a hot beverage and the skin changes may be a result of her mother spilling the hot beverage on herself. She then reported to the oncoming nurse of skin changes and MD/NP will follow up. (It should be noted that E35 did not call the on-call provider at the time, but documented R63's burn/blisters in the MD/NP book to follow up.) - at 11 AM, interviews of multiple nursing staff assigned to provide care for R63 on 11/30/23 day and evening shifts revealed that R63 did not tell anyone that she spilled her tea nor did anyone see any skin issues during care. - On 12/1/23, Therapy was notified of the need for 2 handled lidded cups for hot beverages with meals. Cups ordered with meals and supplied to the kitchen for use. Therapy will evaluate for hand strengthening. - On 12/1/23 at approximately 12 pm, the kitchen manager was notified of incident with resident burn/blisters. Water coming from the coffee machine was tempted and showed to be 170 degrees. Maintenance director contacted manufacturer of coffee machine and was able to lower the temperature. Dietary staff was instructed that the temperature of coffee or hot water has to be served at 150 degrees or lower. Dietary manager immediately initiated new process of temping hot beverages at start of meal service and taking temp of hot beverage of each cart prior to service to ensure temps at 150 degrees or below. Education for dietary staff was initiated on 12/1/23 on new process for taking temperatures of hot beverages prior to service. - On 12/1/23, staff educator initiated education with nursing staff on the importance of notifying the Supervisor of burn/blister for proper resident assessment and investigation. - On 12/1/23 at 1:30 PM, facility reported R63's incident to the State Agency. - The facility identified and noted during the investigation that the Nurse [E35] who first assessed R63 was given a write up and education was conducted on proper process to follow when there is an observed change in a resident's condition. Plan to review the nurse's documentation to ensure proper documentation and following the facility's policy and procedure. 12/5/23 - E2 (DON) completed an Employee Performance Improvement/Action Notification for E35 (LPN) for Violation of Policy #501-1 Failure to report incident or change in resident condition to Supervisor. Failure to provide notification of a residents change in condition to the N.P. and or On Call Service. Failure to document note in chart and obtain treatment orders. Failure to initiate incident report. The corrective actions were: [Name of E35] will receive training on the proper procedure for reporting and documentation change in resident condition and notification of supervisor and or Nurse Practitioner . will be audited by supervisor to review documentation in order to insure following proper procedure for documenting. 12/5/24 at 4 PM - E8 (RN/UM) documented that she educated E35 (LPN) of the proper documentation/notification of a resident's change in condition, which was signed and dated by both nurses. Based on the immediate actions taken after R63's incident, reviewed by the Surveyor and confirmation of no further incidents, the facility returned to substantial compliance as of 12/5/23 at 4 PM. 5/1/24 1:30 PM - All findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E28 (CRM) and representative's of the Ombudsman's Office.

Based on record review, interviews and review of facility documentation, it was determined that for one (R370) out of three (R24, R222 and R370) residents reviewed in the investigative sample, the facility caused harm by failure to ensure that R370 received adequate nursing care after R370 had an unwitnessed fall on 10/1/22. R370 didn't receive ongoing post fall assessments and pain management for injury/pain related to the fall until 10/4/23, three days later. For R222, the facility failed to implement the behavior care plan intervention of two CNAs in the room when offering care as needed. For R24, the facility failed to ensure that the resident received her heel protectors per the Physician's order and plan of care. Findings include: Review of the facility Employee Handbook, revised 7/1/12, Policy #200 Workplace Safety, Resident Injuries: Resident injuries including falls, must be reported immediately to your supervisor. Residents are not to be moved until a nurse or other healthcare professional has seen them. 5/20/21 - R370 was admitted to the facility. Hospice care in the facility was initiated for R370 and a hospice care plan was created that included an approach to administer pain medications (meds) as needed and to monitor for the response. The following pain meds were in place: Acetaminophen Tablet 325 MG, give two tablet by mouth two times a day for pain. Tramadol Tablet 50 MG, give 1 tablet by mouth every twelve hours as needed for moderate pain. Morphine Sulfate Solution 20 MG/ML Give 0.25 ml by mouth every 4 four hours as needed for severe pain. 7/20/22 - The quarterly Minimum Data Set (MDS) assessment revealed a BIMS (Brief Interview for Mental Status) score of 3, which meant R370 had a severe decline in mental status. 9/16/22 - A fall risk assessment documented R370 as being at high risk for falls with a score of 12; any score greater than 10 is high risk. 10/1/22 - A facility video recording revealed that R370 fell in the hallway at approximately 8:40 PM; R370 did not receive a fall assessment from a Nurse before E16 (CNA) and E17 (CNA) lifted R370 with their hands and moved her. 10/2/22 - Review of a staff statement that was completed as part of the facility's investigation of the 10/1/22 fall, revealed that E18 (CNA), who was caring for R370 on the 7AM-3PM shift, believed that R370 was in pain because R370 was usually willing to get out of bed, but that on this day R370 was not willing to get out of bed or stand to use her walker, as she normally had done other times when E18 cared for R370. Additionally, E18 observed R370 moaning during lunch. E18 told the Nurse caring for R370 that she thought R370 was in pain. 10/2/22 10:21 AM - A nursing progress note revealed that R370 was having nonverbal signs of pain. Tylenol was administered at 8:00 AM, however, the resident was still showing nonverbal signs of pain at 10:21 AM. 10/2/22 - A review of the medication administration record (MAR) revealed that R370's pain was assessed at a 7 on a scale of 0-10 (with 10 being the most pain). R370 was given Tramadol 50 MG tablet by mouth at 10:21 AM. R370's untimed post pain assessment was documented as E for effective, a post pain number assessment was not documented. Pain medications, other than routine Acetaminophen, were not documented as given to R370 again on 10/2/22. 10/3/22 - A review of the MAR revealed that R370's pain was assessed at a 7 on a scale of 0-10. R370 was given Morphine 0.25 ml by mouth at 8:10 AM. R370's untimed post pain assessment was documented as E for effective, a post pain number assessment was not documented. Pain medications, other than routine Acetaminophen, were not documented as given to R370 again on 10/3/22. 10/3/22 - A MAR review revealed a 4:45 PM Physician's order for a Stat (immediate) X-Ray to R370's bilateral hips. The chart lacked documentation of when the Stat x-ray was obtained. 10/4/22 - Review of the MAR revealed that R370's pain was assessed at a 6 on a scale of 0-10. R370 was given Morphine 0.25 ml by mouth at 5:20 AM. R370's untimed post pain assessment was documented as E for effective, a post pain number assessment was not documented. Additionally, R370s pain was assessed at an 8 on a scale of 0-10 and R370 was given Morphine 0.25 ml by mouth at 10:16 AM. R370's untimed post pain assessment was documented as E for effective, a post pain number assessment was not documented. 10/4/22 9:07 PM electronically signed - An Encounter note by E21 (NP) revealed that on 10/3/22, E21 was notified by nursing staff that R370 had complained of lower extremity (leg) pain during activities of daily living (ADLs) and an x-ray was ordered. On the 10/4/22 exam, R370's left lower leg was observed to be swollen and R370 showed signs of pain when the leg was moved. The 10/3/22 x-ray revealed a fracture of the left leg/hip. R370 was sent to the emergency room and was admitted to the hospital. 10/4/22 7:55 AM - electronically signed - An X-Ray report revealed that R370 had a left femur fracture. It was still unclear when the X-ray was obtained and why it took 15 hours to get results. 10/5/22 - A facility incident report, dated 10/3/22, for R370, documented an Incident Description: At the start of the 7-3 shift during rounds observed resident to be moaning and groaning, shivering in bed CNA administered care to resident, and stated that the resident complaint (sic) of moderate amount of pain. Resident was crying while being turned during am (morning) care. Care giver stated resident screamed when she touched leg . Immediate Action Taken-Description of Action Taken: Resident was assessed, and observed swollen left hip; sensitive to touch, also complained of increased pain. Resident was given routine Tylenol 0800- (8:00 AM); was ineffective, resident continues to moans (sic) and groans (sic). At 0830 (8:30 AM) . Morphine 0.25 ml administered; meds effective. NP (Nurse Practitioner) was notified and ordered Stat X-Ray to bilateral hips 3 views. 10/4/22 X Ray result came back; positive for Acute displaced fracture of left Femur . 5/25/23 - A review of hospital records revealed that R370 was admitted to the hospital on 10/4/22 at 6:00 PM for a hip fracture and that R370 had surgical hip repair on 10/5/22. 6/6/23 2:33 PM - During an interview, E2 (DON) stated that R370's 10/1/22 fall was unknown to the facility until they performed an investigation after R370 was found to have a hip fracture on 10/4/22. 6/6/23 8:31 AM - During an interview, E34 (LPN) stated that if a resident sustains a fall, the fall should be reported to the Nursing Supervisor. Additionally, a verbal fall report would be given during the nursing shift to shift reports, so that fall assessments would be continued by the oncoming Nurses. 6/7/23 12:15 PM- During a phone interview, E17 (CNA) stated that she was working at the facility on 10/1/22 on the 3:00 PM-11:00 PM shift. E17 was doing rounds and discovered R370 on the floor outside of her room. E17 was not assigned to R370, so she went to get E16, the CNA that was assigned to R370. E17 told E19 (LPN) who was caring for R370, that the resident had fallen, but stated that E19 did not move from the nursing desk where he was sitting. The two Aides then proceeded to lift R370 with their hands and put her to bed. E17 stated that E19 did not assess R370 before she and E16 put R370 in bed. 6/7/23 12:25PM - During a phone interview, E16 (CNA) stated that she was assigned to care for R370 on the 3:00 PM-11:00 PM shift on 10/1/22. E16 said that E17 found R370 on the floor and came to get E16 to assist with R370. E16 stated that she and E17 proceeded to lift R370 with their hands and put her to bed. E16 stated that E19 (LPN) did not assess R370 before she and E17 put R370 in bed. R370 experienced harm when staff failed to assess the resident for injury and pain post fall. Staff reports and pain medication assessments revealed that R370 had nonverbal signs and symptoms of pain which required the administration of Tramadol on 10/2/22 for moderate pain and Morphine on 10/3/22 and 10/4/22 for severe pain. Additionally, the result of the STAT x-ray ordered on 10/3/22 at 4:45 PM did not return until 10/4/22 at 7:55 AM, more than twelve hours after the order was written. R370 remained at the facility for two and a half days with a broken leg before receiving medical treatment at the hospital. During this time there was lack of assessment and intervention for injury and pain. 48409 2. Review of R24's clinical record revealed the following: 2/5/16- R24 was admitted to the facility. 1/30/18- A Physician's order was written for heel boots to bilateral feet as tolerated every shift while in bed. 1/30/18- R24 was care planned for the potential for impaired skin integrity related to incontinence and decreased mobility. 1/30/18- Interventions included, but were not limited to: heel boots to bilateral feet as tolerated when in bed. 7/5/19- A Physician's order was written to consult therapy for interventions as needed. 5/26/23 10:30 AM- R24 was observed lying in her bed. Her right foot was in a soft cast and the left foot/heel was resting directly on the bed. A blue heel protector was on the ledge of the window sill on the right side of the bed and one was in the clear bin near the bedside drawer. No heel boots were on R24. 5/26/23 11:00 AM- R24 was observed lying in bed in the same position. Her left foot/heel was resting on the bed. Heel protectors continued to be on the window ledge and in the bin. 5/26/23 11:05 AM- R24's heel protectors were in the same places. R6 (RN) confirmed that R24's heel protectors remained on the window ledge and in the bin. R6 stated, She (R24) kicks them off sometimes. 5/26/23 11:30 AM- R24 was observed with a soft cast on her right foot and a heel protector on her left foot only. 6/8/23 2:30 PM- Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON) and E3 (ADON.) 40264 3. Review of R222's clinical record revealed the following: 6/11/21 - R222 had a care plan developed and revised (9/9/21) for making false accusations towards staff with interventions including, but not limited to, having two CNA's in the room when offering care as needed. 5/27/22 - A facility Complaint/Grievance Report filed by FM1 revealed that a 3-11 PM shift CNA has been extremely nasty to her mother (R222). 3/27/22 - A written statement by E67 (former DON) documented that on 3/26/22 on the 11 PM-7 AM shift .it was identified that CNA (E41) was assigned to the resident (R222) .E41 stated that she responded to the call light in the bedroom and assisted the resident to the bathroom, utilizing her rollator. After toileting, E41 was assisting the resident back to the bed, the rollator swayed from side to side and as the staff member was attempting to maneuver the rollator, the resident verbalized that the staff was making her sick to her stomach and stated that she did not want her to come back to care for her because she (E41) mistreats her (R222) every night .E41 also indicated that she has not provided care to resident (R222) in quite a long time. 6/5/23 1:03 PM - During an interview, E41 stated that she remembered what happened that night on 3/26/22. E41 also stated R41 had a behavior of making false accusations towards staff providing her care. E41 further confirmed that on 3/26/22 late evening she entered R222's room and was by herself when she provided assistance to R222 to the bathroom. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 6/8/23 at 2:30 PM.

Based on record review, observations and interviews, it was determined that for three (R24, R104, and R221) of twelve residents reviewed for accidents, the facility failed to ensure that the residents' environment remained free of accident hazards. For R104, the facility failed to provide adequate supervision and appropriate care in accordance with professional standards of practice as evidenced by failure to adequately supervise and mitigate accidents when R104 fell out of bed while receiving care. This fall resulted in harm as R104 was transferred to the hospital and was subsequently diagnosed with a right hip fracture. For R221, the facility failed to ensure that the proper Hoyer lift sling was used to transfer the resident from a wheelchair to his bed during which time the resident fell , complained of pain and sustained harm with a left rib fracture. For R24 the facility failed to ensure that the proper equipment was used to transfer R24 from her wheelchair to her bed. The facility's investigation failed to identify the root cause analysis of the fall and educate staff members in a timely manner. Findings include: 1. Review of R104's clinical record revealed: 11/19/21- The Agency Orientation Checklist, which was signed as reviewed and completed by E45 (Agency CNA), included Education on Bed Mobility that stated, How do you find out what the mobility status is of your residents? (if the answer is ask that is NOT correct!) You must look at the Kardex or the POC (plan of care) for each resident . Orders MUST be followed regardless of what you think you or the resident can do .If they are assist of 2 bed mobility, that means when ever (sic) you are providing care that involves moving the resident, you MUST have 2 people. 2/15/22 - 2/16/22- E45 signed a facility Inservice Attendance record for Bed Mobility/Transfers. 2/28/22- R104 was admitted to the facility for long term care with diagnoses including Alzheimer's dementia. R104's Admission Orders stated, TRANSFER STATUS: assist X2 (2 person), BED MOBILITY: assist X2 (2 person) . 3/1/22- R104 was care planned for falls with interventions that included, but were not limited to, bed in the lowest position when care is not being provided, bilateral fall mats down when in bed and call bell within reach at all times. Additionally, R104 was care planned for inability to perform ADL's (activities of daily living) without assistance related to cognitive loss, with interventions that included, but were not limited to, bed mobility- assist X2 (2 persons), transfers- hoyer (mechanical lift) assist X2, and non- ambulatory (does not walk). 3/6/22- R104's Minimum Data Set (MDS) assessment documented ADL Self-Performance for bed mobility as 4 (total dependence) with 3 (two+ person) physical assist. 3/11/22 10:45 AM- R104 rolled off the bed onto a floor mat while E61 (Hospice CNA) was providing care unassisted, despite R104's need for two person assistance for bed mobility. 3/11/22 11:00 AM- E64 (ADON) performed On the Spot Education/Coaching with E61. 3/11/22 12:47 PM- The monthly Documentation Survey report revealed that E63 (CNA) signed off R104's CNA Task of Bed mobility Assist X2 as 4 (total dependence) with 3 (two+ person) physical assist. 3/11/22- R104's Care Plan was revised to add under the Fall care focus, the intervention provide education to ancillary staff. 4/8/22 11:15 AM- R104 rolled off the bed while having incontinence care performed unassisted by E45 (Agency CNA) and landed onto a fall mat. The fall resulted in R104 being transferred to the hospital and being diagnosed with a right femur fracture. 4/8/22 11:25 AM- E45's Witness statement documented, I was doing my residents care and turned around to put brief in trash bag on the floor. When I look (sic) back over, the resident was on the floor with floor mat under her. The bed was at waist length (sic) because I'm 5'7. I told the nurse right when I seen (sic) her fall. 4/8/22 11:45 AM- E6 (RN/Unit Manager) provided On the Spot Education/Coaching to E45 (Agency CNA). 4/8/22 12:48 PM- The monthly Documentation Survey report revealed that E45 erroneously signed off R104's CNA Task of Bed mobility Assist X2 as 4 (total dependence) with 3 (two+ person) physical assist. 4/8/22 7:52 PM- The hospital Trauma History and Physical/ Consult documented CT (computed tomography scan) of the abdomen/chest/pelvis did show patient did have a (sic) intertrochanteric (extracapsular fracture of the proximal femur) fracture on the right hip. 4/9/22 12:58 AM- The hospital History and Physical documented, Assessments/Plan- fall while briefly unattended .Right hip pain .intertrochanteric fracture of right hip. 4/11/22- Despite already being documented as a 2 person assist for bed mobility (Care Plan 3/1/22), R104's Care Plan was revised to add under the fall care plan focus 2 person bed assist for all care. 4/14/22 12:12 PM- The hospital Discharge Summary documented, .following a fall she (R104) was found to have intertrochanteric fracture of the right hip and fracture of the sacrum (large triangular bone at base of the spine). He (sic) underwent operative repair on April 9. 6/1/23 10:20 AM- During an interview, E6 (RN/Unit Manager) stated that the facility process for training agency CNAs involved a book at the Main desk that they have to read. When asked about Agency CNAs' access to PCC (Point Click Care- electronic documentation), E6 stated, They have their PCC sign-on prior to coming on the floor and have access to the TASKs tab so they can see what they need to do for the resident. 6/1/23 1:12 PM- During an interview, E65 (Scheduler) stated that the Orientation book for Agency staff is kept at the office at the Main Desk . the Hospice Aides and staff, as well as Agency staff have to read and sign off on the Orientation book prior to working on the floor. 6/8/23 11:10 AM- E1 (NHA) stated that she was not able to find E45's Agency CNA Orientation sign in sheet. E1 stated, There was no group education after either of R104's falls- only On the Spot educations with the specific CNA each time. Additionally, E1 confirmed that Agency and Hospice staff are made to read and sign off on the facility Orientation book kept at the Main desk prior to working with residents on the floor. 47620 2. Review of R221's clinical record revealed: 2. 7/11/22 - R221 was admitted to the facility with diagnoses including, but not limited to, orthopedic aftercare following surgical amputation of the legs. 7/12/22 - R221 was care planned for the potential for falls with interventions that included, but were not limited to, bed mobility with assistance of two staff and transfers with assistance of two staff with a Hoyer lift (mechanical lift). 7/13/22 - A Physician's order reordered R221's transfer status of assistance of two with a Hoyer lift and bed mobility assistance of two staff with an end date of 8/5/22. 8/15/22 - A Physician reordered R221's transfer status as above (7/13/22) with an end date of 12/2/22. 10/12/22 - The quarterly MDS assessment documented R221 as cognitively intact, bed mobility required extensive assistance with two person physical assist and total dependence for transfers with two staff assist. The MDS also indicated that transfers between the bed and chair or wheelchair as not steady and only able to stabilize with staff assistance. 12/1/22 at 1:07 PM - A nurse's note documented staff were called to R221's room, the resident was lying on the floor, the base of the Hoyer lift was under the resident's head and R221 reported a headache, left rib pain and left elbow pain. The resident was sent to the emergency room (ER). 12/1/22 at 1:35 PM - According to the nurses note, the assigned CNA (E24) notified the Nurse that R221 fell from the sling (that connects to the Hoyer lift) to the floor. Per the note, the Nurse went to the room and found the resident lying on the floor on his left side. The resident reported hitting his head, was assessed and found to have a headache, left rib pain and left elbow pain. R221 was sent to the ER for further evaluation. 12/1/22 - Per a witness statement, E24 (CNA) was transferring the resident with two people, R221 fell out of the lift, and she went to get the Nurse. 12/1/22 - Per a witness statement, E28 (CNA) was asked to assist with the transfer and, as soon as the lift was away from the bed she reached out for the chair, looked back and the resident was on the floor. 12/7/22 - The root cause analysis submitted by E2 (DON) documented that R221 was transferred from the chair to the bed using a mechanical lift sling with assistance of two staff. However, the incorrect type of sling was utilized. The resident was a bilateral above the knee amputee and the split leg/divided leg sling was used. R221 returned to the center from the ER with a diagnosis of a left rib fracture. 6/7/23 at 9:32 AM - During an interview, E24 (CNA) stated that she didn't have the proper sling and that she had the one that crisscrossed. (R221) just slipped through the sling. She reported, it wasn't her by herself. She had another aide with her. They then had the Nurse come. They didn't pick him up, they used the Hoyer lift to get him off the floor. Right away the Administrator inserviced us that day. E24 reported that the Administrator showed them how it's done. 6/7/23 at 10:32 AM - During an interview, E28 (CNA) stated that she went into the room to assist with transferring the resident. She stated that the other E24 (CNA) already had him in the sling and when they went to lift him up, he just fell through. She reported that an inservice on use of the full body sling was given right away and included written information and demonstration. She stated that the full body sling is what they use for transferring the resident now. 6/7/23 at 3:15 PM - During an interview with E1 (NHA), E1 revealed there was no reevaluation or repeat of the Hoyer lift competencies after the 12/1/22 inservice. The facility failed to ensure that the proper mechanical lift device (sling) was used to transfer R221 and subsequently a left rib fracture was sustained. 48409 3. Review of R24's clinical record revealed: 2/5/16- R24 was admitted to the facility. 7/27/16- R24's transfer order stated, Hoyer lift and purple sling with assist of 2 for transfers. Assist of 2 with bed mobility. 3/14/23 7:23 PM- A Health Status Note in the Electronic Medical Record (EMR) revealed that R24 was being transferred from the wheelchair to the bed by two staff members (E25 CNA and E26 LPN) and She started to slide out of the sling of the Hoyer lift. She was lowered down to the floor by the CNA. No pain observed but some redness was noted to her left elbow. 3/15/23- R24's post fall therapy evaluation stated, No therapy needs, refer to nursing. 4/11/23- Per the EMR, R24 was noted with redness, pain and swelling to her right foot. 4/12/23- R24 was ordered an Xray of the right foot which revealed a mildly displaced and impacted (pressed firmly together) subacute comminuted (producing multiple bone splinters and fragments) fracture of the distal tibia and a nondisplaced subacute oblique fracture of the distal fibula at the level of the ankle joint. R24 was sent to the ER for evaluation and received an order to follow up with Orthopaedics. 4/12/23- The investigation was completed by DON (E2) and stated that the fractures were most likely obtained when R24 had a coughing spasm that might have caused her right ankle to roll over and then slide off the footrest after she was placed in her chair. 4/21/23- R24 was seen by the Orthopedic Specialist (E31) whose finding stated, This fracture may be from a month or so ago as there is already evidence of early healing. 4/24/23- R24's therapy order stated- foam padding to the wheelchair leg. 6/1/23 10:00 AM- R24 was sitting on a green sling in the wheelchair in her room. 6/1/23 10:30 AM- R24 was sitting on a green sling in the wheelchair in her room. E25 (CNA) confirmed the sling was incorrect and stated, It should have been a purple one. E6 (RN, Unit Manager) also confirmed the sling was incorrect and stated, I have to follow up with the staff. 6/1/23 12:05 PM- E6 provided a list of eight (8) staff members who were educated today for Sling for lifts to match color in task- not left under resident once in chair. 6/8/23 2:30 PM- Findings were reviewed during Exit Conference with E1 (NHA), E2 (DON) and E3 (ADON).

Based on interview, review of the clinical record, review of the facility's policy and procedure, review of the facility's guideline, and review of professional clinical resources as indicated, it was determined that for two (R1 and R2) out of three sampled residents for pressure ulcer (PU) reviews, the facility failed to ensure that the residents received the necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers (PU's) from developing. R2 was admitted to the facility with no PU's and the facility failed to implement preventative measures resulting in R2 acquiring an avoidable unstageable PU of the sacrum on 2/6/21 and an avoidable deep tissue injury (DTI) PU to his left heel on 2/7/21. R1 was readmitted to the facility on [DATE] with no PU's and the facility failed to implement interventions to relieve pressure from R1's heels. R1 subsequently acquired an avoidable stage II (2) PU of the left heel on 2/2/21 that resolved on 3/2/21. Findings include: Review of the facility's policy and procedure (P & P) titled Prevention of Pressure Injuries [Ulcer], with a revision date of April 2020, stated, .The purpose of this procedure is to provide information regarding the identification of pressure injury risk factors and interventions for specific risk factors .Risk Assessment 1. Assess the resident on admission (within 8 hours) for existing pressure injury (ulcer) risk factors. Repeat the risk assessment weekly and upon any change in condition. 2. Use a standardized pressure injury screening tool to determine and document risk factors. 3. Supplement the use of a risk assessment tool with assessment of additional risk factor . Review of the facility's Braden Scale Guideline, with a revision date of March 2018, stated that the facility would utilize this guideline to implement interventions for the prevention of PU's based on the score from the Braden Scale, a standardized PU screening tool: AT RISK (15-18): Repositioning, protect heels, manage moisture, friction and shear, pressure-reduction support surface to bed and chair, moisture barrier for incontinence. MODERATE RISK (13-14): All the above interventions [as noted for AT RISK] and lateral positioning devices and dietary consult if oral intake less than 50%. HIGH RISK (10-12): All the above interventions [as noted for AT RISK and MODERATE RISK] as well as small repositioning shifts between the scheduled turning and repositioning and a resident nap between lunch and dinner. Review of the facility's P & P titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, with a revision date of April 2018, stated, Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for development of pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissues; b. Pain assessment . According to the National Pressure Ulcer Advisory Panel (April 2019), the stages of pressure injuries/ulcers (categorization system used to describe the severity of PUs): Stage II (2) - skin blisters or skin forms an open sore. The area around the sore may be red and irritated. Unstageable - Tissue loss in which the actual depth of the ulcer is unable to be determined due to the presence of slough (yellow, tan, gray, green or brown dead tissue) and/or eschar (dead tissue that is tan, brown or black and tissue damage is more severe than slough in the wound bed). Deep Tissue Injury (DTI) - Purple or maroon localized area of discolored intact skin. May be preceeded by tissue that is painful, mushy, firm, boggy (wet, spongy feeling), warmer or cooler than adjacent tissue. 1. Review of R2's clinical records revealed the following: 8/12/20 - R2 was admitted to the facility with no PU's and weighed 193 pounds (#). 8/12/20 - The Admission Nursing Assessment documented that R2's skin was intact and had no PU's. 8/12/20 - R2 was assessed as not being at risk for the development of a PU with a Braden Scale score of 19. 8/13/20 (Initial date and revised on 2/24/21) - A care plan for risk for further skin breakdown related to decreased mobility, fragile skin, and incontinence included the following interventions: - apply lotion to skin to prevent dryness everyday with AM and PM care. - monitor alterations in nutrition and notify Medical Doctor and Dietician. - Roho pressure relief cushion to wheelchair (initiated 2/21/21). - pressure relief cushion to wheelchair (initiated 8/13/20). - turn and reposition, check skin and monitor pressure points every two hours and report changes to nurse. - weekly skin assessments by a nurse. 8/18/20 - The Admission MDS Assessment documented that R2 was moderately impaired for decisionmaking with a BIMS of 12, required extensive assistance of two plus staff for bed mobility and transfers, required extensive assistance of one person for toileting, was frequently incontinent of urine, always incontinent of bowel, and had no PU's. 11/12/20 - The Quarterly MDS Assessment documented R2 was cognitively intact for daily decisionmaking with a BIMS of 13, required extensive assistance of one person for bed mobility, transfers, and toileting. required supervision of one person assistance for eating, was frequently incontinent of urine, occasionally incontinent of bowel, and had no PU's. 11/30/20 - The Braden Scale score was 18, indicating that R2 was at risk for the development of PU's. Although R2 was assessed to be at risk for the development of a PU, there was lack of evidence that the facility identified and implemented interventions to protect the heels, manage moisture, friction and shear, and to apply moisture barrier for incontinence per the facility's Braden Scale guidelines. 2/1/21 through 2/6/21- CNA documentation stated that the following interventions were completed: - turned and repositioned and skin assessed every 2 hours. - incontinence care every 2 hours and PRN. 2/6/21 2:33 PM - The Braden Scale score was 12 indicating that R2 was at high risk for PU development. 2/6/21 4:19 PM - A Nurse Progress Note documented that at 2:15 PM, a CNA found and reported a wound to R2's coccyx (tailbone) area. R2 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . New orders were given to cleanse the area with NSS, apply Zinc Guard around the edges and apply Santyl to the open area and cover with a clean dry dressing. E6 (LPN, WCN) and R1's responsible party (RP2) were notified. Despite the fact that R2 was assessed at high risk for the development of a PU, there was lack of evidence that the facility identified and implemented additional measures to include protection of the heels, manage moisture, friction and shear, apply moisture barrier for incontinence, and consult for lateral positioning devices per the facility's Braden Scale guidelines. 2/7/21 - CNA documentation stated that the following interventions were completed: - turned and repositioned and skin assessed every 2 hours. - incontinence care every 2 hours and PRN. 2/7/21 12:33 PM - A Skin Only Evaluation documented the following: .Skin Issue: Deep Tissue Injury. Skin Issue Location: left heel Length: 2 cm Width: 2 cm Wound Bed: Necrotic. Wound Exudate: None. Peri Wound Condition: Fragile. Dressing Saturation: None. No wound odor. No tunneling. No undermining. Tissue: Firm. Tissue: Warm . Based on the above characteristics of the left heel PU, it would be consistent with an unstageable PU due to the presence of necrotic tissue in the wound bed. 2/7/21 3:20 PM - A Nurse's Progress Note documented during routine care at 2 PM, a CNA found and reported a bruise to R2's left heel. R2 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The area was cleansed with NSS and skin prep was applied and the heel was elevated. Notifications were made to E6 (LPN, WCN), E9 (NP) and E10 (MD). 2/7/21 - A NP Progress Note documented that R2 was diagnosed with a urinary tract infection and ordered antibiotics for six days. 2/8/21 - A Health Status Note by E6 (LPN, WCN) documented her wound assessment of the left heel with dry eschar measuring 1.0 cm x 1.0 cm, an unstageable ulceration. The coccyx and bilateral buttocks had necrotic tissue with a split base of the wound that was 100% slough with a necrotic black area to the inner buttocks extending to the left buttock with a non-blanchable area to the left buttock. Santyl was ordered for the buttocks and the skin prep for the left heel. New interventions were to elevate R2's heels up on pillows and a low air loss mattress to the bed frame. 2/9/21 - The facility's contracted Wound Care Consultant (E11) documented R2 was seen for an evaluation and management for wounds to the sacrum and left heel. The sacrum measured 9.0 cm (L) x 9.2 cm (W) x 0.2 cm (D) with 60% slough. R2 had no evidence of pain upon the wound being palpated. The left heel measured 1.4 cm (L) x 1.2 cm (W) purple/maroon intact skin.Plan: Unstageable pressure ulcer/injury of the left heel due to deep tissue injury .cleanse affected area with NSS .Apply skin prep daily and PRN .Unstageable pressure ulcer/injury of the sacrum secondary to slough . 2/9/21 - A Registered Dietician Evaluation by E8 (RD) documented, Resident showing loss of 11.4 # in 6 days and highly likely related to overall decline in condition (noted to have decline in continence of b & b and requires extensive assistance with eating), noted with reduction in po intake past week . Although R2 had a decline in overall condition and the facility was monitoring R2's nutritional status, the facility failed to reevaluate R2's clinical condition and failed to implement interventions for the prevention of PU's. These failures resulted in R2 acquiring an avoidable PU of the sacrum on 2/6/21 and an avoidable DTI of the left heel on 2/7/21. On 2/8/21, the facility identified that both of the PUs were unstageable. 3/9/22 1:35 PM - An interview with E6 (LPN, WCN) confirmed that the facility was utilizing the Braden Scale guideline when R2 acquired a new unstageable PU of the sacrum (coccyx) and a DTI of his left heel, however, E6 reiterated that the final interventions were determined by the Interdisciplinary Team. Cross refer F656. 2. Review of R1's clinical record revealed the following: 11/30/20 - R1 was admitted to the facility with no pressure ulcers (PU's) and weighed 193 pounds (#). 11/30/20 - The Admission Nursing Assessment documented that R1's skin was intact. 11/30/20 - R1's Admission Braden Score was 18 indicating that she was at risk for the development of a PU. 12/8/20 - The Admission MDS Assessment documented that R1 was moderately impaired for decisionmaking, with a BIMS score of 9, required extensive assistance of two plus staff for bed mobility, transfers, toileting, was always incontinent of bowel and bladder, and had no PU's. 12/9/20 (last revised on 12/24/20) - A care plan for the potential for impaired skin integrity related to decreased mobility and incontinence included the goal that the skin would remain intact. Interventions included to provide prompt perineal care following incontinence episodes and to provide turning and repositioning every 2 hours, including checking the skin. 12/16/20 3:32 PM - A Nurse Progress Note documented that R1 was positive for COVID-19. 12/1/20 - 12/30/20 - CNA documentation stated R1 was turned and repositioned every 2 hours, including skin checks. There was lack of evidence that additional interventions to prevent PU's were implemented to include protecting the heels, manage moisture, friction and sheer, and to apply moisture barrier for incontinence per the facility's guideline. 12/24/20 12:48 PM - A care plan review note documented that R1's skin was intact and that the interventions implemented were effective. 12/30/20 8:58 AM - A Nurse Progress Note documented a change in condition including altered mental status and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was transferred to the ER and was subsequently hospitalized . 1/15/21 - R1 was readmitted to the facility from the hospital due to pneumonia from COVID-19, had no PU's and weighed 177.3 #. 1/15/21 - R1's Braden Scale Score was 13 indicating that R1 was at moderate risk for the development of PU's. 1/21/21 - The Significant Change MDS Assessment documented that R1 was moderately impaired for decisionmaking with a BIMS score of 9, required extensive assistance of two plus staff for bed mobility, one person physical assistance for transfers, total assistance for dressing and eating, total dependence of two plus staff for toileting, was always incontinent of bowel and bladder, and had no PU's. 1/22/21 - R1's Braden Scale score was 12 indicating that R1 was at high risk for the development of PU's. Despite R1 being high risk for the development of a PU, there was lack of evidence that the facility identified and implemented additional interventions to include protection of the heels, manage moisture, friction and sheer, apply moisture barrier for incontinence, and consult for lateral positioning device(s) per the facility's Braden Scale guidelines. 1/15/21 through 1/31/21 - CNA documentation stated that R1 was turned and repositioned every 2 hours and skin was checked. 1/21/21 - A Registered Dietician Evaluation revealed that R1's current weight was acceptable and the weight loss was due to the recent hospitalization and COVID pneumonia. The plan was to continue weekly weights and closely monitor weight trend. 2/2/21 - A Skin Evaluation documented a fluid filled intact blister on R1's left heel. 2/1/21 through 2/2/21-CNA documentation stated that R1 was turned and repositioned and skin was checked every 2 hours. 2/2/21 - The facility's contracted Wound Care Consultant (E11) documented the presence of a stage II PU to left heel, an intact blister measuring 5.7 cm (L) x 6.0 cm (W). The plan was to cleanse with NSS and to apply skin prep daily and PRN, continue repositioning in accordance to assessed need, offload pressure to the affected area and monitor nutritional intake via gastrostomy tube feeding. Interventions in place to address the condition of R1's skin and immobility included an alternating low air loss mattress and to order heel boots, which were to be worn at all times while in bed. 2/2/21 - The care plan for actual wounds to the left heel stage II (2) related to immobility was developed and implemented. Interventions included to administer treatments as ordered and monitor for effectiveness and educate caregivers as to the causes of skin breakdown, including transfer/positioning requirements, importance of taking care during ambulation/mobility, and good nutrition. 2/2/21 beginning on the evening shift - 2/28/21 - CNA documentation revealed heel booties were on at all times except during hygiene, in addition to turning and positioning and skin checks every 2 hours. 3/2/21 - The facility's contracted Wound Care Consultant (E11) documented R1's left heel PU was resolved. 3/8/22 2:30 PM - An interview with E6 (LPN), the facility's designated Wound Care Nurse (WCN) was asked by the Surveyor if the interventions to prevent PU were revised following R1's readmission to the facility on [DATE] prior to the new stage II PU on the left heel. E6 stated she was unable to determine if there were any changes in interventions for the prevention of PU's and confirmed there was no intervention to offload R1's heels. During this interview, it was unclear what the facility's system was to ensure that appropriate preventative interventions were implemented for the prevention of a new PU. 3/9/22 1:35 PM - The Surveyor was provided the above guideline titled Braden Scale Guideline by E6 (LPN, WCN) who stated this was the guideline which were in place when R1 acquired a new left heel stage II (2) PU. E6 stated that this was the guideline to be utilized, but E6 emphasized that the final interventions were determined by the Interdisciplinary Team. 3/9/22 2 PM - An interview with E7 (LPN, MDSAC) revealed that the MDSACs did not determine the interventions for PU prevention and it was her understanding that it was the responsibility of the Unit Manager. The facility failed to ensure interventions were implemented to prevent new PU development, resulting in R1 acquiring a stage II PU on the left heel on 2/2/21. 3/10/22 2:50 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (ADON), E4 (Director of Clinical Services), and E5 (RN Risk Manager).

Based on observation, clinical record review, interviews, review of the facility's policies and procedures, and review of other facility documentation as indicated, it was determined that the facility failed to ensure that emergency equipment was available for accidental dislodgement for two (R6 and R8) out of two active residents in the facility reviewed for [CONDITION(S)] ([CONDITION(S)]) related care. The lack of available emergency equipment, in addition to the lack of competent trained staff in [CONDITION(S)] care posed an immediate jeopardy (IJ) situation to the residents with tracheostomies. The IJ was identified on 2/2/22 at 6:00 PM and was abated on 2/3/22 at 3:45 PM. Additionally, it was determined that the facility failed to ensure that one (R6) out of two residents in the sample received [CONDITION(S)] care consistent with professional standards of practice and facility policies and procedures. Findings include: 1. EMERGENCY EQUIPMENT: The facility's policy, titled [CONDITION(S)] Care, revised August 2013, stated, General Guidelines .a replacement [CONDITION(S)] tube must be available at the bedside at all times .a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times . 1a. Review of R6's clinical record revealed the following: 8/2/18 - R6 was admitted to the facility with chronic [CONDITION(S)] and a [CONDITION(S)]. 12/30/20 - A Physicians order for R6 stated, [CONDITION(S)] care .a disposable inner cannula (fits inside of the [CONDITION(S)] tube) size 6.0 and 1 size down, ambu bag (used for emergency resuscitation), functioning suction .to be kept at bedside at all times. 6/17/21 - A Physicians order for R6 stated that R6 had a [CONDITION(S)] size 6.0 [MEDICATION(S)] (non-cuffed) Type: Shiley 6.0 mm (size and type of [CONDITION(S)]) . (will be referred to as Shiley #6 [MEDICATION(S)] non-cuffed). 2/1/22 at approximately 9:34 AM - During an observation at R6's bedside with E7 (LPN), it was revealed that a replacement [CONDITION(S)] Shiley #6 [MEDICATION(S)] (cuffed), Shiley #6.5 inner cannulas, and Shiley #6 [MEDICATION(S)] inner cannulas were at R6's bedside. An Ambu bag was not visible at R6's bedside. E7 was unable to confirm what size [CONDITION(S)] R6 had and stated she .was a new nurse . and needed to get another nurse to assist her . in identifying R6's [CONDITION(S)] supplies. A Shiley #6 [MEDICATION(S)] non-cuffed [CONDITION(S)] was not observed at R6's bedside. 2/1/22 9:49 AM - Another nurse, E8 (LPN) entered R6's room to assist E7 (LPN) and was observed removing R6's Ambu bag from the closed bottom drawer of the dresser and hung it on R6's wall. E8 revealed that the Ambu bag should have been hanging on the wall and also confirmed that the Shiley #6.5 inner cannulas at R6's bedside were the incorrect size for R6 and then removed them from R6's room. 1b. Review of R8's clinical record revealed the following: 8/27/20 - R8 was admitted to the facility with chronic [CONDITION(S)] and a [CONDITION(S)]. 1/15/22 - A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . a disposable inner cannula size 6.0 and 1 size down, ambu bag, functioning suction .to be kept at bedside at all times. 1/15/22 - A second physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2/1/22 10:22 AM - Observation at R8's bedside with E8 (LPN) revealed that an Ambu bag and one size smaller [CONDITION(S)] was not in R8's room. At R8's beside was a [CONDITION(S)] #7.5 labeled back up [CONDITION(S)] in marker and size #5 inner cannulas. E8 confirmed that an Ambu bag and any additional size [CONDITION(S)] supplies were not in R8's room. 2/1/22 10:34 AM - The Surveyor notified E1 (NHA) regarding the findings for R6 and R8. 2/1/22 10:39 AM - E1 advised that an Ambu bag was placed in R8's room. 2/1/22 12:30 PM - During an interview with E2 (DON) and E13 (RN Supervisor) it was confirmed that the facility did not have the Physician ordered sizes of back up trachs for R6. Per E2 and E13, the facility just ordered the back up [CONDITION(S)] set for R6, and it will arrive in the facility on 2/2/22 at 11:00 AM. E13 revealed that the facility had a size 4DCFS (#5 cuffless) and that they planned to consult E21, the respiratory therapist (RT) upon her arrival to the facility to determine if that would be acceptable as a temporary emergency size one down back up [CONDITION(S)] for R6. 2/1/22 2:26 PM - During an interview with E21 (RT), E21 confirmed that the #6 (cuffed) [CONDITION(S)] observed in R6's room could be used in the event of dislodgement, but that it was the improper type of [CONDITION(S)] (cuffed). E21 stated this would be considered a safe practice if staff did not inflate the cuff when the [CONDITION(S)] was inserted into R6's [CONDITION(S)]. E21 also stated that in the event the cuff was inflated, it could cause damage to R6's airway over time. E21 confirmed that R6 did not have the next size down [CONDITION(S)] available at the bedside at the time of observation and the facility had ordered the correct back up [CONDITION(S)] (#6 non-cuffed), in addition to the next size down [CONDITION(S)]. 2/2/22 at approximately 11:40 AM - During an observation at the beside of R6, E10 (LPN) confirmed that the temporary back up smaller size [CONDITION(S)] set now at the bedside was a size 4DCFS (#5 cuffless), which was one size down for R6. 2/2/22 3:53 PM - During an interview with E13 (RN Supervisor), it was revealed that the correct replacement [CONDITION(S)] set the facility ordered for R6 and one size smaller just arrived at the facility. 2. COMPETENT TRAINED STAFF: The facility's policy, titled [CONDITION(S)] Care, revised August 2013, stated, General Guidelines .Aseptic technique must be used .during [CONDITION(S)] changes, either reusable or disposable .a replacement [CONDITION(S)] tube must be available at the bedside at all times .a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times . The facility's policy did not include steps to be taken during the event of a [CONDITION(S)] dislodgement. The facility's competencies, titled Competency Assessment [CONDITION(S)] Care, did not include steps to take during a [CONDITION(S)] dislodgement. 2/2/22 12:39 PM - During an interview with E8 (LPN), it was revealed that during the event of a dislodgement, a 14-16 (size) Foley catheter could be placed in the tracheotomy (hole the [CONDITION(S)] tube goes in) to keep it open . 2/2/22 12:58 - During an interview with E10 (LPN), it was revealed that in the event of a [CONDITION(S)] dislodgement E10 had No idea what to do, but would call the supervisor for help. 2/2/22 1:48 PM - During an interview, E4 (SE/ICP) confirmed that the facility had no evidence of [CONDITION(S)] emergency training or competencies for all current staff. 2/2/22 6:00 PM - During an interview with E1 (NHA), E2 (DON), E4 (RN Risk Manager) E6 (SD/IC), and E13 (RN Supervisor), the parties were advised that the lack of emergency equipment and lack of competent trained staff for dislodgement of a [CONDITION(S)] was an Immediate Jeopardy. Findings were confirmed with E1, E2, E4, E6, and E13. 2/2/22 9:52 PM - The facility had evidence of training for the three staff caring for residents with trachs initiated by E4 (SD/IC). 2/2/22 10:44 PM - A written plan to train the remaining nursing staff was received. 2/3/22 9:30 AM - Training for all but two licensed staff on the 2/2/22 7-3/3-11/11-7 shifts was received. 2/3/22 1:20 PM - Interviews were conducted with current nursing staff to determine they received training as outlined in the written plan. 2/3/22 3:45 PM - It was determined that the facility abated the IJ. 2/3/22 5:18 PM - During an interview with E1 (NHA), it was reported that the facility had trained 76% of full-time nurses and 53% of agency nurses were trained. 2/9/22 1:00 PM - Findings were reviewed at the exit conference with E1 (NHA), E2 (DON), E3 (Director of Clinical Services), E4 (Risk Manager) E6 (SD/IC), and E13 (RN Supervisor).

Based on interviews and reviews of clinical records, facility documentation, and hospital records, it was determined that for two (R1 and R4) out of three residents reviewed for accidents, the facility failed to ensure that the residents' environment remained free of accident hazards. For R1, the facility failed to ensure that bilateral body pillows were securely in place on the 11 PM to 7 AM shift on 1/13/22 when she had an unwitnessed fall out of bed and sustained a hematoma to her left forehead. R1 was picked up by two CNAs using their hands and placed back into bed. Over seven (7) hours later, R1 was transferred to the emergency room for evaluation and diagnosed with a new subluxation of C1, compression fracture of L4, right femur fracture, right hip fracture and severe osteopenia (weak bones). The facility failed to ensure that R1's bilateral body pillows were securely in place and failed to prevent two staff from lifting her off the floor, which resulted in harm for R1. For R4, the facility failed to ensure that R4 received adequate supervision with two staff assistance for bed mobility during toileting resulting in a hematoma and transfer to the hospital for evaluation. Findings include: 1. Cross refer to F580, F684, F697 Review of R1's clinical record revealed: 3/4/15 - R1 was admitted to the facility for long term care with diagnoses including, but not limited to, a stroke, dementia and aFib. 3/5/15 - R1 was care planned for falls with interventions that included, but not limited to, bed in the lowest position, bariatric low air loss mattress, bilateral body pillows and bilateral fall mats. In addition, R1 was care planned for transfers using a hoyer lift with the assistance of two staff. 10/26/21 - The quarterly MDS assessment documented R1's BIMS as zero (severe cognitive impairment), her vision was impaired, and R1 had no other falls since the prior assessment. 1/13/21 at 2 AM - According to the nurses note, R1 had an unwitnessed fall out of bed and was found moaning and face down on the fall mat. After an initial assessment was done by E15 (RN), R1 was placed back in bed. R1 was noted to have a bump on her left forehead. 1/13/22 at 3:40 AM - A fall note with the root cause analysis by E14 (LPN, 11 PM to 7 AM Supervisor) documented that all fall interventions per R1's care plan were in place at the time of her fall, including bedside body pillows, fall mats and the bed was in the lowest position. 1/13/22 at 9:08 AM - A nurses note documented that the Physician ordered R1 to be transferred to the ER at 8:55 AM. R1 was on anticoagulant medication, [MEDICATION(S)], that thins the blood. 1/13/22 - The hospital ER record documented that R1 was placed in a cervical collar and noted with bruising and swelling to the left forehead and left eye and exhibited pain by grimacing and withdrawing. The results from multiple diagnostic tests showed R1 with a new subluxation of C1, compression fracture of L4, right femur fracture, and right hip fracture. In addition, R1 was also diagnosed with severe osteopenia. 1/24/22 - E2's (DON) telephone interview with E17 (agency CNA) documented, .Me (E17) and (E16, CNA) put her back in the bed. I know she uses the hoyer lift, but she's so light we just picked her up . She (R1) even had her body pillows in place. Usually they put the pillows under her fitted sheet, but I put them under her transfer sheet . her body pillow was still halfway on the bed. 1/24/22 - E2's (DON) telephone interview with E14 (LPN, 11 PM to 7 AM Supervisor) documented, . I saw her (R1) body pillow that is on the side of her window was in place, but not the one on her other side was not . 2/8/22 at 9:13 AM - During an interview, E16 (CNA) stated that R1's body pillows were under the sheets and the pillow rolled with R1. 2/8/22 at 1:20 PM - During an interview, E13 (RN, 7 AM to 3 PM Supervisor) stated that the facility has oversized fitted sheets for the bariatric low air loss mattresses and the body pillows would be placed under the fitted sheets. The facility failed to ensure that R1's body pillows were securely in place and failed to prevent two staff from lifting her with their hands and placing her back in bed. 2/9/22 at 2:15 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E3 (Director of Clinical Services), E4 (RN Risk Manager) and E13 (RN Supervisor). Cross refer to F600 and F610 2. Review of R4's clinical records revealed the following: 8/22/18 - R4 was admitted to the facility with diagnoses including dementia with muscle weakness and unsteadiness on the feet. 8/23/18 (revised 12/22/21) - R4 was care planned for potential for falls related to poor safety awareness with interventions including bed in lowest position when care is not being provided (initiated 8/23/18) and two person staff assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) (initiated 9/17/18 and revised 4/27/20). 8/23/18 (revised 5/1/20) - R4 was care planned to require ADL assistance that included toilet use due to cognitive loss with interventions including two person staff assist for bed mobility (initiated 8/23/18). 7/13/20 - A Physical Therapy discharge summary revealed that R4's mobility with rolling from left and right required substantial or maximal staff assistance and dependent for toilet transfer. 12/3/21 - R4's quarterly MDS Assessment for ADL revealed that R4 needed extensive assistance requiring 2 person staff to provide weight bearing support for bed mobility and that R4 was always incontinent of bowel and bladder requiring extensive assistance of 2 staff person for toilet use. 2/1/22 at 10:00 AM - Review of E11's (RN) nurse progress note dated 12/22/21 at 9:10 PM revealed that while CNA (E12) was providing care, resident (R4) rolled out of bed onto the floor mat. R4 was noted with a hematoma to upper forehead and was sent to the ER for evaluation. 2/1/22 at 10:40 AM - During interview, E12 revealed that on 12/22/21 at 9:00 PM she entered R4's room to do a toileting activity or incontinence care. E12 stated that, Resident (R4) had a bowel movement and I was getting ready to clean him up as he was already lying on his left side - facing the door with the pillow on his back. He started moving so I moved him a little bit towards the center of the bed. I went to the other side of the bed to get some wipes but he started rolling off the bed and by the time I got to him he was already on the floor. E12 further stated that, They said in the POC (Point of Care documentation instruction) kiosk that he is always a 1 or 2 person assist for bed mobility depending on R4's tolerance because he does fight back and resists care while lying in bed. If I started moving him and he doesn't fight back, I will do the incontinence care and just change him in bed by myself. I don't have to call for other people to help me. When asked if R4's bed was in low position prior to the fall, E12 stated, No, I don't think so. I can not remember'. 2/1/22 at 11:30 AM - In an interview, E11 stated that on 12/22/21 at 9:10 PM, she responded to E12's report of resident (R4) falling onto the floor. E11 further stated that E12 needed 2 person staff assist with bed mobility including toileting activity or incontinence care being done in bed. E11 also added that E12 had a spot on education to ensure bed is kept in low position when direct care is not provided and to make sure all her supplies are set to avoid interruptions, leaving the resident unattended when providing toileting activity of a dependent resident in bed. 2/2/22 at 2:10 PM - A review of the facility's CNA/Nurse Fall Reporting Form revealed that prior to the fall, R4's bed was not in the low position. 2/1/22 at 3:30 PM - Findings were discussed with E2 (DON). The facility failed to ensure that R4 was free from accident hazards and that R4 received adequate supervision with a 2 person staff assist for bed mobility during a toileting activity. R4's bed was not in a low position prior to him rolling onto the floor on 12/22/21 causing a hematoma on his forehead that lead to his transfer to the ER for evaluation. Findings were reviwed with E1 (NHA) and E2 (DON) during the Exit Conference on 2/9/22 beginning at 1:51 PM.

Based on interviews and reviews of clinical records and facility documentation as indicated, it was determined that for one (R58) out of 5 hospitalization s reviewed, the facility failed to ensure that each resident received treatment and care that was in accordance with professional standards of practice and the plan of care. For R58, the facility failed to ensure that R58 was served a mechanically altered diet for lunch on Sunday, 8/18/19; and failed to follow the 8/2/19 physician's orders [REDACTED]. R58 choked on a mouthful of food, resulting in R58 becoming limp and unresponsive. R58 required life-saving efforts of the [MEDICATION NAME] Maneuver, back thrusts and finger sweeps to dislodge the food bolus. R58 was transferred to the hospital for evaluation and admitted . R58 developed aspiration pneumonitis and sustained harm from the 8/18/19 choking incident. Findings include: Cross refer to F610 The facility's policy and procedure entitled Assisting the Resident with Meals, last revised on 12/2013, stated, .Preparation . 1. Review the resident's care plan and provide for any special needs of the resident . 3. Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow . Review of R58's clinical record revealed: 1/24/14 - R58 was readmitted to the facility and had [DIAGNOSES REDACTED]. 4/16/18 - R58 was care planned for unable to do own ADL's without assistance secondary to cognitive loss with interventions that included, but were not limited to: - assist with meal tray, opening items and set-up as needed; and - supervision assist with feeding. 6/14/19 - A quarterly MDS assessment stated that R58 was severely cognitively impaired for daily decision making; had disorganized thinking where the behavior comes and goes and changes in severity; required eating setup help only by one staff person and supervision (oversight and cueing); required a mechanically altered diet (change in texture of food or liquids); R58 was 5 feet tall and weighed 197 pounds; and had no swallowing disorders or dental issues noted. R58 resided in a locked dementia unit. 8/2/19 - A Speech Therapy evaluation stated, .referred for coughing occasionally during meals . reportedly has rapid rate of presentation . has had acute presentation of tremors in her jaw and arms, predominantly in right arm and this has overall impacted her ADL task of eating/drinking . 8/2/19 at 11:07 AM - A Speech Therapy Progress Note stated, .Patient now on caseload after referral for coughing noted on (sic) meals. The following is recommended: 1) Community dining/supervision during meals. 2) Upright out of bed for all meals. 3) She warrants verbal/tactile assistance during meal intake where staff can help her modify her rate of presentation so she does not stuff her mouth. 4) SLP (Speech Language Pathologist) recommends external environmental modifications of community dining staff to administer verbal cueing or tactile cueing to finish what is in her mouth before adding more food. 5) SLP recommends help patient control her amounts of food or liquid through pinching the straw during drinking on occasion to help ration off the liquid or help her with her cup sips by helping her hand bring it to her mouth if she has difficulty to minimize labial spillage. 6) SLP also recommends pharmaceutical review/MD review for potential adjustments as needed because tremors in the arm can also contribute to tremors in swallow muscles which can impact patient airway safety during ADL task of eating. 8/2/19 at 6:41 PM (last revised) - An electronic physician's orders [REDACTED]. Provide verbal/tactile cues as needed. Offer finger foods when available (e.g. sandwiches no crust, potato wedges, etc.). 8/7/19 at 3:34 PM - An Occupational Therapy note stated, . Pt (patient) seen during breakfast meal requiring SUP (supervision) and verbal and tactile cues for pacing, HOH (hand over hand) to stabilize sippy cup for intake of beverages. COTA discussed recommendations with nursing staff. 8/16/19 (last revision) - R58's care plan stated, . potential for altered nutrition r/t (related to) need for Therapeutic diet, due to DM, obesity. Mech altered diet due to hx (history) coughing with meals/dysphagia .Interventions: . - Resident requires supervision and 1:1 as needed . - Serve diet as ordered: CCD, mechanical soft with thin liquids. Offer finger foods when available (e.g. sandwiches no crust, potato wedges, etc.). Continue all other therapeutic dietary restrictions. Special Instruction: No crust on sandwiches. Moisten food items, emphasis on meats, with extra sauce/gravy (last revised on 8/2/19) . R58's care plan was not updated with the Speech Therapy recommendations of 8/2/19. 8/16/19 - A Speech Therapy treatment note stated, .Precautions: tremors (acute) . trained patient in rate of presentation through verbal cues and tactile redirection. patient insisted on attempting to stuff mouth. (R58) benefited from tactile cues and verbal cues . to swallow 'slowly' . and take small bites . to maximize patient safety during ADL task of eating . 8/18/19 at 1:47 PM - The EMS Prehospital Care Report stated the following: - Facility staff reported R58 was eating lunch which included spaghetti and ground up meatballs when R58 started choking; - Facility staff reported that they performed numerous abdominal thrusts and 'deep' finger sweeps in the pt's (patient's) mouth to remove the lodged food; - Observed red substance that appeared to be blood around R58's mouth; and - Facility staff confirmed it is blood noting they 'had to go down in there pretty far' (while performing the finger sweeps) to get the food out of the pt's (patient's) airway. 8/18/19 at 1:55 PM - The facility's incident report stated, . Nursing responded to an overhead emergency page to go to Eastburn wing as there was a resident is (sic) distress. Upon arrival to the unit, nursing staff was performing the [MEDICATION NAME] maneuver to resident as the resident was observed unable to clear her airway. Resident was unable to speak or respond when asked if she was choking. Cyanosis noted to resident's lips. Per verbal report, resident began choking on food during lunch meal service on the unit dining room under staff supervision. Her current diet confirmed as CCD/Mechanical Soft/Thin Liquids. Finger sweeps of airway, [MEDICATION NAME] maneuver, and back thrusts in progress when supervisor arrived. 911 was activated by nursing staff. [MEDICATION NAME] maneuver and back thrusts continued until resident airway cleared and resident was able to breathe on her own. Resident was able to expel food bolus as a result of the interventions implemented by staff. Oxygen applied via mask and oxygen saturation noted at 90% and increased to 92% when rescue (EMS) arrived to the facility. HR, pulse, oxygen saturation and respiratory status monitored closely throughout the incident. Circulation, skin color and resident's baseline cognition returned to normal and the resident was transferred (sic) the emergency room for further evaluation. MD and RP notified of resident's transfer . Resident's normal baseline is AAO to self only . At time of choking episode, patient was limp and not responsive. 8/18/19 at 2:38 PM - The hospital record stated, . Patient is reported to have been eating spaghetti and meatballs when she began choking. Staff at her facility vigorously attempted to finger sweep the obstruction . Patient is considered to be high risk for development of aspiration pneumonia . Patient did have mild bleeding from pharynx after this event which is currently resolved . Plan to admit . monitoring for development of pneumonitis . 8/19/19 - The OT Discharge Summary for R58's dates of service from 7/31/19 to 8/16/19 stated, .Pt progressed in decreased spillage during self-feeding tasks and requires SUP (supervision) during self-feeding tasks in the form of verbal cues for pacing and occasional proximal support to right elbow for distal stability during hand to mouth movements secondary to tremors . Caregivers educated on proper verbal and tactile cues to . monitor pacing, and provide RUE (right upper extremity) support during self-feeding tasks . 8/21/19 - A Speech Therapy Discharge Summary for services provided from 8/1/19 through 8/16/19 stated, . Prior to patient discharge to hospital, patient was making gains in her tremors after medicine was adjusted by MD and returned to being able to self-present food items. She warrants environmental cueing for slow rate of presentation, to finish what is in her mouth before adding more. She was orally manipulating soft solids and thin liquids with external cueing and modification of rate of presentation. Then patient got discharged to hospital. 8/25/19 - R58 was discharged from the hospital with a [DIAGNOSES REDACTED]. 8/26/19 - A Speech Therapy evaluation stated, . readmitted from the hospital with a [DIAGNOSES REDACTED]. It should be noted that a chest x-ray was administered and it showed NO acute process. Patient did have mild bleeding from pharynx after episode per evaluation in the hospital .Prior Level of Function: Intake/Diet Level=thin liquids ., soft and bite sized . (Mechanical Soft/Chopped); swallowing abilities=distant supervision; .Assessment: clinical impressions: patient at a level 4 - pureed solids. her prior level of function was level 5. Patient has improving tremors that were a side effect of her [MEDICATION NAME]. Patient mild dysphagia was exacerbated following a x1 choking incident on 'spaghetti and meatballs' and became acutely hypoxic. Her chest x-ray did not show any acute process forming but from the choke incident itself, she had a mild bleeding from pharynx after the episode. Patient had some increased acute chronic mouth stuffing more recently that increased her choking hazard risk. She is currently on pureed solids and warrants retraining for rate of presentation . Recommendations: thin liquids, pureed .supervision yes (verbal cues for patient to finish what is in her mouth before adding more). 11/6/19 at 8:28 AM - During an interview, E3 (Dietician) stated that she has seen R58 eat very quickly. When asked to describe a mechanical soft diet, E3 stated meats chopped up with sauce or gravy on it to make it moist, buttered noodles that break apart easily, not like regular pasta like spaghetti, and mashed potatoes. E3 stated that a machine in the kitchen was used to chop food items for residents on a mechanical soft diet. When asked if spaghetti and meatballs are served on a mechanical soft diet, E3 stated yes, as long as they are cut up separately in the kitchen and then put back together on the plate. 11/6/19 at 9:10 AM - During an interview, E27 (Speech Therapist) stated that R58 can handle meals and liquids in small amounts with supervision, which means community dining, not direct supervision. E27 stated that R58 needs verbal cueing by staff for rapid eating. E27 stated that R58 was placed on a pureed diet because the resident shovels food in her mouth. 11/6/19 at 9:48 AM - During an interview, E7 (CNA) stated that she recalled the incident and the residents were served spaghetti and meatballs for lunch. E7 stated that she and the other CNA (E8) were in the Eastburn dining room and they were supervising and assisting the residents. E7 stated that R58 was seated apart from the other residents because R58 will grab food from other residents trays and other items. E7 stated that R58's meatball was ground, however, the spaghetti served was not cut up. E7 stated that the spaghetti was like how we eat it, long noodles. When asked if R58 was served a roll or garlic bread, E7 stated she could not recall and stated that R58 could not have them because she couldn't chew them. E7 stated another resident (R98) needed attention with something and when we looked at R58, she was turning blue. E7 stated that E8 (CNA) immediately responded and performed the [MEDICATION NAME] Maneuver and couldn't dislodge, performed back blows and a finger sweep. E7 stated it was when E8 (CNA) did the finger sweep that dislodged the obstruction. E7 stated that nursing responded with the crash cart. E7 stated that once the obstruction was dislodged, R58 was alert and smiled and lowered to the floor. E7 stated that EMS personnel responded and R58 was taken to the hospital. E7 stated that she was assisting the other residents as they were present in the dining room when this was occurring. 11/6/19 at 11:11 AM - During an interview, E28 (Nurse) stated that she observed R58 sitting in a chair in the dining room slumped over with E8 (CNA) performing the [MEDICATION NAME] Maneuver and reaching into R58's mouth and pulling out spaghetti noodles. E28 stated that the spaghetti noodles were not cut up. 11/6/19 at 12:41 PM - During an interview, E29 (Nurse) stated that she observed R58 choking and E8 (CNA) performing the [MEDICATION NAME] Maneuver with a nurse next to the CN[NAME] E29 stated that R58 had a habit of stuffing food in her mouth. E29 stated at first that she didn't remember specifically what food was involved. When asked what did the food look like coming out of R58's mouth, E29 stated ground meat and spaghetti (some was chopped in smaller pieces and some in longer pieces). 11/6/19 at 1:16 PM - During an interview, E30 (Nurse) stated that she was told during nursing shift report that the CNAs had been cutting R58's food. E30 stated that she walked to the nurse's station in the Eastburn unit to put something in the refrigerator for a resident when she heard yelling and her name being called. E30 stated that she went back to the dining room and saw that R58's color was navy blue and E8 (CNA) was performing the [MEDICATION NAME] Maneuver. E30 stated that she said to E8 (CNA) to let me take over, but E8 (CNA) would not let me. E30 stated that R58 was hard to perform the [MEDICATION NAME] Maneuver due to her size and stature. E30 stated that E8 (CNA) had her hand down R58's throat and pulled out a roll and spaghetti. After R58 started breathing again, E8 stated that she did a sweep of R58's mouth and got a hand full of blood. When asked about what came out of R58's mouth again, E30 stated that a big piece of a soft roll and a bunch of long spaghetti came out of R58's mouth. E30 stated that R58 doesn't chew her food and grabs food off of other residents plates. E30 stated that R58 was the last person to get her tray. E30 stated that she was told in nursing shift report that staff had been feeding R58. E30 stated that R58 can eat very quickly. 11/6/19 at 2 PM - During a combined interview with E31 (FSD #1) and E9 (FSD #2), E9 stated that mechanical soft diets are prepared in a [NAME]ot Coupe machine in the kitchen. E9 (FSD #2) stated that food items are done individually in batches in the [NAME]ot Coupe machine. E9 confirmed that the [NAME]ot Coupe was used for chopping pasta. E9 stated that the [NAME]ot Coupe machine operated with only 2 speeds: the high speed prepared pureed food and the low speed prepared ground food in one size only. When asked if E31 (FSD #1) was aware of a choking incident on 8/18/19, he stated No and stated that No one talked to me about it. E31 stated that he participated in morning meetings with facility staff around the time of the incident. 11/6/19 at 2:17 PM - During an interview, E32 (Cook, Supervisor) stated she was in charge on Sunday, 8/18/19. E32 stated that no one spoke to her about the choking incident. When asked if there were any problems identified with the [NAME]ot Coupe machine during the month of (MONTH) 2019, E32 stated, No. E32 stated that a dinner roll was part of the mechanical soft diet. 11/6/19 at 2:28 PM - During an interview, E8 (CNA) stated that all residents were sitting down for lunch. E8 stated that E7 (CNA) went over to another resident (R98) to check on the resident as she was coughing. E8 stated she was sitting next to another (unidentified) resident and looked over at R58. E8 stated she saw that R58's face was red; R58 was sitting with her hands laying on the table; and R58 was shaking, like a [MEDICAL CONDITION]. E8 stated that R58 eats very fast. E8 stated that she took her finger to clear R58's mouth and R58's top denture came out with spaghetti. E8 stated that she got around her to do the [MEDICATION NAME] Maneuver trying to clear her airway. E8 stated that R58 had a lot of food in her mouth. E8 stated that she opened R58's mouth and pulled out spaghetti. When asked if any nurses offered to help, E8 stated, Nope. E8 stated that she did hear nurses responding. E8 stated she was focused on R58. E8 stated that they did not have to feed R58. E8 stated that she thought E7 (CNA) cut R58's food. 11/6/19 at 2:58 PM - During a follow-up interview with E7 (CNA), when asked if she cut up R58's food on the day of the choking incident, E7 stated, No, I did not give (R58) her meal tray. 11/7/19 - Review of the CNAs' Tasks (both current and resolved) for R58 revealed a lack of evidence of Speech Therapy's 8/2/19 recommendations for verbal and tactile cueing R58 during meal intake so staff can monitor and help pace so R58 does not stuff her mouth. The CNA tasks listed at the time of the incident on 8/18/19 were: CCD mechanical soft diet with thin liquids. (MONTH) have pleasure smooth mechanical soft snacks (e.g. bananas, etc.) as tolerated with distant supervision/community dining for enhanced quality of life; Eating: Feeds self after set up with sippy cup with lid and handles. 11/7/19 at 11 AM - During a follow-up interview with E8 (CNA), this surveyor showed E8 her typed statement that was just handed to the surveyor. E8 stated, Yes that is what I told E2 (DON) and she wrote it. E8 was asked when she signed this statement as it was not dated, E8 stated, I signed it today (11/7/19). 11/7/19 at 12:18 PM - During a follow-up interview with E8 (CNA), the surveyor asked if she was aware about using verbal and tactile cueing when R58 was eating. E8 stated, Yes, I was aware. I have been working with the resident for a long time. I know that the resident shovels food in her mouth. 11/7/19 at 2:07 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E33 (Corp. Nurse). R58 sustained harm from the 8/18/19 choking incident when the facility failed to do the following: - failed to ensure that R58 was served a mechanically altered diet for lunch on Sunday, 8/18/19; - failed to ensure that Speech Therapy recommendations from 8/2/19 were communicated in the CNA Tasks screen and in R58's plan of care; and - failed to follow the 8/2/19 physician's orders [REDACTED]. R58 choked on a mouthful of food, resulting in R58 becoming limp and unresponsive.

Cross Refer to F726 and F919 Based on observation, staff and resident interviews, review of residents' clinical records, facility policy and procedures, hospital records, facility documentation and the facility's Trilogy 100 Clinical Manual for AVAPS (Average Volume Assured Pressure Support), as indicated, it was determined that a resident who needs respiratory care failed to be provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (R3) out of 3 sampled residents. For R3, who needed respiratory care with a Trilogy 100 AVAPS (non-invasive ventilator/life saving respiratory device), with a built in alarm system, failed to be provided such care. The facility failed to have a system in place for continuous monitoring of R3 and the ventilator for signs of respiratory compromise in order to ensure R3's safety. On 5/31/19 at 10:45 PM, after E3 (3-11 shift LPN) had R3's mask adjusted and both (oxygen) tubings were secured tightly E3 left the room. The facility failed to ensure that R3 was continuously monitored while the incoming 11-7 AM staff were receiving reports during the change of shift and while the outgoing 3-11 PM nursing staff were still on the unit. During that period of time, R3's ventilator tubing became disconnected from the mask on the Trilogy 100 AVAPS ventilator, designed to move breathable air into and out of R3's lungs. R3 became severely hypoxic at a level of 50% oxygen saturation (normal range 92-100%) and experienced a respiratory arrest (stopped breathing). Upon being found by facility staff, rescue breathing was initiated with a BVM. R3 was then transferred to the hospital ER per physician's orders [REDACTED]. The facility's lack of a system for continuous monitoring resulted in harm to R3 and the facility's lack of intervention presented the continued likelihood of repeated harm. An immediate jeopardy was identified on 8/8/19 at 3:20 PM and was abated on 8/8/19 at 7:30 PM. Findings include: Review of R3's clinical records, facility policy and procedures, hospital records, facility documentation and the facility's Trilogy 100 AVAPS Clinical Manual revealed the following: The facility's policy and procedures entitled [MEDICAL CONDITION]/[MEDICAL CONDITION]/AVAPS updated 7/18 stated, PURPOSE: To provide non invasive support for patients who are diagnosed with [REDACTED].Manufacturer's recommendations should be followed. The facility's Trilogy 100 Clinical Manual (for AVAPS), dated 6/15/17, stated under Warning and Caution to follow manufacturer's recommendations: .Ventilator dependent patients should be continuously monitored by qualified personnel .For ventilator dependent patients, do not rely on any single alarm to detect a circuit disconnect condition .Trilogy 100 is a restricted medical device designed for use by Respiratory Therapists or other trained and qualified caregivers under the supervision of a physician .Respond immediately to any alarm. It may indicate a potentially life-threatening condition .Visually monitor the patient and ventilator at all times during an Alarm Silence Period (such as during meals, personal care and maintenance of the ventilator). Allowing alarms to continue without intervention may result in harm to the patient .Make sure the alarm volume is set loud enough to be heard by the care giver. Consider the use of a remote alarm . R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3 required use of a life saving respiratory device/ventilator the Trilogy 100 AVAPS with humidifier and connecting alarm system device to detect a circuit disconnect condition. R3's treatment orders included the following: 2/7/17 - AVAPS Use Nasal Pillows during the day - No O2 (oxygen), no humidifier. Switch to AVAPS face mask at HS and turn humidifier on. Do not undo side straps. You may tighten and loosen by using forehead knob for comfort .Check placement of tap call pad (tap-to-click function allows you to tap your touchpad as a click, instead of pressing the button). Resident prefers pad to be clipped to the pillow by his feet. 2/8/17 - AVAPS on at all times .May remove for eating. Nasal pillows During Day without Humidity and Mask at night with Humidity - Remember to turn on Humidifier Machine. 2/9/17 - Please ensure HOB less than 45 degrees when care not being provided (safety precautions) . 2/14/17 -A Care plan entitled, The resident has altered respiratory status/Difficulty Breathing related to ALS, Utilizes AVAPS 23 hours/day was initiated. Interventions included: Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger; Monitor/document/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. 5/7/19 - The quarterly MDS assessment revealed that R3 had a BIMS ((Brief interview for Mental Status) score of 15 (cognition, mental status was intact). R3 was totally dependent and required the total assistance of 2 person/staff for all of his/her activities of daily living, such as bed mobility, transfers from one surface to another, hygiene/bathing, toileting, and others. 5/26/17 - A care plan entitled, Impaired verbal communication related to [MEDICAL CONDITION] secondary to ALS. He/she can mouth word was revised. The care plan included the intervention, Eyegaze technology via resident's laptop for communication (must be out of bed to recliner to utilize laptop); 8/10/17 an additional intervention was added to the care plan that stated, Unable to response (sic) to knock on the door, continue to knock first then enter room. An undated written statement by E3 (LPN) stated, On 5/31/19, I was the nurse on the 3-11 shift .R3 went to bed at around 10:15 pm. I was called to his/her room to put in (sic) Mask on (sic) at around 10:30 (PM). I put his/her mask on adjusted it as he/she instructed me to .I pushed on both tubings (ends connected to the ventilator and to the mask) to make sure they were secured tightly. I left R3's room at around 10:45 pm. After 10:45, I was still on the unit. I did not see or hear R3's light. 5/31/19 11:15 PM - A Nursing Progress Note stated, nurse (E4, LPN) entered room at 23:15 (11:15 PM) to answer call light and found resident not breathing. Supervisors were notified and immediately initiated rescue breathing. 5/31/19-11:17 PM - A Nursing Progress note stated, This writer was alerted to come to R3's room immediately .Resident's color is pale. Resident has a pulse but no measurable respirations. Rescue breathing initiated with BVM. Pulse Ox went from 50% - 97 % . Per a doctor's order and the POA's permission, R3 was transferred to the hospital ER for evaluation and treatment. 6/1/19 - The hospital ER physician's record stated, Respiratory arrest stabilized enroute with bag valve mask. [MEDICAL CONDITION] initiation on arrival for comfort only .Resident's VBG/Venous Blood Gas laboratory report was consistent with respiratory acidosis and lactic acidosis, unclear if due to [MEDICAL CONDITION] or underlying infection .improvement in mental status with [MEDICAL CONDITION], patient opening eyes . 6/4/19 - A written statement by E4 (LPN) revealed, On 5/31/19, I was the nurse on (Name of unit) for 11-7 shift. I entered the building at 2300 (11:00 pm). I received report and counted narcs (narcotic drugs) with two nurses. After receiving report, I sat down at the nurses station. I seen (sic) the call bell for (R3's room number) ringing at the nurses station, answered the bell and found resident not responding. Prior to report, I did not see the resident's call bell ringing. Upon discovering resident had no respirations, supervisors were alerted, rescue breathing initiated and 911 activated. 7/9/19 at approximately 3:30 PM - Interview with R3 revealed the following sequence of events: R3 stated that approximately after 10:30 PM that night and I believed before 11:00 PM, the end of the hose (tube) fell off from the mask and fell against the blanket. As soon as the hose slipped off, I kicked the call button, (tapped with foot) and turned the call light on before the alarm sounded. Alarm went off 2 times and stopped. My last memory was trying to kick the blanket off to cause the hose to fall on the floor. I hoped that would get the alarm going. It took forever service (sic) to respond. I passed out before they (staff) came. According to R3, the pressure of air on the tube against the blanket is similar to breathing and caused the alarm to stop. 7/15/19 at approximately 1:00 PM, Surveyor 1 and E11 (RRT) tested the alarm system of the Trilogy 100 AVAPS ventilator, for volume sounds at it's highest setting with R3's door closed. It was determined that the ventilator alarm sound could be heard when standing near R3's entry door. The ventilator alarm could not be heard at all when standing in the hallway further away from the resident's door. The facility failed to ensure that R3's Trilogy 100 AVAPS ventilator alarm was able to be heard by staff members up and down the unit's hallway. Additionally, R3 stated to the surveyor and E11, that he/she wanted the door closed at all times for 2 reasons: to confine the humidifier mist to the room, and to prevent wandering residents from entering his/her room. 7/16/19 to 7/17/19 - Four (4) CNAs (E5, E6, E7, E8) and 3 LPNs (E4, E9, E10) who worked in the unit where R3 resides were interviewed. It was revealed that the Trilogy 100 AVAPS alarm could be heard when standing next to R3's door, but it was not loud enough to be heard when further away from the door or down the hallway. In addition, the call light above R3's door could not be seen from the other areas of the unit or from the nursing station. The call light sounds could be heard from the nursing station via a call light panel that identified the room number where the call was coming from. However, the staff had to be inside the nursing station to see it. 7/17/19 at approximately 11:30 AM - Surveyor 1 (RN) and Surveyor 2 (EHS) observed the call light on R3's room. The call light above R3's door was not visible on the other areas of the unit. The door frame above the door leading to the hallway blocked R3's call bell overhead light from being seen from the nurse's station. The call light sounds could be heard from the nursing station via a call light panel that showed the room number where the call was coming from. However, the light above R3's room could not be seen outside of the nursing station and from other areas of the unit. Review of facility provided training sign in sheets for licensed nursing staff revealed that there was no training completed for use of the Trilogy 100 AVAPS, nor any competencies completed in (YEAR) or (YEAR). In 2019, training records revealed that a total of seven (7) nurses received training on the Trilogy 100 AVAPS, however, there had not been any competencies completed. The facility failed to ensure for R3, who required the non-invasive Trilogy 100 AVAPS, as a life saving respiratory device, that care was provided consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. The facility failed to ensure a system of continuous monitoring was in place for R3 and the Trilogy 100 AVAPS ventilator for signs of respiratory compromise to ensure R3's safety. 8/8/19 3:20 PM - A meeting was held with E1 (NHA) and E2 (DON) and the survey team. The survey team informed the facility that an Immediate Jeopardy was identified involving R3 and the facility's failure to ensure continuous monitoring of R3 and the Trilogy 100 AVAPS ventilator. 8/8/19 6:00 PM - The facility submitted an abatement plan to the survey team. A remote alarm was installed at the nurse's station on R3's unit. The remote alarm was connected to the Trilogy 100 AVAPS ventilator and when triggered could be heard throughout the unit. Additionally, the remote alarm flashed with a red light at the nurse's station. The facility also inserviced nursing staff and other auxiliary staff on the remote alarm from the 7-3 PM and 3-11 PM shift from that day. The evening supervisor was to train the night supervisor and then both would train the night shift staff. Training would be ongoing until 100% was achieved. The Immediate Jeopardy was abated on 8/8/19 at 7:30 PM. 8/13/19 3:30 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

Based on observations, clinical record review, interviews, review of facility's policy and procedures and review of other facility documentation as indicated, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases and infections, for one (R72) out of 42 residents on the Hammond unit. The facility failed to implement their infection prevention and control program by failing to initiate Contact Isolation Precautions when R72 was experiencing loose stools with a positive stool culture for [DIAGNOSES REDACTED]. The lack of Contact Isolation Precautions posed an immediate jeopardy (IJ) situation to residents located on the Hammond unit and potentially all residents in the facility. The IJ was identified on 8/8/18 at 12:30 PM and abated on 8/8/18 at 6:25 PM. Findings include: The facility's [MEDICAL CONDITION] (C. Diff) Guidelines, undated, stated, [DIAGNOSES REDACTED] is usually spread by hands or inanimate objects that have been in contact with someone or something contaminated with the organism. This can be bed linens, bed rails, bathroom fixtures, door knobs and medical equipment .Prevention of Transmission: Nursing will initiate Contact Precautions. Strict hand washing with soap and water. Do not use alcohol rubs. The gel will not remove the spores. Ensure PPE (gloves, gowns, red bags) are available. Designate B/P cuff, stethoscope and bathroom for resident. Wipe frequently touched surfaces with Bleach Sani-wipes (Contact Time 3 minutes). Instruct resident to use designated bathroom. Provide notice to other departments per policy. Review of R72's clinical record revealed: 7/31/18 - A physician's progress note by E23 (NP) stated that R72 was seen per nursing request for loose gelatinous stools with foul odor. The resident stated the stool looked like jelly. R72 was recently on an antibiotic. The plan was to order a stool culture for [DIAGNOSES REDACTED]. 7/31/18 - A physician's orders [REDACTED]. diff toxins. 8/2/18-8/4/18- Review of the laboratory results for R72's stool test revealed that R72's stool specimen was collected by the facility on 8/2/18 at 9:30 AM, and was received by the laboratory on 8/3/18 at 1:40 PM. R72's stool specimen was confirmed to be positive for [DIAGNOSES REDACTED] toxins on 8/4/18 at 3:06 PM. 8/4/18 at 7:54 PM - A progress note stated that R72's lab results were in and were positive for [DIAGNOSES REDACTED]. The results were called to the physician, and a new order for [MEDICATION NAME] (antibiotic) 500 mg 3 times a day for 10 days was ordered. 8/4/18 at 9:00 PM - Review of R72's eMAR revealed R72 received the first dose of [MEDICATION NAME]. 8/5/18 at 5:56 AM - A progress note stated that, R72 continued on [MEDICATION NAME] for [DIAGNOSES REDACTED] in the stool and that all precautions were maintained. However, it was unclear how precautions were maintained when equipment was not found to be in place during observations on 8/8/18. 8/6/18 - A care plan was initiated for R72's [DIAGNOSES REDACTED] infection. Interventions included to wear gowns and masks when changing contaminated linens; place soiled linens in bags marked biohazard and close the bag tightly before taking it to laundry; disinfect all equipment used before it leaves the room; and, educate the resident/family/staff regarding preventive measures to contain the infection. 8/6/18 at 4:54 AM - A progress note stated that R72 continued on [MEDICATION NAME] for [DIAGNOSES REDACTED] and safety precautions were maintained. However, it was unclear how precautions were maintained when equipment was not found to be in place during observations on 8/8/18. 8/8/18 at 10:49 AM - A progress note stated that R72 continued on [MEDICATION NAME]. There was no documentation of precautions being in place. 8/8/18 at 12:30 PM - An observation of R72's room revealed there was no signage outside of the room to signify any precautions. In addition, there was no isolation cart with PPE located by R72's room. 8/8/18 at 12:38 PM - E37 (CNA) was observed going in to R72's room without any PPE and delivering her lunch tray. E37 set up R72's food on her tray table and helped R72 get positioned to eat. E37 left R72's room and never washed her hands or used hand sanitizer before going into other residents rooms on the Hammond Unit to pass out lunch trays. 8/8/18 at 1:05 PM - An observation was made of a visitor going into R72's room looking for her roommate. The visitor did not wash his hands and when he left the room he then proceeded to go to the Hammond lounge and sat down on the couch. 8/8/18 at 1:06 PM - During an interview with E36 (CNA) it was observed that there was a cart located down the opposite end of the hall from R72's room. The surveyor asked about the cart and E36 stated it was an isolation cart, but that was just where the cart was kept. E36 stated that she was not aware of any residents on the Hammond unit that were on isolation. 8/8/18 at 3:15 PM - During an interview with E38 (Housekeeping), the surveyor asked E38 about the process for cleaning resident rooms that are on isolation. E38 stated if a resident was on isolation there would be a sign on the resident's door stating to see the nurse and that meant the resident was on precautions and the room would be cleaned differently and with the required PPE. E38 was unaware that R72 was on isolation due to the lack of signage outside of her room. 8/8/18 at 3:40 PM - During an interview with R72, she stated that she had not observed staff ever wearing gowns in her room when providing care or changing her linens. R72 stated that staff only helped her wash her hands when she requested assistance. R72 also stated that on 8/6/18 she attended bingo and a music activity, and after she went to visit other residents in their rooms. R72 was not aware that she was on any kind of isolation precautions. 8/8/18 at 3:45 PM - E39 (CNA) was observed answering R72's call bell. E39 went into R72's room without any PPE and turned off her call bell. R72 asked E39 for a new drink. E39 picked up R72's old cup then walked out of the room with the cup and refilled R72's drink at the hydration area and brought the drink into her room. While in R72's room, E39 fixed her pillows and blankets. E39 left R72's room and never washed his hands or used hand sanitizer before pushing another resident in their wheelchair back to their room. 8/8/18 at 5:15 PM - Interview with E1 (NHA) and E2 (DON) was conducted and they were advised that the lack of [DIAGNOSES REDACTED] Contact Isolation Precautions for R72 was an immediate jeopardy (IJ) citation. 8/8/18 at 6:25 PM - Interview with E2 was conducted and she confirmed that R72's room now had signage for isolation precautions and the isolation cart with PPE was in place. All staff that were currently in the building were re-educated on [DIAGNOSES REDACTED] precautions. After this confirmation the IJ was abated. 8/9/18 at approximately 12:00 PM - A copy of the facility's written statement was provided to the survey team. This documentation indicated R72's room had been cleaned with the appropriate sporicidal agent. The Hammond unit, the nursing station, the dining room, and the common areas were being cleaned with sporicidal agent by 8/10/18. Staff in all departments would be re-educated on [DIAGNOSES REDACTED] isolation precautions and infection control, including handwashing, on 8/9/18. All residents identified with active infections or significant organisms were reviewed to ensure precautions were in place. An audit was completed from the period of 7/1/18 to present, and would now be ongoing to ensure compliance. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 8/20/18 at 7 PM. The facility failed to implement their infection prevention and control program by failing to initiate Contact Isolation Precautions when R72 was experiencing loose stools with a positive stool culture for [DIAGNOSES REDACTED]. This lack of [DIAGNOSES REDACTED] Contact Isolation Precautions posed an immediate jeopardy (IJ) situation to residents located on the Hammond unit and potentially all residents in the facility.

Based on clinical record reviews, interviews and review of other documentation, it was determined for 2 (R64 and R144) out of 52 sampled residents, the facility failed to ensure that the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and residents' choices. R64's right femur surgical wound was healed as of 4/5/18. On 5/9/18, R64's surgical wound dehisced. R64 suffered harm when the facility failed to do the following after the surgical wound dehisced: perform ongoing monitoring of the dehisced area, obtain and initiate a treatment order for the dehisced area, and notify the Orthopedic Surgeon (OS) of R64's surgical wound acute change in status on 5/9/18. The dehisced area of R64's surgical wound worsened where the wound bed was covered with slough and had odor. R64 was sent directly to the ER for admission from her scheduled appointment at the Orthopedic Surgeon's office on 5/16/18. The following day, R64 underwent a debridement of the surgical wound, wound vac was placed and IV antibiotics were ordered for 4 to 6 weeks for the wound infection. For R144, the facility failed to provide timely treatment and care following a 4/10/18 incident, resulting in R144 waiting 13 hours to be transferred to and evaluated in the ER and diagnosed with [REDACTED]. 1. Review of R64's clinical record revealed: 3/9/18 - R64 was admitted to the facility for short term rehabilitation status [REDACTED]. 3/9/18 at 9:25 PM - A nurse's note stated that R64's surgical incision had 52 staples. 3/14/18 at 4:26 PM - A nurse's note stated a new order received from C1 (OS) to remove R64's staples tomorrow and the facility's wound nurse was notified. 3/15/18 - The admission MDS assessment revealed that R64 was cognitively impaired, did not reject care, had active [DIAGNOSES REDACTED]. 3/15/18 at 3:30 PM - The wound nurse's note stated that R64's staples were removed without difficulty, the incision remained intact and no dehiscence was noted. 4/4/18 at 4:41 PM - A nurse's note stated that R64 returned from an appointment with C1 (OS). R64 was being seen for wound healing and [MEDICAL CONDITION]. C1 made the following recommendations: need more elevation to reduce swelling, continue non-weight bearing for 8 more days then progress to weight bearing as tolerated on 4/12/18 and follow-up appointment in 5 weeks. 4/5/18 at 12:17 PM - A wound nurse's note stated that R64's right thigh incision was resolved with no drainage or signs of any infection. 5/9/19 at 9:30 AM - A physician's orders [REDACTED]. [MEDICATION NAME] antibiotic twice a day for 10 days for right leg wound. 5/9/18 at 11:13 AM - A nurse's note stated that an area on the right leg was open and draining. E6 (Physician) was in to see R64 and ordered to culture the area. 5/9/18 at 4:59 PM - A nurse's note stated, CNA called nurse to rm (room) stating leg was draining. Upon exam of R (right) leg, noted incision line from hip to knee to be red, inflamed, more so at the top of the incision and at the base of the incision. 2/3 of the way down the incision line was an open area of 0.5 x 0.3 x .01 (sic) cm opening. Area is pink w/ (with) no slough noted. Upon palpation of distal end of opening, scant amt (amount) serous drainage noted. Upon palpation above the opening, sm (small) amt (amount) of purulent drainage. Resident c/o (complained of) mild discomfort at site, but no where else along incision line. Area was cleansed, dry dressing applied. E6 (Physician) was in and visualized incision. N/O (New order) for wound culture and to start [MEDICATION NAME]. (family member name) made aware. Following shift informed of order and requested to obtain culture prior to starting antibiotic. Will follow up w/ results and continue to monitor site. The facility failed to obtain a treatment order for the dehisced open area and failed to notify C1 (OS) of the acute change in the surgical wound. 5/9/18 at 11:13 PM - R64's eTAR revealed that the wound culture was obtained. 5/10/18 at 9 AM - R64 received the first dose of [MEDICATION NAME]. 5/10/18 at 10:28 AM - A wound nurse's note stated that E6 (Physician) saw R64's healed incision on right hip and noted slight dehiscence and redness present around incision. The note also stated that R64 was placed on antibiotic for skin infection. 5/10/18 at 2:26 PM - R64's wound culture sample was picked up by laboratory services. 5/11/18 at 2:46 PM - A wound nurse's note stated that E5 (UM) alerted this nurse regarding small open area at resident's lower incision on her right thigh. Assessed area and note small 0.3 cm open area that was dry and scabbed over with no redness noted. 5/11/18 at 9:04 PM - A nurse's note stated, .Currently pending a wound culture of slightly dehisced surgical wound . 5/11/18 at 11:37 PM - A nurse's note stated that R64 was on [MEDICATION NAME] for right leg wound infection. The facility failed to accurately document R64's correct antibiotic. 5/12/18 at 3:12 AM - A nurse's note stated that R64 was on [MEDICATION NAME] for right lateral leg infection. While R64 was currently receiving an antibiotic for a wound infection, the facility lacked evidence of ongoing monitoring of R64's infected surgical wound site. 5/12/18 at 12:11 PM - R64's wound culture results were received which revealed the organism was Staph Aureus. 5/12/18 at 5:44 PM - A nurse's note stated that E6 (Physician) ordered to stop [MEDICATION NAME] and to start [MEDICATION NAME] twice a day for 7 days. 5/13/18 - The facility lacked evidence of ongoing monitoring of R64's infected surgical wound site. 5/14/18 at 5:57 AM - A nurse's note stated that R64 was [MEDICATION NAME] a right lateral leg infection, the dressing was intact and the area slightly red. It was unclear as to what dressing was in place as R64's clinical record lacked evidence of a treatment order. Without a treatment order in place, it was unclear whether nursing staff were removing the dressing to monitor the infected surgical wound site. 5/14/18 at 2:54 PM - A nurse's note, written by E34 (LPN), stated that R64 continues on an antibiotic for [MEDICAL CONDITION] to the right foot. The antibiotic was changed [MEDICATION NAME]. The facility inaccurately documented the reason for R64's antibiotic and the location of the infected site. 5/14/18 at 3:52 PM - A nurse's note, written by E9 (LPN), stated that R64 was [MEDICATION NAME] infection to right lower leg; right lower extremity slightly red no drainage noted; no foul odor. The facility inaccurately documented the location of the infection and lacked evidence of ongoing monitoring of R64's infected surgical wound site. 5/15/18 at 12:44 PM - A nurse's note stated that R64's right leg was open with no drainage at this time. 5/15/18 at 2:10 PM - A nurse's note stated that R64 continued [MEDICATION NAME] the right lower extremity infection (RLE). There was no drainage, foul odor, redness and [MEDICAL CONDITION] to RLE. The facility inaccurately documented the reason for R64's antibiotic and the location of the infected site. 5/15/18 at 4:03 PM - A nurse's note, written by E5 (UM/RN), stated that an assessment of R64's wound to the right thigh incisional area measured 1 cm x 0.5 cm x 0.1 cm and the wound bed was covered with yellow slough. There was a small amount of serous drainage noted. Blanchable redness was noted around the incision. Redness along the remaining healed incision line decreased from 5/9/18. No odor or other signs or symptoms of infection were noted. The note also clarified [MEDICATION NAME] for the infection to this site from the drainage R64 had on 5/9/18. 5/15/18 at 9:21 PM - A nurse's note, written by E35 (LPN), stated that R64 continued [MEDICATION NAME] right thigh [MEDICAL CONDITION]. The note also stated that no drainage was noted, area was warm to touch and no odor was present. 5/16/18 at 5:57 AM - A nurse's note stated that R64 continued [MEDICATION NAME] right lateral leg infection. The area was red, warm to touch, dressing was intact and no drainage noted. It was unclear as to what dressing was in place as R64's clinical record lacked evidence of a treatment order for the infected surgical wound site. Without a treatment order in place, it was unclear whether nursing staff were removing the dressing to monitor the infected surgical wound site. 5/16/18 at 8:30 AM (Late Entry) - A wound nurse's note stated, This nurse alerted by E5 (UM/RN) of incision that had slight dehiscence at the base of the incision that was healed. Wound bed had thin slough present measuring 1 x 0.6 cm and no induration felt at site. Slight musty odor from wound, resident denied any pain with site Alerted UM of change, E6 (Physician) here to assess resident and alerted him to wound and also lower extremity and concern since this is a new change for leg. He informed this nurse that resident is [MEDICATION NAME] seeing ortho today, and ortho would address the incision . 5/16/18 at 1:14 PM - A nurse's note stated that R64's area to right leg was open with some drainage at this time. R64 went to Ortho appointment this shift and from there she was sent to the ER for evaluation of the right leg. 5/16/18 at 1:55 PM - A nurse's note stated that R64 continued [MEDICATION NAME] infection to RLE. The note also stated that treatment was in progress to R64's open area right thigh. The facility inaccurately documented the location of the infected surgical wound site that was being treated with an antibiotic. It was unclear as to what treatment was in progress as the facility lacked evidence of an ordered treatment for [REDACTED]. 5/16/18 - C1's (OS) Ortho Consultation paperwork stated that R64's family member reported a small opening was cultured 5 days ago and grew Staph. C1's office was not informed until 2 days ago (5/14/18). R64's wound with a small opening was likely a stitch abscess. There was surrounding [DIAGNOSES REDACTED] and pressure creates drainage. R64 was sent to the ER for admission and to the operating room. 5/16/18 at 5:26 PM - The hospital records stated that R64 complained of mild pain at right femur site. Upon admission, the right femur open wound exhibited white discharge with surrounding tenderness, [DIAGNOSES REDACTED] and warmth. R64's right lower extremity exhibited [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. R64 was scheduled for an incision and drainage of the open wound in the OR the following morning with C1 (OS). 5/17/18 - The hospital's Operative/Procedure Report written by C1 (OS) stated, Preoperative Diagnosis: [REDACTED].Operative Procedure: 1. Incision and drainage of right thigh abscess. 2. Placement of negative pressure wound therapy device Tissue was sent for culture .Indications for Procedure: The patient is a [AGE] year old .who suffered a rather severe femoral fracture and underwent a very large plating of a distal femoral shaft fracture .back in early March. The patient had been doing well until the nursing home called us and said that there was some drainage coming from a small spot on the wound. This started on Friday (5/11/18). They watched it over the weekend, called us 3 days after it started, she came to see us 2 days after that. She had a very obvious stitch abscess, which was draining purulent material. She was sent from my office to the emergency room for admission. Although C1 (OS) was told the wound started on Friday, 5/11/18, it was identified by the facility on 5/9/18. 5/19/17 at 7:57 AM - The hospital records stated that Infectious Disease physicians were consulted for management of the infected right hip wound. The wound culture results confirmed that the organism was MSSA. R64 was ordered IV antibiotics (Ancef) every 8 hours for approximately 4-6 weeks. 5/24/18 at 8:53 AM - A nurse's note stated that R64 returned to the facility status [REDACTED]. The wound measured 11 cm x 2 cm x 1.9 cm with 100% granular tissue present and no drainage noted. R64 had a physician's orders [REDACTED]. 8/20/18 at 4:04 PM - During an interview with the Wound Care Nurse, E4 (LPN) confirmed that wound treatment was not in place when the surgical wound dehisced. E4 stated that she was monitoring the wound, but failed to document her assessments in R64's record. 8/20/18 at 4:05 PM - During an interview, E5 (UM/RN) acknowledged that C1 (OS) was not notified of the acute change in the surgical wound on 5/9/18 and the lack of ongoing monitoring of the dehisced surgical site. 8/20/18 at 7 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON) and E3 (DCS). The facility failed to do the following after R64's right femur surgical wound dehisced: perform ongoing monitoring of the dehisced surgical wound site, obtain and initiate a treatment order for the dehisced site, and notify the Orthopedic Surgeon of R64's surgical wound acute change in status when it was identified on 5/9/18. The dehisced area of R64's surgical wound worsened where the wound bed was covered with slough and had odor. R64 was sent directly to the ER from her follow-up appointment with C1 (OS) for admission to the hospital. The following day, R64 underwent debridement of the surgical wound, placement of a wound vac and was ordered IV antibiotics for 4 to 6 weeks for a surgical wound infection. 2. Review of R144's clinical record revealed: 10/27/15 - R144 was admitted to the facility for long-term care with [DIAGNOSES REDACTED]. 10/13/17 (last revised) - R144 was care planned for alteration in comfort and pain with approaches that included: administer pain medications as ordered; assess response to pain medication and notify MD if resident not having positive response to pain management and notify MD if pain medication is not effective in managing discomfort. 4/10/18 at 9 PM - The facility's incident report and investigation revealed during a transfer, R64's knees buckled and E9 (CNA) heard a crack or pop (sic) placed resident on bed. R64 reported instant pain. A STAT x-ray was ordered. 4/10/18 at 9 PM - E24 (LPN) recorded R144's pain as 10 out of 10 on the numerical pain scale. For the pain scale, 0 was no pain and 10 was the worst possible pain. 4/10/18 at 9:32 PM - R144's eMAR stated that E28 (LPN) recorded R144's pain level as 7 out of 10 and administered R144 the scheduled medications for pain: [MEDICATION NAME] 5 mg and Tylenol Extra Strength 1000 mg. 4/10/18 at 10:49 PM - A nurse's note, written by E24 (LPN), stated that R144's POA was called and left message to call back in reference to x-ray of right hip. 4/10/18 at 10:42 PM - R144's eTAR stated that E28 (LPN) assessed R144's pain after her pain medication was administered and recorded her pain as 0 out of 10. 4/10/18 at 10:52 PM - E25 (RN) recorded R144's pain as 10 out of 10. 4/10/18 at 10:54 PM - A nurse's note, written by E25 (RN), stated that while R144 was being transferred, a pop was heard coming from her right hip. R144 was assessed with [REDACTED]. The physician was notified, vital signs checked and a STAT x-ray was ordered. The note stated that x-ray results were currently pending. 4/10/18 at 11:01 PM - R144's STAT x-ray results were sent by fax with a transmittal time of 11:01 PM. The STAT x-ray results had ALERT written across the document and stated, Modest [MEDICAL CONDITION] .Old impacted fracture of left femoral neck with minimal displacement unchanged from 10/13/17 .subtle non-displaced fracture in right greater trochanter new since 10/13/17. Please correlate clinically and F/U is recommended. The facility failed to check the fax machine during night shift and/or follow up with the Radiology Company to obtain R144's STAT x-ray results with positive findings until 8 hours later. 4/10/18 on 11-7 AM Shift - The eMAR, recorded by E27 (RN), stated that R144's pain assessment was rated 0 out of 10. It was unclear in the clinical record exactly what time R144's pain assessment occurred. In addition, the clinical record lacked evidence of ongoing monitoring and follow up of R144 after the incident on the prior shift, in which a STAT x-ray was ordered and results were pending. 4/11/18 at 3:05 AM - The eTAR, recorded by E27 (RN), stated that R144 refused to wear hipsters for safety. 4/11/18 at 7:11 AM - A nurse's note, written by E29 (RN), stated, Called MD to notify of results of x-ray. No answer and no machine to leave a message. Despite having R144's STAT x-ray results with positive findings in the facility for 8 hours with no action taken by nursing staff, the facility failed to ensure that a physician was available 24/7 to receive the STAT x-ray results with positive findings until 3 hours later. 4/11/18 - Review of R144's (MONTH) (YEAR) eMAR and eTAR revealed: - at 8 AM, E9 (LPN) recorded R144's pain level as 10 out of 10 and administered the routine scheduled Tylenol 1000 mg medication for pain; - at 9 AM, E9 (LPN) recorded R144's pain level as 10 out of 10 and administered the routine scheduled [MEDICATION NAME] 5 mg medication for pain; and - at 10 AM, E9 (LPN) recorded R144's post-pain level after receiving pain medication as 10 out of 10. R144 had no pain relief from Tylenol and [MEDICATION NAME] that were given within the last 2 hours. 4/11/18 at 10:08 AM - The EMS report stated that R144 complained of right hip pain and right upper leg pain, described the pain as sharp and rated the pain 10 out of 10. 4/11/18 at 10:23 AM - A nurse's note stated, E6 (Physician) gave N/O (new order) to send pt (patient) to .ED for eval (evaluation) of (a) femur displacement. Non emergent 911 picked up pt. Called report in to .ED. Message left on RP voicemail to call facility back to update her on status. Awaiting call back. 4/11/18 at 10:26 AM - A telephone physician's orders [REDACTED]. R144 was sent to the hospital ER approximately 13 hours after the incident occurred; approximately 11 hours after the STAT xray results with positive findings were faxed to the facility; and approximately 3 hours after the facility attempted to notify E6 (Physician). 4/11/18 at 10:34 AM LATE ENTRY (documented on 4/11/18 at 2:38 PM) - A nurse's note, written by E9 (LPN), stated that R144 remained in bed this a.m. C/O (complaining of) pain to right thigh rating it at a 10. Routine meds given with some relief . 4/11/18 at 6:58 PM - A nurse's note stated, Called .ER and spoke to the nurse .that had her all day. Stated that the surgeon was gonna operate but decided not too. She has bilateral [MEDICAL CONDITION] which are small. She will be coming back to (facility name) once he get (sic) the discharge information and pain medication . 4/11/18 at 10:43 PM - A nurse's note stated that R144 returned from the hospital at 9:40 PM with a [DIAGNOSES REDACTED]. 4/11/18 at 11:47 PM - A nurse's note stated, .In addition: Ortho deamed (sic) resident to not be a surgical candidate at this time. She is on comfort care with possible [MEDICAL CONDITION] .Impression: . femoral neck fracture .Radiographs of the right femur demonstrate a right hip prosthesis with .fracture noted about the greater trochanter. 4/11/18 at 12:06 AM - The eMAR revealed that R144 complained of bilateral hip pain with a rating of 5 out of 10 and was administered prn [MEDICATION NAME]. 4/11/18 at 5:31 AM - A nurse's note stated that R144's post-pain assessment was 0 out of 10. 4/12/18 at 11:58 AM - A nurse's note stated that E6 (Physician) reviewed R144's ER records and spoke with Ortho. E6 ordered [MEDICATION NAME] every 6 hours as needed in addition to R144's routine pain medication. 8/20/18 at 11:47 AM - During an interview with E5 (UM/RN), findings were reviewed. E5 stated x-ray results are sent to the fax machine behind the front desk. When asked if the night shift nurse and/or the night shift supervisor should have followed up on pending STAT x-ray results, E5 agreed. E5 acknowledged the lack of ongoing monitoring of R144 during night shift after the incident requiring a STAT x-ray. When reviewing that nursing staff were unable to contact E6 (Physician) the following morning to report STAT x-ray results with positive findings for approximately 3 hours, E5 acknowledge the finding. 8/20/18 at 7 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON) and E3 (DCS). Following the 4/10/18 incident at 9 PM involving R144, the facility failed to do the following: - failed to check the fax machine during night shift and/or follow up with the Radiology Company to obtain R144's STAT x-ray results with positive findings until 8 hours later; - failed to assess R144 during the night shift after the Pop incident on the prior shift, which a STAT x-ray was ordered and results were pending; and - failed to ensure that a physician was available 24/7 to receive the STAT x-ray results with positive findings after the x-ray results were located on the fax machine at the start of day shift on 4/11/18. R144 was sent to the ER approximately 13 hours after the Pop incident occurred and diagnosed with [REDACTED].

Based on observations, clinical record review, interview and review of facility documentation, it was determined that for one (R139) out of 52 sampled residents, the facility failed to ensure that R139's physician-ordered intervention/assisted device was in place to prevent an accident that caused harm to R139. R139 sustained harm when she fell and sustained a broken bone in her left arm. Additionally, the facility failed to ensure that R139's environment remained as free of accident hazards as possible as evidenced by the facility staff allowing R139 to keep her cigarettes and lighter in her possession after assessing it to be an unsafe practice. Findings include: Review of R139's clinical record and facility documents revealed: A. R139 was admitted to the facility on [DATE] with a history of falls and gait imbalance. Review of R139's care plan revealed that starting on 5/14/15, R139 had the potential for falls and injury related to a history of falls prior to admission. A progress note from 7/25/15 at 11:10 PM, stated that R139 had a fall and was observed sitting on the floor in the hallway in front of her geri-chair. Review of R139's physician orders [REDACTED]. Review of R139's potential for falls care plan revealed that on 7/29/15, an intervention was added for R139 to have Dycem to her chair when out of bed and to check placement every shift. A progress note from 8/3/15 at 1:50 PM, stated that R139's fall on 7/25/15 at 4:45 PM was due to her sliding out of her Geri chair and resulted in R139 obtaining a bruise to her right leg. The physician order [REDACTED]. A progress note, dated 1/18/18 at 2:34 PM, stated that R139 was witnessed falling face forward from her wheelchair into the hallway. After the fall, R139 complained of left arm and shoulder pain. E23 (NP) examined R139 and ordered an x-ray of her left shoulder. The incident report on 1/18/18 at 2:50 PM, stated that R139 had a witnessed fall from her wheelchair to the floor resulting in complaints of pain. R139 required an x-ray to her left arm and shoulder. R139 was unable to describe what she was attempting to do at the time of the fall. On 1/18/18 at 4:50 PM, a progress note stated that R139's x-ray results revealed that R139 had a left non-displaced fracture to the neck of the humerus (bone in the arm). E23 (NP) was notified and gave new orders to increase R139's [MEDICATION NAME] (pain medication), for R139 to wear a sling to her left upper extremity at all times, except during personal hygiene, and for R139 to be non weight bearing to the left upper extremity. R139 was to follow up with orthopedics as soon as possible. Review of an Employee Performance Improvement/Action Notification dated 1/18/18, revealed that E20 (CNA) signed off on 1/18/18 that R139's Dycem was in place at 1:08 PM. The document stated that, R139 fell at 1:20 PM and R139's Dycem was not in place. Review of R139's actual/potential for further falls care plan revealed that after the fall on 1/18/18, R139's interventions were revised to replace R139's Dycem when not effective and to check placement every 2 hours. It was unclear from this intervention how staff determined the effectiveness of R139's Dycem. Review of the facilities witnessed fall report, revised on 1/19/18, revealed that at the time of R139's fall on 1/18/18, the physician-ordered Dycem was not present in her wheelchair (although E20 documented it was in place). E20 was disciplined and the Dycem was replaced to R139's wheelchair. On 1/25/18, R139 had a consultation with orthopedics. The orthopedic physician recommended that R139 was to wear a sling to her left arm, to give pain medication PRN, and to follow up in one month with x-rays. The incident report 5-day follow-up on 1/25/18 stated that R139 was found on the floor in front of her wheelchair. She was sitting in her wheelchair in the doorway of her room prior to the fall and staff had just left the room and all her needs were met. She complained of left arm pain at the time of the fall. Stat x-rays were ordered. X-ray results showed left non displaced humeral neck fracture. Resident is alert and oriented x 3 but does not know what happened causing the fall .It is unknown at this time if the resident slid out of the wheelchair .Dycem was replaced to her wheelchair and her transfer status was downgraded .She became non weight bearing to her left arm and is to wear a sling .Her pain medications were increased and resident states they are effective. She followed up with ortho. Ortho did not add any new recommendations. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 8/20/18 at 7 PM. The facility failed to ensure that R139 received assistive physician ordered device to prevent fall, as evidenced by a fall on 1/18/18. R139 sustained harm when she did not have a Dycem in her wheelchair and fell from her wheelchair resulting in a left humeral neck fracture. B. Review of R139's care plan revealed that starting on 2/5/16, R139 was at risk for injury related to smoking. Interventions included that R139's cigarettes, cigars, lighters and matches would be kept in the nurses cart. R139's most recent Smoking Screen Evaluation dated 7/22/18, stated that R139 had a dexterity problem and required supervision when smoking. The evaluation stated that R139's plan of care was used to assure that she was safe while smoking. During an interview on 8/7/18 at 4:32 PM, R139 stated that she keeps her cigarettes and lighter in her room and that staff were aware. On 8/9/18 at 2:18 PM, R139 was observed bringing her own cigarettes and lighter outside with E32 (CNA). R139 lit her own cigarette and after she finished smoking at 2:22 PM, she went back to her room and placed her cigarettes and lighter in her bedside table. On 8/13/18 at 3:59 PM, R139 was observed rolling down Bancroft hallway past several staff members with her lighter and cigarettes in a holder on the side of her wheelchair. At 4:18 PM, E33 (LPN) went outside with residents for their smoking time. R139 lit her own cigarette then passed her lighter to E33 who gave it to another resident to use and then passed E33 passed it back to R139. At 4:27 PM, R139 finished smoking and went back to her room where she placed her cigarettes and lighter in her bedside table. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 8/20/18 at 7 PM. The facility failed to ensure that R139's environment remained as free of accident hazards as possible as evidenced by the facility staff allowing R139 to keep her cigarettes and lighter in her possession after assessing it to be an unsafe practice.

Based on closed record review, interview and review of other documentation as indicated, it was determined that for one (R1) out of 6 sampled residents, the facility failed to ensure that R1 received adequate supervision and remained in an environment as free of accident hazards as is possible. R1, had poor body trunk control, required total assist of 2 staff for bed mobility and was in bed on a low air loss mattress. On 12/1/16, R1 was left unsupervised with the head of the bed elevated at 90 degrees. R1 was found on the floor with her right cheek pressed against the baseboard radiator and a second degree burn to her right cheek that required hospitalization for treatment and evaluation. Findings include: The facility's Instructional Manual on Air Flow Mattress - Resident Safety/SPAN Product Statement stated, Subject: Head of Bed (HOB) Elevation: Cause and Effect: Yes, Head of the bed may be .for many patient care reasons: procedures, eating .can be accomplished at a 30 degree elevation, .Limit head of bed elevation for an individual on bedrest unless contraindicated by medical condition or feeding and digestive considerations . Review of R1's clinical record revealed: R1 was admitted to the facility on [DATE] for Palliative Care with [DIAGNOSES REDACTED]. R1's admission Fall Risk assessment dated [DATE] indicated that she was a high risk for falls. R1's care plan was initiated and dated 6/14/16 (admitted [DATE]) entitled Resident had actual/potential for further falls r/t her cognitive impairment, non compliance with call bell, impulsive behavior and poor safety awareness. The interventions included, Bed in lowest position; call light within reach at all times; Fall mats down while in bed. The care plan failed to identify and list other contributing factors such as poor body trunk control and use of the low air loss mattress, to potential for falls. Therefore, it failed to include resident related interventions to address appropriate positioning for R1's safety. The admission MDS assessment, dated 6/21/16, stated that R1 had a severely impaired cognition, needed 2 staff assistance/support for bed mobility (turning side to side and positioning body while in bed) and transfers between surfaces including to or from bed, chair and wheelchair. 7/14/16- R1 was seen and evaluated by PT for bed mobility (rolling left and right; lying to sitting on side of bed; sit to lying) related to generalized muscle weakness. According to Physical Therapy, R1 needed the helper/staff to support her trunk or limbs. Despite the above assessments, the facility failed to include the need for body trunk support in the care plan. 12/1/16 at 9:11 PM, R1 was found lying on the floor with the upper portion of her body on the fall mat at the right side of her bed, bed in low position, body pillow underneath her, with her right cheek pressed against the baseboard radiator. The lower portion of her body from the waist down remained on the bed, head of the bed was elevated to 90 degrees. Upon assessment by E9 (LPN), R1 was found with a burn on her face (right cheek) that measured 4.6 x 6 cm with small amount of blood. R1 was sent to the hospital ER for further evaluation. R1 was admitted to the hospital with [REDACTED]. 12/2/16 - E8 (CNA) in her written investigation statement stated that she fed R1 at 6 PM for 15 minutes, then left the room to assist another resident, returned at 6:15 PM to check R1 for incontinence care and left. At 7:45 PM (an hour and a half later), E8 realized that she left R1's head flat in bed after feeding her meals, returned to elevate the head of the bed (90 degrees) since she was on choking precautions. Review of the hospital record dated 12/2/16 confirmed that R1 sustained a second degree burn (the outer layer and the layer underneath it) on the right cheek when she fell and her right cheek pressed against the baseboard radiator. Treatment was administered and additional instructions given to the patient's family member included to call for an appointment with the burn clinic. 12/6/16 - The facility's investigation report stated that Resident requires total assist with care, has poor trunk control and was on an air mattress at the time of the fall. Positioning of the head of the bed may have contributed to her fall. Staff will be educated that when caring for resident's with poor trunk control/total assist with care, they must ensure the head of bed be elevated at a maximum of 45 degrees when the resident is unattended. 1/11/17 at 1:45 PM-Interview with E8 (CNA), she stated that it was the first time that she took care of R1. She confirmed that she left R1 seated in an upright position (90 degrees) and placed the body pillows in upright position on both sides of the resident's body. 1/13/17 at 12:00 PM Surveyor and E4 (RN) observed that the body pillow used for R1 were 2 standard soft pillows placed together inside a long pillow case creating a longer pillow. Because it was not one long pillow, it was not firm enough to provide support when placed vertically. The upper pillow breaks from the lower pillow and will fold down if the resident leans on it. 1/19/17 at 10:50 AM- Interview with E3 (RN) confirmed that R1 was bed bound, unable to move on her own in bed and needed 2 staff to change her position. Staff used body pillow for support since she was unable to control her trunk when in a sitting position. E3 stated that the body pillow is good support for some residents who are able to hold self, to serve as a reminder to change position. However, it did not support R1 since it was not firm enough to hold her trunk when seated upright in bed. 1/19/17 at 12:10 PM-Interview with E7 (ST) confirmed that R1 was at risk for aspiration and when being fed in bed, the HOB should be elevated at the maximum of 45 degrees. The facility failed to ensure that R1, a resident with severely impaired cognition, with poor body trunk control, who required total assist of 2 staff for bed mobility, and was in bed on a low air mattress received adequate supervision and provided appropriate assistive device to prevent fall with serious injury. R1 sustained harm when left unsupervised with HOB elevated at 90 degrees which resulted in a fall and a second degree burn to her right cheek that required treatment in the hospital. The facility provided an In-Service Training on Resident Safety, Fall Risk when caring for a resident who has an airflow mattress for all the Nursing Staff from 12/19/2016 through 1/20/2017. The subject of the training stated : If a resident has poor trunk control, he/she cannot be left unattended with the HOB> (greater than)45 degrees. The HOB should be returned to < (less than) 45 degrees prior to leaving the bedside. Findings were reviewed and confirmed with E1 (NHA), E2 (DON), E3 (ADON) on 1/23/17 at 3:30 PM.

Based on record review, observation and interview, it was determined that the facility failed to ensure that one resident (R98) out of 35 Stage 2 sampled residents, who was non-compliant with safety due to severe cognitive impairment (unable to make own decisions) and who required constant supervision while in bed and supervision for all meals received supervision to prevent accidents. On 9/26/13 R98's breakfast tray was left in her room on the overbed table while the resident was asleep. R98 was found on a wet floor next to the bed along with the meal tray. R98 sustained a skin tear to her right arm, a bruise on her left forehead and a bleeding laceration (cut/tear in skin) that measured 1.5 cm (centimeter) by 0.1 cm to the back of her head that required emergency room (ER) treatment. The facility failed to constantly supervise R98 as per her care plan while the resident was in bed. R98 fell unobserved and sustained injuries including a head laceration that required the treatment in the ER. Findings include: According to R98's quarterly Minimum Data Set (MDS) assessment, dated 9/9/13, her cognitive skills for daily decision-making were "severely impaired-never/rarely made decisions". R98 required extensive assistance of one nursing staff member to eat and drink and required extensive assistance of two nursing staff members to transfer from one surface area to another and to walk in her room. R98 had [DIAGNOSES REDACTED]. The facility initiated a care plan, dated 6/16/13, entitled, "Potential for falls and injury related to (r/t) poor safety awareness, history of falls prior to admission causing left hip fracture." The care plan goal was "Will be free from fall, related injury." Approaches included, "... Constant check on resident when in bed...". R98's Nutrition care plan, initiated on 6/26/13, included the intervention, "Resident requires supervision and set up help for meals." On 7/30/13, the facility initiated a care plan for actual falls with an approach to "Continue interventions on the at-risk (care) plan." Review of R98's Incident Report provided by the facility, dated 9/26/13 at 9:25 AM, revealed that R98 was found on the floor at her bedside and she sustained a laceration to the back of her head that measured 1.5 cm (centimeter) by 0.1 cm. R98 was sent to the hospital ER per physician order [REDACTED]. Review of the facility's Fall Investigation Form, dated 9/26/13 and timed 9:25 AM, stated that at 9:25 AM on 9/26/13, E24 (Certified Nurse's Aide/CNA) found R98 on the left side of her bed on the floor. The floor was wet when R98 was found with her "trayer" (sic) (breakfast tray which contained spilled food and drinks). In E24's written statements, dated 9/26/13 and obtained during the facility investigation: When asked "When was the last time you saw resident", E24 stated, "This morning (no time given)" when asked "What was resident doing?" E24 stated "She was in bed sleeping" when asked "When was the last time you toileted or did incontinence care?" E24 stated "Didn't do care yet because resident was asleep". These statements were obtained by the facility during their investigation. R98 sustained a skin tear on her left elbow measuring 2 centimeter (cm) by 0.5 cm, a bruise on her left forehead and a 1.5 by 0.1 cm laceration to the back of her head that required hospital ER evaluation and treatment. In the ER, R98 had adhesive/glue applied to close the laceration on the back of her head. R98 returned to the facility from theER on [DATE] at 4:30 PM. In an interview with E7 (Licensed Practical Nurse) on 11/15/13 at approximately 4:00 PM, she stated that she carried R98's breakfast tray into her room on 9/26/13 and left the resident's breakfast tray on her overbed table. E7 told E24 (CNA) to help R98 with her breakfast. Review of the facility's meal schedule revealed that breakfast was served between 7:45 to 8:05 AM in the unit in which R98 resided. The facility failed to provide constant checks (supervision) for R98 as per her plan of care on the morning of 9/26/13. Consequently, R98 had an unwitnessed fall and sustained harm with multiple injuries including a laceration to the back of her head which required evaluation and treatment in the hospital ER. Findings were discussed with E2 (Director of Nursing) and E3 (Assistant Director of Nursing) on 11/18/13 at approximately 11:30 AM.

Based on interview, record review and review of other facility documentation, it was determined that the facility failed to ensure that one resident (R5) out of seven sampled residents received the necessary care and services in accordance with the comprehensive assessment and plan of care. On 5/22/12, the facility failed to ensure staff followed the plan of care for R5 when care was not provided by the required 2 staff members. This failure resulted in a hematoma and a concussion for R5. Findings include: R5 was a resident at the facility for about eight years with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS), dated [DATE], revealed that R5 was moderately cognitively impaired; had both physical and verbal behavioral symptoms; required extensive assistance with one person assistance for bed mobility, dressing, hygiene and toilet use; required extensive assistance with a two person assist for transfer; did not ambulate and was dependent with assist of 1 person for locomotion in the room or in the corridor; was incontinent of bowel and bladder and received anti-psychotic, anti- anxiety and anti-depressant medications daily. Review of the "Nurse Aide's Information Sheet" (also known as the profile) revealed that R5 was to have "2 staff members in room during care". Review of the care plan entitled, "Unable to provide own ADL's (Activities of Daily Living) Total Care", established 4/8/10 and last reviewed on 6/8/12 with the statement, "Res (Resident) cont (continues) to be a total care" had the approach, "2 staff members during care". The care plan entitled, "Agitation with Physical abuse R/T (related to) cognitive level", established 4/8/10 and last reviewed on 6/8/12, included the approach, "Allow resident time to calm down and then reapproach, change staff member if needed ..." Review of the care plan entitled, "Agitation with Verbal abuse R/T (related to) cognitive level", established 10/4/10 and last reviewed on 6/8/12, included the approaches, "Meds as ordered, record side effects, Explain all procedures prior to care given, Approach in a calm, quiet manner, Allow resident time to calm down and then reapproach, change staff member if needed, Redirect with conversation ...". Review of the "Skin Injury Statement Form", dated 5/22/12, regarding the incident of a hematoma on R5's forehead revealed that on 5/22/12 at 2 AM, E17 (CNA) wrote, "I went to change resident was very combative. She had loose BM. So I went to call the nurse to help me. She was very upset and combative towards me. She hit her hand on the table and she said I stole her bag ..." Review of the "Skin Injury Investigation Form", dated 5/22/12, regarding the incident of a hematoma on R5's forehead revealed that on 5/22/12, untimed, E18 (LPN) completed the form. E18 replied that the injury was found "changing resident diaper" and... how it happened was, "Resident became combative during care/turning.CNA was doing her ADL's." Also, E18 answered the following to the question, "What do you think caused the injury?" by writing, "Resident may have hit her head on the bed side table during turning 2 (secondary to) diaper ^'d (changed) around 2 AM but CNA did not (sic) aware that Res (resident) may have hit her head during that care". Review of the Nurses Notes (NN), dated 5/22/12 at 3 AM revealed, "...During care Resident was very combative...She stated that CNA Stole her band and woke her up and then she hit her hand on the table ... Assessed her hand; was no apparent bruise noted. Res (resident) also denied any discomfort but was very upset with the CNA ..." The nurses' note (NN) at 4 AM stated, "Assigned CNA informed this nurse that resident noted with bruise to her head ... was slightly swollen and I asked the resident what happened. She told be (sic) she hit her head on the bedside table whilse (sic) the CNA was cleaning her. Ask the CNA to get some ice of which I applied and initiated neuro checks, VS (vital signs) ..." The NN at 5 AM stated, " ... Noted site has become bigger; Supervisor was informed and she came and assessed and advice (sic) me to send Res out for an evaluation ..." Review of the Emergency Physician Record, dated 5/22/12 at 6:55 AM, recorded, "CT Scan - Head - no [MEDICAL CONDITION]. NH (Nursing Home) reports that pt (patient) was turned to clean during night. Later, red mark was noticed on pt's hand. Then, swelling noticed. Assumption was made that pt hit head on bedside table during turning ... Clinical Impression - Concussion w/o LOC (Without loss of consciousness)". The CT scan of R5's head, dated 5/22/12 at 7:11 AM stated, "... A hematoma is seen in the scalp anteriorly on the right. Conclusion: No acute intracranial abnormality. " Review of the hospital's Elder Physical Abuse and Neglect Forensic Evaluation, dated 5/22/12, recorded the right forehead with "Bruising 8 cm x 8 cm light blue with areas of purplish and red noted. [MEDICAL CONDITION] to forehead noted surrounding bruise" and right hand with "Abrasion with [DIAGNOSES REDACTED] (redness) 0.5cm x 1 cm noted". On 8/9/12, in an interview E4 (LPN Risk Management) stated that E17 (CNA) went into R5's room by herself to check and change the resident who was incontinent of stool and was combative. E4 stated that she always teaches staff to follow the CNA profile and plan of care and if a resident is combative to leave and get additional staff and re-approach when the resident is less agitated. E4 stated that E17 did not do that. E4 also stated that E17 told the nurse, E18 (LPN), that R5 hit her hand and later told E18 that E5's head was bruised and then E18 waited another hour before notifying the nursing supervisor on the night shift. E4 stated that E18 focused on the R5's hand initially rather than assessing the resident including her forehead. On 8/9/12, in an interview with E3 (ADON) regarding R5's hematoma, she stated that E17 (CNA), "Did not follow the profile and plan of care for the resident - 2 persons for all care". Additionally, E3 stated that E18, "Failed to inform the supervisor of the hematoma until 5 AM when the supervisor advised to call the MD and to get the resident sent to the ER to be evaluated". The facility failed to ensure care and services were provided in accordance with the plan of care and the comprehensive assessment for R5. The facility failed to have 2 staff when care was being provided for R5 who was combative with care on 5/22/12. This failure resulted in R5 sustaining a hematoma when turned during incontinent care on 5/22/12 which was incorrectly provided by 1 staff person. The facility also failed to thoroughly assess R5 when the incident occurred at 2 AM, looking at R5's right hand and finding "no apparent bruise". The supervisor was not notified of the head injury until 5 AM when per the 5/22/12 NN stated, "... site has become bigger ..." R5 was sent out to the ER to be evaluated and was diagnosed with [REDACTED].

Based on record review, observations and interviews it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for two (R2, R3) out of 4 sampled residents. The facility failed to ensure that when R2 developed a shin wound, it was thoroughly assessed, monitored and evaluated in accordance with facility policy, resident's care plan and acceptable standard of nursing practice. The facility failed to ensure that R3 followed swallowing strategies as per physician and Speech Therapist's plan of care to prevent aspiration accident. Findings include: Cross refer F441 example #1a 1. R2 had [DIAGNOSES REDACTED]. According to R2's Minimum Data Set (MDS) assessment dated [DATE], R2's BIMS (brief interview for mental status) score was 7 out of 15 would identify this resident as having moderately impaired cognition for daily decision making. R2 needed extensive assistance of staff for all activities of daily living (ADLs). R2 was non-ambulatory. R2 was frequently incontinent of bowel and bladder. The facility updated R2's care plan dated 5/7/11 on "At risk for skin breakdown R/T (related to) decreased mobility, incontinence of urine". The care plan interventions included, "Turn and position and assess skin q 2 hrs"., "apply lotion to skin to prevent dryness qd with am/pm care & prn", "weekly skin assessments done by nurse". R2 was not prescribed any anti-coagulant drug except for Aspirin Chewable 81 mg tablet 1 tablet by mouth every day for [DIAGNOSES REDACTED]. Review of R2's medical records revealed that on 11/30/11 while being transferred from her wheelchair to her bed by E15 (CNA-Certified Nursing Assistant), she received a significant skin tear (#1) to her right shin measuring 5 centimeters (cm) x 1.5 centimeters (cm). Interview on 2/20/12 with E15 (CNA), she stated, "I thought I gave her a skin tear. I noticed it when she was in bed. I notified the nurse. There was already a dark spot where the skin tear was. We are always told to take foot rests off the wheelchair before we transfer residents. Her foot rests were off." E15 also stated that she could not remember which leg received the skin tear. A physician's orders [REDACTED]. Observe steri strips every shift for signs and symptoms of infection". Review of facility policy for Skin Treatment Protocol for Skin Tears stated to, "notify wound nurse of all skin tears and fill out wound notification sheet and weekly wound assessment sheet". Interview on 2/22/12 with E9 (wound care nurse) confirmed that she was never notified of R2's skin tear on 11/30/11. Therefore, the wound was not assessed by E9 on a weekly basis. There was no documentation in the physician progress notes [REDACTED]. Interview on 2/22/12 with P1 (physician) confirmed that she was never notified of R2's significant skin tear to right shin which occurred on 11/30/11. A care plan was initiated on 11/30/11 entitled "Skin Tear site L shin" (supposedly right shin). The goal based on assessed needs was "Resident's skin tear will be healed and infection will be prevented x 30 days". The interventions included, "Treatment as ordered" and "Assess skin tear qd (every day) for s/s (signs and symptoms) of infection". On 12/17/11 (18 days later) a nurse's note stated that the right shin was draining and [DIAGNOSES REDACTED]tous (red). No steri strips were in place to cover the wound. Even though treatment/assessment was being provided to this skin tear on a daily basis, the nursing staff failed to recognize that it was not healing. They also failed to recognize the signs and symptoms of an impending infection to the site until it occurred. New telephone verbal treatment orders were prescribed by P2 (Nurse Practitioner) for the draining wound which consisted of "normal saline, rinse site, pat dry, and apply [MEDICATION NAME] (topical antibiotic) and border gauze every day". Again, there was no documentation in the Physician's progress notes that R2's right shin wound was seen/assessed by the Physician and/or Nurse Practitioner. During an interview with E9 (Wound Care Nurse) on 2/22/12, she stated, "I would have expected staff to notify me with the change in condition of the resident's wound. I would have expected the doctor to assess the wound." On 12/21/11 while being transferred from bed to wheelchair by E16 (CNA), R2 received a second (#2) significant skin tear to her right shin (above draining skin tear #1) measuring 5 cm x 3 cm. The area was bleeding and direct pressure was applied and then a bulky dressing was applied. Review of a written statement from E16 (C.N.A) dated 12/21/11 revealed that R2 was being transferred by E16 to her chair when she noticed blood on the floor and looked to see where it was coming from and noticed it was R2's leg and went to call the nurse right away. E16 stated, " I never seen the resident hit her leg or rub her leg against anything. I was very surprised to notice she had hurt her leg like that". P2 was present and assessed R2's #2 wound and an order was given to send R2 to the ER (emergency room ) for evaluation. R2 returned to the facility three hours later with a [MEDICATION NAME] dressing in place on the right lower leg. The report from the ER stated that the patient had area "glued" (Derma bond) back together. Per the ER physician, patient also has an old skin tear(#1) area below new skin tear. Area looks infected with questionable [MEDICAL CONDITION]. No culture was done. Hospital discharge orders were for Keflex (antibiotic) 4 times per day and Bactrim (antibiotic) twice a day. These orders were called to P2, which in turn only discontinued the Bactrim (due to her creatinine level (kidney function) of 235).and maintained the Keflex 500mg (milligram) twice a day. Interview on 2/20/12 with E9 (Wound Care Nurse) stated, "If doctor at the ER said that it (wound #1) looked infected on 12/21/12, then someone here at the facility should have picked up on that before she went to the hospital." On 12/24/11 (3 days after R2 returned from hospital) R2's interested family member expressed concern about R2 having [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) in the first wound (wound #1) which occurred on 11/30/11. In response to this concern a culture was obtained on 12/24/12 and a positive result [MEDICAL CONDITION] was reported on 12/28/11. At this time the antibiotic was changed from Keflex to [MEDICATION NAME] 100mg twice a day for ten days. Review of physicians progress notes revealed, there was no documentation that would indicate that R2 was seen by the physician or nurse practitioner from 12/22/11 until 1/4/12 a total of 13 days after the second injury occurred. On 2/21/12 E10 (LPN) was observed performing R2's dressing change to the right shin on wound #2, (with +MRSA infection). After E10 removed the old dressing, she never washed her hands or changed her gloves and E10 proceeded to clean the second wound with the same gloves and applied a new dressing. E10 failed to follow acceptable standard of practice in dressing R2's wound and failed to follow the facility policy. (Review of facility policy entitled, Clean Dressings revealed, Step 17. Put on exam glove. Loosen tape and remove dressing. Step 18. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands.) In addition, it was also observed that the old dressing was dated 2/19/12 which indicated that the wound treatment and assessment were not done on 2/20/12. Per physician's orders [REDACTED]. E8 (RN) and E10 (LPN) confirmed this finding. 2. R3 had [DIAGNOSES REDACTED]. According to R3's Minimum Data Set (MDS) assessments dated 1/3/12, her BIMS (brief interview for mental status) score was 11 out of 15 (cognitive skills for daily decision-making were poor: cues/supervision required). R3 was dependent of staff for ADLs (activities of daily living) including eating. R3 had severe pain almost constantly due to [MEDICAL CONDITION] arthritis. She was non-ambulatory and used the wheelchair for mobility device. She used adaptive utensils device for eating and needed extensive assistance. The facility initiated a care plan dated 10/20/11 on "Alteration in Nutrition Below Ideal Body weight R/T fair to good appetite; Dementia" The care plan interventions were: Diet as ordered; supplements as ordered; monitor weight per policy; Honor food preferences as able and voiced; Monitor PO intake, encourage meal completion; assist with meals as needed; provide environment conducive to eating. R3 had history of [MEDICAL CONDITION] stricture/narrowing. R3 was referred to the Speech Therapy for potential diet advancement from mechanical soft diet. R3's SLP (Speech Language Pathology/Speech Therapist) evaluation dated 1/4/12 included the onset [DIAGNOSES REDACTED]. The recommended plan of care/treatment (with physician's consent) were as follows: Regular diet and thin liquid To prevent aspiration, E13 (Speech Therapist) recommended the following aspiration precaution strategies: "Supervision for oral intake - close supervision" "Swallow strategies; small bite size, pieces; chew and swallow one bite at a time; alternate solids and liquids frequently throughout the meal" R3 was observed in her room at breakfast on 2/21/12 at approximately 9:00 AM. R3's body motion and facial expression indicated that she was feeling pain. R3 confirmed that she was not feeling well and had arthritic pain all over her body especially her hands. Her breakfast tray contained adaptive (personalized) utensils ([MEDICAL CONDITION] arthritis on both hands) but she refused to eat. R3 acknowledged that she only drank a glass of cranberry juice. Asked if a staff watched her eat, she stated nobody stayed after the staff served her breakfast tray. She ate alone in her room. On 2/22/12 at approximately 9:00 AM, R3 was observed again at breakfast. R3 was smiling and stated that she felt much better. R3 stated that she took her bowl of oatmeal and drank it "alone". On 2/22/12 R3 was in the unit's dining room for lunch at approximately 12:45 PM. There were 23 residents including R3 and 4 nursing staff. One resident was being fed by a family member and three nursing staff were feeding 3 residents and one (1) CNA was busy circulating around the room getting water/juice and watching the other residents from a distance (distant supervision). R3 was served noodles and veal marsala which was cut for her by a CNA, then left her to eat alone. R3 ate her noodles and cut veal and did not follow the recommended swallowing strategies due to the lack of close supervision to ensure the provision of the necessary care and services as stated in the physician's and speech therapist's plan of care. . Review of R3's CNA's Resident Care profile failed to indicate R3's need for close supervision for oral intake and the need to follow the swallow strategies recommended by E13 (SLP). Interview with E13 (SLP) and E12 (Rehabilitation Director) on 2/24/12 at 2:45 PM, they acknowledged this finding. The facility failed to ensure that E13's (Speech Therapist) aspiration precaution strategies as recommended were followed for R3's safety.

Based on record review, interview and review of other facility documentation, the facility failed to ensure that one (1) Resident (R2) out of 6 sampled residents was free of a significant medication error that resulted in a a low blood sugar of 28 and required hospitalization for treatment. R2 was administered [MEDICATION NAME] (rapid acting insulin) 60 units instead of [MEDICATION NAME] (blood thinner) 60 mg. which was not in accordance with the physician's orders [REDACTED]. (milligram) was incorrectly transcribed as [MEDICATION NAME] 60 mg. on the physician's orders [REDACTED]. R2 ' s blood sugar (per accucheck via glucometer) dropped to 28, (normal range 70-120 mg/dl). Per facility's hypoglycemic protocol/physician's orders [REDACTED]. [MEDICATION NAME] via intramuscular injection (IM), however, his blood sugar accucheck result dropped to 23. A second dose of 1mg [MEDICATION NAME] IM was administered plus [MEDICATION NAME] 10% was initiated intravenously (IV). 911 was called and R2's blood sugar only rose to 34 when paramedics arrived. R2 was transported to the hospital for evaluation and treatment. Findings include: R2 had [DIAGNOSES REDACTED]. According to R2's admission Minimum Data Set (MDS 3.0) assessment dated [DATE], R2 had alteration in thought process (unable to recall). He had limited assistance with his ADL's (activities of daily living). R2's prescribed medications included [MEDICATION NAME] Sodium (anticoagulant) 4 mg. tablet by mouth at bedtime. According to the 02/11 MAR, R2's BID (twice a day) blood sugar accucheck/glucometer ranged from 102 through 121. R2 was not on any insulin medication. The facility initiated a care plan on 2/12/11 on the problem of "Altered peripheral tissue perfusion R/T [MEDICAL CONDITION] RLE". According to a nurse's note (E4's, LPN) dated 2/8/11 R2's 2/8/11's venous study result to RLE (right lower extremity) read positive (+) for [MEDICAL CONDITION]. E4 (LPN) notified E11, R2's attending physician's CNP (Certified Nurse Practitioner) of the laboratory blood result. In an interview with E11 (CNP) on 4/4/11 at approximately 12:45 PM revealed that on 2/8/11, she confirmed that she received R2's [MEDICAL CONDITION] laboratory result from E4 (LPN). E11 (CNP) via telephone verbal communication prescribed for R2 "[MEDICATION NAME] 60 mg sq (subcutaneous injection) every 12 hours, [MEDICATION NAME] 5 mg po (by mouth) 1 tab. tonight, [MEDICATION NAME] 5 mg tab. PO 1 tomorrow, PT ([MEDICATION NAME] time-clotting time) and INR (International normalized ratio-clotting tendency of the blood) on Thursday. [MEDICATION NAME] may be discontinued when R2's INR level reached 2 (normal range is 0.8 - 1.2 seconds)". E11 (CNP) also stated that she repeated the order ([MEDICATION NAME]) 3 times to E4 (LPN). Review of the "Physician's Interim/Telephone Orders" sheet (undated) timed 2200 (10:00 PM) and R2's February/2011 MAR indicated [MEDICATION NAME] 60 mg (always ordered in units) SQ (subcutaneous injection) q (every) 12 hrs"...."May D/C [MEDICATION NAME] 60 mg SQ Q 12 hrs when INR level reach 2". (INRs do not monitor [MEDICATION NAME]) Review of the 2/11 MAR, the [MEDICATION NAME] was signed off as administered by E8 (LPN) at 9:00 AM and E7 (RN) signed off as the #2 nurse.In an interview with E8 (LPN-medication nurse) on 4/4/11 she stated that she assumed the "mg (milligram) was an error for unit" and E8 administered the 60 unit of [MEDICATION NAME] to R2. She also stated that prior to administering the insulin, she went to look for a nurse, she found E7 "down the hall", told her she was giving a 60 unit [MEDICATION NAME]. E8 stated that she heard E7 say OK but she didn't wait for E7 (RN) to witness her preparation of the insulin prior to administering it to R2 and as per facility policy. According to the facility's policy entitled "Second Nurse Check For Insulin Administration" established on 1/28/2011, "to provide safe and effective administration of insulin, a second nurse will check all insulins drawn up prior to administration". On 4/4/11, surveyor observed a written note posted on the top cover of the MAR indicated . A nurse's (E8, LPN) note dated 2/9/11 stated, "this nurse was called into resident's (R2) room at 9:15 AM, resident was noted with [MEDICAL CONDITION] activity, two other nurses were in room at that time....this nurse (E8, LPN) checked blood sugar with results of 28. E10 (Medical Doctor) in facility at the time and notified, hypoglycemic protocol initiated, administered [MEDICATION NAME] 1 mg via IM. Blood sugar was then rechecked within a few minutes with a reading of 23, orders from E10 (MD) to give a second dose of [MEDICATION NAME] via IM and start [MEDICATION NAME] 10% via IV (intravenous). 911 was called, when paramedics arrived resident's BS (blood sugar) was up to 34. Resident (R2) was taken to (name of hospital)...". The hospital physician's consultation summary record dated 2/22/11 stated, "...is profoundly hypoglycemic from insulin and this I suspect is the source of his [MEDICAL CONDITION] as he has normalized with correction of his sugar". Mandatory Inservices were immediately given to all nursing staff related to policies and procedures, medication errors, competency skills, insulin review and documentation before and during the survey visit. Despite these efforts by the facility it is unclear from interviews and review of documentation why at least 3 staff members failed to adhere to facility policy and why the facility failed to identify this system problem.