Every finding on record at Regency Care Center

Based on observations, interviews, and record review, the facility failed to ensure that a resident was treated with respect and dignity for 1 out of 3 residents reviewed (Resident #18). Resident #18 reported she had laid in urine for a delayed period of time without Staff X, Certified Nurse Aide (CNA), cleaning her up after asking this CNA to clean her up, causing her pain. This resident reported that she felt fearful that Staff X was going to hit her (Resident 18) and did not want Staff X to return to her room. The facility reported a census of 58 residents. Findings include:A Minimum Data Set, dated [DATE], documented that Resident #18's diagnoses included acute respiratory failure with hypoxia and cardiorespiratory conditions. A Brief Interview for Mental Status revealed a score of 13 out of 15, which revealed her cognition was intact. This resident was always incontinent of urine and bowel. She required substantial/maximal assistance to roll left and right in bed and to sit up and lie down in bed. She was dependent on staff for transfer. A Care Plan initiated on 4/29/26, documented that Resident #18 had a self care deficit as evidenced by requiring assistance with ADLs (Activities of Daily Living). The care plan directed Resident 18 required a 2 person assist for bed mobility and toileting. Staff were to provide peri-care with every incontinent episode and as necessary. This care plan documented that Resident #18 was incontinent of bowels and was at risk for impaired skin, rashes, and irritation in the peri-area. It directed staff to provide bedpan/bedside commode as Resident #18 requests, and to provide peri-care after incontinent episodes. It documented that REsident #18 was incontinent of bladder and at risk for impaired skin, UTI's (urinary tract infections), and irritation in the peri-area. Staff were to clean peri-area with each incontinent episode. It documented that Resident #18 is at risk for psycho-social well being deficit and is at risk for changes in appetite, sleep patterns, ADL's, mood, socializations and increased sensitivity to environment. Staff were to encourage Resident #18 to express her feelings and concerns, to listen with empathy and report additional needs to nursing. A 5-Day Investigation summary for Self-report 5/9/26, documented that Resident #18 reported the evening of 5/9/26 that a CNA was in her room assisting her and the CNA started yelling at her. Upon initial interview Resident #18 did not state exact quotes or words used but stated the: staff member yelled at her. The staff member was immediately sent home. The investigation summary documented that after further interview, Resident #18 stated she could not provide exact quotes but stated she heard the f word, you're lying and I will get even with you. On 5/11/26 at 1:07 PM, Resident# 18 was lying in bed. She stated that she didn't remember the girl's name. This resident stated she told Staff X that she needed changed (cleaned up after urination). Staff X had probably stopped in Resident #18's room [ROOM NUMBER] or 5 times that day, but wouldn't change Resident #18. Staff X told Resident #18 that she should not have turned her call light off as Staff X had turned it on. Resident #18 reported that Staff X left her lying flat and Resident #18 could not reach her bed controls. Resident #18 stated she called her grandson and told him, and then Staff X came back into the room and was upset. Staff X left again without cleaning Resident #18 up. Resident #18 said that Staff Z, Licensed Practical Nurse (LPN) entered this resident's room. Resident #18 told Staff Z that she needed to be changed and that she had been lying in her urine and it was starting to hurt. Staff Z replied that she would get the CNA and she would help clean this resident up. Staff Z then got the CNA and they started to clean me up. Staff Z had to leave the room. This resident stated that's when the CNA started yelling at this resident. This resident reported that Staff X said 'you know you got me in trouble. You are not the only person who needs help here and(Staff X) couldn't get to all of them'. Resident #18 stated that the CNA started to leave the room and then yelled at resident #18. Staff X was cussing too. This resident stated she was not used to that kind of language. Resident #18 stated she had never talked like that and neither had her daughter. This resident stated that maybe her grandsons and her son in law may talk like that but they do not do it in front of me. This resident said that Staff X then started coming toward this resident and this resident thought Staff X was going to hit this resident. Resident #18 told Staff X to get out of this resident's room and don't come back. Resident #18 stated she was afraid. She repeated she thought Staff X was going to hit her. This resident stated that she probably didn't have the right to say that because the facility isn't her place, but this resident was scared. When asked about her hurting related to lying in urine, she said oh they put a medicine on me and that took care of it. She stated they have been using that medicine. This resident could not say exactly how long she had been lying in urine. On 5/11/26 at 2:31 PM, Staff Z stated she did go into the room with Staff X and then she (Staff Z) had to leave. Staff Z said this happened around 6:30 PM., Staff X was upset. Resident #18 was the first one Staff Z went to to pass medication after Staff Z started her shift for that night. Staff Z stated this resident reported that she needed to be changed and had needed to be changed for a while. Staff Z went and found Staff X and Staff X said that nobody had helped her all day and she needed help. Staff Z and Staff X went and changed Resident #18. This resident required a complete bed change. Staff Z assisted with changing this resident. Resident #18 asked if she could get her night cares done, like brushing her teeth and washing her face. Staff Z told this resident that Staff X would finish up with brushing this resident's teeth. This resident had told Staff Z that she had been waiting to be changed since 2 p,m, and Staff X had been in the room several times and would not change her. This resident said this in front of Staff X and Staff Z. Staff Z thinks Staff X said something like 'no one would help'. Staff Z said Staff X said something about that she had left this resident's call light on to get help. Staff Z didn't remember if this resident's call light was on. There wasn't any tension that Staff Z had noticed when Staff Z left the room. STaff Z stated they might have put some moisture barrier on this resident's peri area. Staff X was in the room for a little bit after Staff Z left. After this Staff X went up to the nurses' station and wondered why somebody had turned off the call light. Staff Z stated she told Staff X the call light being shut off was beside the point, that Staff X had to take care of residents needs and that Staff X can't just leave the call light on for several hours. It was apparent this resident had been laying in urine for awhile and this resident had a bowel movement as well. She didn't say how long she had been lying in the feces. Staff X proceeded to say that nobody had helped her all day. Staff BB, Certified Medication Aide (CMA), said that was not true. Staff Z said that Staff BB told Staff X that they had been helping Staff X and Staff X had been on her ipad for 3 hours sitting in the chair. Then Staff X got upset and went back to the breakroom. Staff X then came out of the breakroom and went into Resident #18's room. Staff Z stated she didn't know what went on in Resident #18's room as it was just Resident #18 and Staff X in the room. Staff Z said that Staff Y, Registered Nurse (RN) asked what was happening. Staff X said Resident #18 did not want Staff X taking care of her and did not want Staff X back in the room. Staff Y then went to talk with this resident and Staff X to find out what was going on. Staff Y came out of the room with Staff X and said that Staff X was going to go home. Staff Z stated that she had not seen this resident get upset with any staff before. Staff Z stated that Resident #18 was a very sweet lady. She wasn't even upset about not even being changed for a few hours. On 5/11/26 at 2:53 PM, Staff Y, Registered Nurse (RN), stated that she was covering the floor in the backside of the building. Staff Y said that Staff X was up front and they were talking. Staff X came up to them and said Resident #18 didn't want Staff X in her room anymore. Staff X could not give a specific reason. Staff Y said let's go talk with Resident #18. Staff X didn't really go into the room when they went to go talk with Resident #18, she just stood in the doorway. Staff Y asked this resident what was going on. Resident #18 replied that she didn't want Staff X her room. Resident #18 stated she felt uncomfortable with Staff X and that Staff X was accusing this resident of turning off her own call light. Staff Y said this resident reported that Staff X was raising her voice at this resident and Staff X's tone of voice was raised and she was really sassy with what she was saying. This resident reported it made her feel uncomfortable. Staff Y said that this resident's grandson was on the phone with this resident. The grandson was saying he was getting dressed and was coming up to the facility right now to talk to Staff X. Staff Y stated the grandson said that Staff X was not going to talk to his grandma like that or treat his grandma that way. Staff Y stated that Staff X remained in the doorway and when Staff Y looked back at Staff X, Staff X kind of said under her breath she's lying, that's not true. Staff Y stated it wasn't an unsafe environment where the residents could not be cared for. She stated Staff X came in around 1:00 PM. on that day. Staff Y had told her multiple times to go help the other aides. Staff X would grab the tablet and look at it like she was looking at the care plans saying she didn't know them. She was just walking around like she was lost and she wanted to go fill ice cups. Staff Y stated she didn't feel Staff X was very competent with organizing her day and knowing what the needs were at that time. That was the conversation Staff Y had with Staff X. STaff Y stated that Resident #18 was a very sweet lady. She is alert and oriented X3. Staff Y told Staff X she didn't see why this resident would lie and also told Staff X that this resident wouldn't be able to reach behind her to turn the switch for the call light off because it needs to be turned off at the wall. Staff Y told Staff X to go home. Staff Y said it was around 4 pm when they were getting residents up. Staff Y stated she asked Staff AA, CNA and Staff BB what Staff X had been doing because none of her people were up. They said they didn't know but she clocked in early. Staff X may have helped with transferring maybe a couple of hours. Staff Y said Staff X had went to Staff Y several times to ask what she should be doing. Even after they got everyone up she asked what she should do. She just didn't seem like she knew what to do. Staff Y had directed Staff X to go talk to her team and see what she could do to help. Staff Y said that Staff X told Staff Z that she was going to answer call lights and Staff Z said can you finish up with Resident #18 first. Resident #18 told Staff Y that Staff X had left her lying flat on her bed when Staff X had left the room to get this resident a blanket. On 5/12/26 at 11:28 AM, this resident's grandson stated he was on facetime with his grandma. He stated during the phone conversation he could hear the staff person throwing the blanket at his grandma. The blanket covered the phone as the facetime call went dark. Staff X said 'you don't know anything, you turned your own call light off'. This grandson said that there was no possible way Resident #18 could have turned the call light off. This resident said during a 1:30 PM call (this grandson calls her several times a day just to check in on her) she still didn't have water that she had asked for at 1:00 PM. This grandson called her back at 7 PM to see how it was going and this resident told him they hadn't gotten her the water and they hadn't come in to change her, they hadn't done anything for her. He said that during the facetime call he overheard Staff X say to his grandma to 'Shut the fuck up. You know nothing, you are going to get me in trouble. You turned off your own call light, no one else turned it off.' Staff X was yelling at my grandma and definitely sounded threatening. He stated he was getting dressed and was going to get to the facility to intervene and get my grandma some help. He stated he was in tears because of what Staff X was doing to my grandma. He said he wanted to get up there and stop it. On 5/12/26 at 12:55 PM, Staff BB stated that Staff X didn't ask Staff BB for assistance. After supper Staff BB saw Staff X go into Resident #18's room [ROOM NUMBER] or 3 times. Staff BB saw Staff X grab wipes after she came out and then she went back in. Staff BB was standing with Staff Y, and Staff X was yelling at Staff Y saying it wasn't my (Staff X's) fault, I (Staff X) haven't gotten any help since I got here. Staff BB stated she said (to Staff X) you don't need to be lying, that's not true. Staff BB said she helped with transferring Staff X's residents and assisting to dine in the dining room. Staff BB told Staff AA before supper that she needed to help Staff get 2 residents up for supper. Staff AA did go help her. Staff BB said she told Staff X that the ipad was attached to her hand since she got to the facility and she had been sitting down in the chair. Staff BB stated there is enough staff if we work together, but you have to communicate. STaff BB hadn't worked with Staff X before. She really didn't know much about Staff X and hadn't seen her interact with any of the residents. Staff BB stated she had told Staff X that if she needed assistance she needed to go to Staff AA and ask her. Staff BB said that she told Staff X this early on in the shift when Staff X first got there. Staff BB stated Staff X said 'I know, I know'. Staff BB said that the next morning, Resident #18 asked Staff BB if she heard- 'that girl was in here and was cursing at me and accused me of shutting off my own call light. She came to my room [ROOM NUMBER] or 4 times and she didn't do anything for me'. ON 5/12/26 at 1:13 PM Staff AA, stated that anytime she would ask Staff X for help, Staff X would put it off so I would have to ask the nurse. Staff X got there at 1 and sat around and did nothing. Later that evening, Staff X wanted to say that nobody was helping her and Staff BB defended us because we were all helping her. One of the aides from the back had to come help me lay a resident down because she hadn't laid anyone down. I think it was close to 7:30/8:00 PM when Staff X left. The CNA came up front from the back and it was like 8:15 PM and we didn't get everyone laid down until after 10:00 PM. This was just the residents on Staff X's hall. Staff AA was done with the residents on her hall around 7 PM. Some of the residents we laid down had not been changed in awhile. Residents don't ever really stay up that long. Staff AA said she oriented Staff X a while back roughly around the first of April. Anytime Staff AA would tell her to do something or try to guide her she would just go and do her own thing. Staff AA stated she would ask Staff X to do something easy like assist residents to dine. It was almost like she was too afraid to do anything by herself. She would bring people back to their rooms instead. On 5/12/26 at 2:09 PM, Staff X stated she arrived at the facility that day about 1:00 PM. She wasn't there to work (until 2:00 PM) but her supervisor told her to go ahead and clock in. Staff X went to the hall she knew she was assigned to and asked if anyone needed help. She ended up assisting another CNA in a different hall. She asked Staff BB and another CNA if they needed help and they didn't so she started passing ice water and checking rooms. Staff X wasn't feeling well. Rounds were not going to be done. Resident #18 had pushed her call button and wanted to be cleaned up. They had told Staff X to look at the kardex before she did anything and if Staff X was unable to do something she should not turn the call light off. Resident #18 asked if she could be cleaned up. Staff X thought this was around 3:45 or 4 PM. Staff X reported this to Staff Y and Staff Y stated Resident #18 would have to wait a little while as they were getting people up for dinner. Staff X asked Staff Y who had turned the call light off. Staff X really didn't know who turned the call light off. Staff X said she tried to talk to the lady (Resident #18). Didn't go into her room until 3:45 PM. Staff X stated there was no truth to her sitting in the chair most of the shift. She was trying to show the other staff that Resident #18 was a check and change with an assist of 2. She denied cursing in front of the resident. Staff X stated they had her pretty upset. Staff X knew how bad it looked. Staff X stated that when Staff Y told her Resident #18 would have to wait, Staff X thought 'we know how bad' that was going to look. Staff X denied asking this resident if she shut off her own call light. Staff X said she told Staff Y that staff were supposed to leave the call light on if someone still needed help. Other residents needed help too. Staff BB was yelling and screaming. Staff X said she then asked Staff Z who turned the call light off?. Staff X said Resident #18 told her she didn't want Staff X in her room. Other residents needed help too. Finally Staff Z came in and Staff X asked her if she could help clean up Resident #18 as she hadn't been cleaned up since Staff X started her shift. Staff X thought Staff Z started her shift around 6:00 PM. Staff Z started freaking out because Resident #18 hadn't been checked and changed. Staff Z told me this lady has not been cleaned up so we are going to go in and clean her up. Then Resident #18 told me that she didn't want me in her room. Staff X stated that when they finally changed Resident #18 she was a complete bed change. Staff X verified that she had started work around 1 p.m. that day, didn't check on Resident #18 until 3:45 PM, and knew at that time she needed to be changed, but did not change her until after 6:00 PM. She stated she needed a second person and nobody would help her. Staff X stated that she had never been investigated before but prior to this was sent home for another resident who had concerns. Staff X stated the facility had brought her back but then this happened. 5/11/2026 12:12 PM Administrator acknowledged the concerns with this investigation. She stated that after their internal investigation this employee was no longer on their payroll. A Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated on 7/8/24, included the following direction:To achieve compliance with state and federal requirements for preventing, identifying, investigation and reporting abuse in all CSSL facilities. Scope: All employees of [NAME] Street Senior Living managed facilities. Rational: All Residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in personal degradation* including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (c.g., cameras, smart phones, and other electronic devices) to take, keep. or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property.These procedures shall include the screening and training of employees, protection of Residents and the prevention, identification. investigation, and timely reporting of abuse, neglect mistreatment, and misappropriation of property, without fear of recrimination or intimidation. *Verbiage related to personal degradation is only written in lowa Code: therefore, only applicable to facilities located in lowa.Employee Screening: The facility shall screen all potential employees for a history of abuse, neglect, exploitation, misappropriation of property. or mistreatment of Residents. The facility will not employ or otherwise engage individuals who: (i) Have been found guilty of resident abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law: (ii) Have had a finding entered into the State nurse aide registry concerning resident abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property: or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. This will be accomplished through the following (including maintaining documentation of such results): Any of the following as a result of the willful misconduct or grossnegligence or reckless acts or omissions of a caretaker, taking into account the totality of the circumstances: a. A physical injury to, or injury which is at a variance with the history given of the injury, or unreasonable confinement, unreasonable punishment, or assault of a dependent adult which involves a breach of skill, care, and learning ordinarily exercised by a caretaker in similar circumstances. Assault of a dependent adult means the commission of any act which is generally intended to cause pain or injury to a dependent adult, or which is generally intended to result in physical contact which would be considered by a reasonable person to be in: insulting or offensive or any act which is intended to place another in fear of immediate physical contact which will be painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act.b. Neglect of dependent adult(tm) means deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care. or other care necessary to maintain a dependent adult's life or physical or mental health. 6. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. 7. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds. to residents within hearing distance, regardless of age. ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limited to: * Harassing a resident: * Mocking, insulting, ridiculing; * Yelling or hovering over a resident, with the intent to intimidate; * Threatening residents, including but limited to, depriving a resident of care or withholding a resident from contact with family and friends: and * Isolating a resident from social interaction or activities Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

Based on record review, interview, and facility policy review, the facility failed to assess and provide pain management to adequately control residents pain for 1 of 3 residents (Resident 68) reviewed for pain management. This failure put the resident at risk of uncontrolled pain and a diminished quality of life. The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #68 documented a [DATE] admission date to the facility from an acute hospital stay. Her diagnoses included dementia, difficulty in walking, unsteadiness on feet, repeated falls, and need for assistance with personal care. The MDS showed the Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident was cognitively severely impaired. The MDS documented the resident's health conditions included pain management with scheduled pain medications and that the resident had not received PRN (as needed) pain medications or non-medication interventions for pain. Resident #3's Pain Assessment Interview revealed she had not experienced pain in the last 5 days. The MDS further documented the resident had shortness of breath when lying flat and with exertion. The MDS documented the resident had 2 or more falls in the past 3 months. The MDS documented the resident's medications did not include any high-risk drugs. The Care Plan for Resident #68 dated [DATE] identified the resident was at risk for falls, had pain or the potential for pain related to a history of pain to her right shoulder and arm. The interventions for Resident #68's pain directed the staff to: a. Anticipate the resident's need for pain relief and respond as soon as possible to any complaint of pain. b. Monitor and record the resident's pain severity on the 1 to 10 scale (a standard 0-10 tool where 0 is no pain and 10 is the worst imaginable pain) every shift and as needed. c. Report to Nurse any s/sx [signs or symptoms] of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). The care plan had not been updated to include the resident's right leg pain noted on [DATE] for which she was hospitalized from [DATE] to [DATE]. Resident #68's care plan also included her need for assistance with personal care which informed staff of her non-weight bearing to her right lower extremity and the need for a knee immobilizer brace to her right leg with skin checks two times daily. The care plan also directed staff check and change her incontinent brief as needed. Her care plan had been updated on [DATE] to include her need for hospice care related to her terminal prognosis with the goal to maintain the resident's comfort and directed staff to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met and to provide maximum comfort for the resident. Resident #68's electronic medical record (EMR) review revealed the pain medication Acetaminophen Tablet Give 650 mg (milligrams) by mouth every 6 hours as needed for Pain. not to exceed 3000 gm (grams) a day was prescribed upon her [DATE] re-admission to the facility from the hospital. Review of Resident 68's Medication Administration Record (MAR) for [DATE] showed Resident 68 was administered the pain medication on the following dates and times, and for the following documented pain levels:On [DATE] at 6:36 p.m., for a pain level of 5 which indicated moderate pain (pain level of 4 to 6, on the pain scale of 0 to 10 with 0 = no pain and 10 = worst)On [DATE] at 8:01 a.m., for a pain level of 5.On [DATE] at 8:18 a.m., for a pain level of 6.On [DATE] at 8:09 p.m., for a pain level of 4. On [DATE] at 7:36 p.m., for a pain level of 5. Review of Resident 68's EMR progress notes dated [DATE] revealed:A social service note at 8:53 a.m. indicating a referral had been made to a hospice agency as requested by Resident 68's daughter. A nurses note at 10:54 a.m. documented new physician orders had been received to discontinue Resident #68's oral medications and start the hospice comfort medications. The last progress note on [DATE] was at 1:39 p.m. which was a social service note. Review of Resident 68's Hospice paperwork revealed her Medication Orders SNF (Skilled Nursing Facility) form for PRN (as needed) Medications Orders dated [DATE] that included: Acetaminophen 650mg suppository - quantity 6 Insert 1 suppository rectally every 6 hours as needed for mild pain or fever. Morphine sulfate 20 mg/ml oral concentrate - quantity 30ml Take 0.25 ml (5mg) by mouth or under tongue every 2 hours as needed for moderate to severe pain or shortness of breath. Lorazepam mg/ml 0.25 ml Take 0.25 ml by mouth every 2 hours as needed for terminal restlessness/anxiety. Review of Resident 68's paper medical record revealed the record of the resident's pain severity indicated the resident had experienced moderate pain daily since her return from the hospital on [DATE] to [DATE]. When Resident #68 was admitted to hospice care on [DATE] the facility failed to monitor and record the resident's pain severity on [DATE] and [DATE] and no pain medications had been administered those two days. On [DATE] Resident #68's granddaughter visited the facility and sat at the resident's bedside from approximately 3:30 p.m. to 9:30 p.m. during this time period facility staff came into the room twice to check the resident's incontinent pad. During the first instance Resident #68 cried out as she was checked, the unidentified Certified Nursing Assistant (CNA) stated Resident #68's incontinent pad was dry and did not need to be changed. The resident's granddaughter asked the CNA if there was pain medication the resident could be given since Resident #68 had been restless, whimpering, and crying in pain during her visit. No staff returned to the room with any pain medication. During the second instance a different unidentified staff person checked her incontinent pad and needed to change the pad as it was soiled. The staff person rolled Resident #68 on her left side and the resident's granddaughter helped hold her on her left side and comforted her as she cried out while the staff person changed her into a clean incontinent pad. Resident #68's granddaughter asked this staff person for some pain medication to be given since Resident #68 had been whimpering and crying for hours. The staff person stated she would let the nurse know of the resident's need for pain medication. When Resident #68's granddaughter left the facility around 9:30 p.m. no nurse or staff person had returned to the resident's room with pain medication. A review of Resident #68's paper medical record and EMR revealed the there was no documentation regarding the resident receiving any pain medications on [DATE]. Review of Resident 68's EMR progress notes revealed no progress notes had been documented following the [DATE] social service progress note at 1:39 p.m. until [DATE] at 7:30 a.m. when a physician progress note had been documented that indicated Resident #68 had been admitted to hospice care on [DATE]. The [DATE] physician progress note indicated the resident was Still with uncontrolled pain to her right knee [due to] a periprosthetic fracture [ a fracture around a joint replacement implant] around [her] internal prosthetic right knee joint [an artificial implant used to replace damaged bone and cartilage in the right knee]. Seeing her today she is still in significant pain and appears very uncomfortable. Hospice was contacted regarding medications/pain management. Review of Resident 68's Hospice paperwork revealed the Hospice Registered Nurse (RN) had visited the resident at the facility on [DATE] from 8:47 a.m. to 9:59 a.m. and noted . upon entry pt [patient] is in her bed, occasional moans and facila [facial] grimacing noted. Facility struggled to get Morphine and Ativan delivered. Call placed to ARNP [Advanced Registered Nurse Practitioner] and collaborated with facility LPN [Licensed Practical Nurse] and morphine was taken from facility E [Emergency] kit and dose administered. The Hospice RN documented Resident #68's pain was at a level 4 (moderate pain). This was the first documented administration of the Morphine sulphate 20mg/ml oral concentrate . Take 0.25 ml (5mg) by mouth or under tongue every 2 hours as needed for moderate to severe pain or shortness of breath that was listed on the Hospice's Medication Orders dated [DATE]. Review of Resident #68's paper Individual Patient's Narcotic Record revealed Staff K, LPN, documented 0.25 mL (milliliter) of morphine was administered at 9:30 a.m., The Narcotic Record revealed the resident's morphine pain medication was further administered on [DATE] at 11:30 a.m. and 1:30 p.m. by Staff K, LPN.; at 6:30 p.m. by another LPN; and at 8:30 p.m. by Staff E, LPN. Review of Resident #68's paper [DATE] MAR revealed the resident's Lorazepam 0.25 ml medication to be taken by mouth every 2 hours as needed for terminal restlessness/anxiety had been given on [DATE] at 6:30 p.m. by a staff LPN and at 8:30 p.m. by Staff E, LPN. Review of Resident #68's Narcotic Record revealed on [DATE] at 8:30 a.m. Staff K, LPN, administered Resident 68's final dose of morphine pain medication and review of the resident's [DATE] MAR revealed Staff K, LPN had administered the final dose of the resident's Lorazepam medication at the same time 8:30 a.m. On [DATE] Staff K, LPN was called to Resident #68's room at 9:20 a.m. when the resident had passed away. In an interview on [DATE] at 1:50 p.m. the Administrator and the [NAME] President (VP) of Clinical Operations revealed Resident #68 had been a long-term resident who had admitted in 2020 and died in the facility on [DATE]. They stated that [DATE] the facility had changed from the previous ownership group to the current ownership group who currently managed the facility. They revealed that the facility's EMR's database had changed on [DATE] and the facility had completed documentation on paper in some areas and they would access Resident #68's paper medical chart to provide what was needed. The Administrator and VP of Clinical Operations revealed that Resident #68's daughter had been given a list of hospice agencies on [DATE] and on [DATE] a referral was made to the hospice agency the resident's daughter had chosen and Resident #68 had been admitted to hospice care on [DATE]. The VP of Clinical Operations verified that the pain medications ordered by hospice were available in the facility's e-kit which was kept in the nurses' medication room. On [DATE] at 3:22 p.m. the VP of Clinical Operations provided Resident #68's paper medical record for the pain medications administered [DATE]. In an interview on [DATE] at 12:15 p.m. with the Administrator Resident #68's pain records were discussed which revealed no monitoring of the resident's pain level had been documented and no pain medications had been provided to the resident on [DATE] and [DATE]. The Administrator agreed and further agreed that the hospice medication orders had been made on [DATE]. Discussion continued regarding Resident 68's November MAR that had a starting date of [DATE] at 10:30 a.m. for the pain medications to which she agreed and stated the Director of Nursing (DON) was working at the facility during that time period and could provide further information. Discussion then focused the Resident 68's family being in facility on [DATE] from 3:30 - 9:30 p.m. while the resident experienced pain and the family had requested her pain medications with no pain medications having been given and no documentation of pain medications administered on [DATE]. The Administrator stated her expectation was for the nursing staff to address a resident's pain and administer the resident's pain medications appropriately to alleviate a resident's pain. In an interview on [DATE] at 2:17 p.m. with Staff L, CNA stated she had worked at the facility for 10 months and usually worked the evening shift from 2 p.m. to 10 p.m. Staff L, CNA recalled caring for Resident #68 and stated the resident was in a lot of pain in late October to [DATE], but could not recall any specific event that had caused the pain. She stated that Resident #68 had pain every day in her right knee and that every time she was moved, she would vocalize her pain. She stated she had no knowledge about the resident's pain medications as she was not responsible for giving those pain medications. Further discussion on the day of [DATE] and review of the nursing schedule for that day had Staff L, CNA assigned to Resident #68's hall for the 2:00 p.m. to 10:00 p.m. shift. She stated that she could not recall if she had told the nurse about Resident #68's pain that day as it was six months ago. She further stated that Resident #68 was always in pain, so she thought the nurse would have known about her pain. She agreed that the staff would allow Resident #68 to remain in bed as transferring the resident had caused her pain. She stated that when she rolled the resident, the resident would hold on to the side rail while she changed the resident's incontinent pad and that rolling Resident #68 had caused her to experience pain. In an interview on [DATE] at 3:05 p.m. with Staff E, LPN regarding Resident #68 she stated she could recall the resident, but could not recall specifically what had happened or when the resident was uncomfortable or in pain. In an interview on [DATE] at 10:55 a.m. with the hospice agency's RN Regional Director of Clinic Operations she revealed Resident #68 had been admitted to hospice the afternoon of [DATE] by one their agency's Hospice RNs that currently no longer worked for their agency. She stated that another Hospice RN had visited Resident #68 at the facility on [DATE] from 1:55 p.m. to 2:45 p.m. and at that time she had noted the patient appeared comfortable. She stated that Hospice RN also noted that the facility was changing from pharmacy provider to another pharmacy and that a conversations with the facility's DON revealed the DON stated they would pull medications from the facility's e-kit if needed. The hospice agency's RN Regional Director of Clinic Operations further revealed that the Hospice RN that had admitted the resident to hospice care visited the resident at the facility on [DATE] at 8:47 a.m. and noted that upon entry occasional moans and facial grimacing noted and that the Hospice RN worked with facility staff that day to have Morphine taken from the facility's e-kit and administered. In an interview on [DATE] at 12:17 p.m. with Staff K, LPN revealed she had worked at the facility for two and a half years and recalled caring for Resident #68. She stated Resident #68 was not a resident that complained a lot, but liked things to be done in a certain way and was a tough lady. She could not recall specific events as those events had occurred six months ago. She did recall that Resident #68 upon her return from the hospital in late [DATE] refused to get out of bed, would not feed herself, but would eat some of each meal when staff assisted her. She stated that when Resident #68 was moved, she would grimace and be in pain. Staff K, LPN recalled Resident #68's daughter had visited often and the resident's granddaughter had also visited her. She stated Resident #68's daughter had not wanted the resident to be in pain. She recalled that it was the resident's right lower leg that caused her pain and that when the staff turned her by rolling her to her left side, they would talk to her, and let the resident hold on to the staff as that appeared to comfort the resident. She stated that in early [DATE] the facility was changing their pharmacy provider and she could not recall which pharmacy had been used for Resident #68's medications. She stated the facility was having some problems with both pharmacy providers, but was not aware of any specific problems. She agreed that the facility's e-kit had pain medications available. Further discussion focused on [DATE] when Staff K, LPN had worked from 6:00 a.m. to 6:00 p.m. and the afternoon and evening that day when Resident #68 was experiencing pain. Staff K, LPN stated she could not recall that specific day, but stated the staff were aware of Resident #68's pain as she would literally just lay in her bed with her immobilizer on her right leg. She stated she could not recall any pain medications that had been requested by the granddaughter. She stated she recalled the resident's daughter asking her about the resident's pain medications and she recalled that on [DATE] she had administered her pain medications multiple times that day. In an interview on [DATE] at 1:30 p.m. with the DON she revealed she had worked at the facility for the past 4 years as their DON. She recalled Resident #68 had been hospitalized from [DATE] to [DATE] for her right lower extremity pain. She reviewed the resident's EMR and hospital reports and stated the reports indicated no acute fracture with swelling around the prosthetic joint in her right knee. The DON agreed that on [DATE] at 1:09 p.m. she had entered a progress note in Resident #68's EMR regarding the resident's current non-weight bearing status and that her assistance with personal cares had increased. She had noted the family's decision to pursue hospice services for Resident #68. The resident's pain was discussed and the monitoring and documentation of her pain level after returning from the hospital on [DATE] until [DATE], with no documentation of monitoring the resident's pain level on [DATE] until the resident's death on [DATE]. The DON stated that when hospice care began on [DATE], the facility had discontinued the oral medications when they had received the medication orders from the hospice agency. She stated that when the facility's pain medications were discontinued, the facility had also inadvertently discontinued the monitoring and documentation of the resident's pain level on the pain scale. The DON stated that Resident #68 was very stoic and did not like taking medications. She would clamp her mouth shut at times and refuse her medications. The DON agreed that after her return from the hospital on [DATE] the resident experienced pain with movement. After reviewing that upon her hospital return, the resident was getting pain medication daily from [DATE] to [DATE] and when asked regarding no pain medication administration was documented on [DATE] or [DATE], she replied that if pain medication was not documented then it had not been given. The DON stated that during that time period when the resident was admitted to hospice care on [DATE], the facility's management changed from the previous management company to the current management company and stated there was a lot of chaos and electronic down time during that transition. She also stated that during that time the facility was also changing its pharmacy provider. After reviewing Resident #68's EMR documentation, she stated the documentation had not reflected the resident's pain status. The DON stated the reason for no documentation in Resident #68's EMR after the [DATE] 1:39 p.m. progress note until the [DATE] 7:30 a.m. progress note, [42 hours of no documentation] could have been related to the chaos and electronic down time with the change in the nursing facility's management company. She stated she would check Resident #68's paper medical record to see if there were any handwritten progress notes. On [DATE] at 2:04 p.m. the DON stated she had not found any hard copy progress notes for Resident #68. Review of the facility's Pain Management policy dated 2025 revealed The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The policy revealed that the facility used a systematic approach for recognition, assessment, treatment, and monitoring of pain. The facility would evaluate the resident for pain when a significant change in condition or status occurred (e.g. with new pain or an exacerbation of pain) and staff would observe for nonverbal indicators which may indicate the presence of pain which included increased or recurring restlessness, facial expressions (e.g. grimacing), and negative vocalizations (e.g. groaning, crying, whimpering, or screaming). The policy stated the facility would use a pain assessment tool, which was appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. The policy further indicated that the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative would develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. The policy indicated the interdisciplinary team was responsible for developing a pain management regimen that was specific to each resident who has pain or who has the potential for pain. Review of the CMS [DATE] Psychosocial Outcome Severity Guide revealed that examples of negative psychosocial outcomes as a result of the facility's noncompliance that resulted in actual harm included verbal and/or non-verbal expressions of pain (moaning, whimpering, and crying) and distress (restlessness).

Based on the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Reports, staff interviews, facility assessment review, and facility record review, the facility failed to provide sufficient staff to meet resident needs for 12 of 26 weekend days during the months of October, November, and December 2025. The facility reported a census of 58 residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for the facility for October 1 through December 31, 2025 revealed the facility had triggered the metric for Excessively Low Weekend Staffing which required follow-up during the survey process. The PBJ Nurse Staffing and Non-Nurse Staffing datasets provided information submitted by the facility on a quarterly basis. CMS had long identified staffing as one of the vital components of a nursing home's ability to provide quality care. In an interview on 5/5/26 at 1:59 p.m. Staff I, Certified Nursing Assistant (CNA) stated she had worked at the facility since July 2024. She stated the facility was really short staffed and as a result the residents showers had not been completed as assigned. In an interview on 5/6/26 at 8:26 a.m. with Staff M, CNA stated We used to have 4 CNA's but currently we have 3 [CNAs] and have been running around like chickens with our heads cut off. I don't even have time to chart as she had wiped sweat off her forehead and then she helped to pass breakfast trays to the residents. In an interview on 5/6/26 at 2:00 pm. Staff N, CNA stated she had worked at the facility for one year. She stated that down the hall that she had been assigned, she was by herself that day with six residents that required a Hoyer lift to transfer and at least eight residents that required two staff members to care for them. She stated I don't like the staffing and that the facility managers needed to look at how much care the residents needed. She stated that most of the staff try to get the residents showered as assigned, but the agreed that resident showers had not always been completed. She stated she felt that all the tasks assigned was not getting done, and stated at times the staff cannot get residents' incontinent pads checked and changed every two hours according to the residents' care plans. She stated I just feel we just don't have enough time [or staff] to give adequate care. In an interview on 5/6/26 at 2:54 p.m. with Staff O, CNA stated she had been a CNA for 20 years. She stated that staffing gets stressful at times and that at times she would stay to work the next shift because another CNA staff person had called in. She stated she was stressed as for the upcoming weekend the nursing schedule was short staffed. In an interview on 5/7/26 at 12:50 p.m. with the Administrator the PBJ Staffing Data Report for October 1 through December 31, 2025 was discussed which revealed the facility had triggered the metric for Excessively Low Weekend Staffing and the weekend Daily Staffing sheets were requested for those months. Review of the facility's 2026 Facility Assessment, revised November 2025 revealed it had been reviewed on April 2026 by the Administrator. The stated purpose of the Facility Assessment was a complete review of internal human and physical resources required by the facility to care for residents competently during day to day (including nights and weekends). operations. The assessment identified two distinct nursing units and that the CNAs were scheduled for three different eight-hour shifts: Day, Evening, and Night. On the Day Shift there were seven to eight CNAs needed, three on the smaller nursing unit and four to five on the larger nursing unit. On the Evening Shift, there were six to eight CNAs needed, two to three on the smaller unit and four to five on the larger nursing unit. On the night shift three to four CNAs were needed, the assessment did not differentiate the nursing units for the night shift. The assessment identified the licensed nurses were scheduled for two different 12-hours shifts: Day and Night. Each shift had two to four nurses working or a combination of nurses and Certified Medications Assistants (CMAs). The assessment did not differentiate the number of nurses/CMAs for each nursing unit. A review on the requested weekend Daily Staffing sheets for October 1 through December 31, 2025 revealed: a. On Sunday, 10/5/25: The Day Shift on the larger nursing unit was staffed with three CNAs. The Facility Assessment documented four to five CNAs were needed. The Evening Shift on the larger nursing unit was staffed with four CNAs, but two of the CNA staff were crossed out with CI (Called In) noted by their names, which left two CNAs. The Facility Assessment documented four to five CNAs were needed. The Night Shift for the facility was staffed with one CNA on the smaller nursing unit and two CNAs on the larger nursing unit, but one of the CNA staff was circled with CI noted by her name, which left two CNAs for the night shift for the facility. The Facility Assessment documented three to four CNAs were needed. b. On Saturday, 10/11/25; Sunday, 10/26/25; the Evening Shift on the larger nursing unit was staffed with three CNAs. The Facility Assessment documented four to five CNAs were needed. c. On Sunday, 11/9/25 the Day Shift on the larger nursing unit was staffed with three CNAs. The Facility Assessment documented four to five CNAs were needed. c. On Sunday, 11/16/25:The Day Shift on the larger nursing unit was staffed with four CNAs, but one CNA was circled with NCNS (No Call No Show) noted by her name and another CNA was circled with CI noted by her name, which left two CNAs. The Facility Assessment documented four to five CNAs were needed. The Evening Shift on the larger nursing unit was staffed with four CNAs, but one CNA was circled with CI @ 2pm (Called In at 2:00 p.m.) noted by her name, which left three CNAs. The Facility Assessment documented four to five CNAs were needed. d. On Saturday, 11/22/25 the Day Shift on the larger nursing unit was staffed with five CNAs, but three CNAs were circled with CI noted by each of their names, which left two CNAs. The Facility Assessment documented four to five CNAs were needed. e. On Sunday, 11/23/25 the Day Shift on the larger nursing unit was staffed with four CNAs, but one CNA had been moved to the smaller nursing unit for a CNA that had CI noted by their name, which left three CNAs, The Facility Assessment documented four to five CNAs were needed. f. On Sunday, 11/30/25 the Day Shift on the smaller nursing unit was staffed with three CNAs, but on CNA had been crossed out with CI noted by their name, which left only two CNAs. The Facility Assessment documented three CNAs were needed. g. On Saturday, 12/6/5 for the Evening Shift:The smaller nursing unit was staffed with one CNA. The Facility Assessment documented two to three CNAs were needed. The larger nursing unit was staffed with three CNAs. The Facility Assessment documented four to five CNAs were needed. h. On Sunday, 12/14/25, the larger nursing unit had three CNAs scheduled. The Facility Assessment documented four to five CNAs were needed. i. On Saturday, 12/20/25 the smaller nursing unit had three CNAs scheduled with two CNAs crossed out with CI noted by their names, which left one CNA and an RN/CNA or two CNAs. The Facility Assessment documented three CNAs were needed. j. On Sunday, 12/21/25 the Day Shift on the smaller nursing unit was staffed with two CNAs. The Facility Assessment documented three CNAs were needed. In an interview on 5/11/26 at 12:06 p.m. with the Administrator the days noted above with excessively low staffing were reviewed. The Administrator revealed that the CI noted on the Daily Staffing sheets indicated that the CNA staff member had Called In for the shift that day and had not reported for work. She also revealed that the NCNS noted on the Daily Staffing sheets indicated that the staff person had been a No Call No Show for the shift that day, meaning that staff person had not called in and had not reported for work that day. The Administrator agreed with findings for the days and shifts noted above with excessively low weekend staffing.

Based on observation, clinical record review, resident and staff interviews, the facility failed to assess if a resident was appropriate to self-administer medications for one of one residents review for self-medication administration. Resident#54 was left unsupervised with medications. The facility reported a census of 58 residents. The Minimum Data Set (MDS) dated [DATE] for Resident #54 revealed the diagnoses of a heart dysrhythmia, high blood pressure, arthritis, depression and long-term gall bladder inflammation. The MDS identified that Resident #54 was taking antidepressant medication. A Brief Interview for Mental Status (BIMS) score of 13 suggested Resident #54 was cognitively intact. The Care Plan for Resident #54 revealed the risk for pain, a potential for altered mood and was elected for Hospice care due to his terminal condition. The Hospice care plan directed licensed nursing staff to provide medications as ordered. During an observation on 5/4/26 at 1:05 pm, Resident #54 was laying in bed with a bedside stand in front of him with a medication cup that contained a large pink pill, a large white pill and two smaller pills. It appeared that Resident #54 had a pill in his pinched fingers of the right hand. There was no licensed nursing staff in the room with Resident #54. Two Certified Nursing Assistants (CNA's) were assisting the room mate into the other bed in the room. Subsequent observations on 5/4/26 revealed: a. At 1:09 pm, Resident #54's left hand was holding the medication cup on his night stand with the same amount of medication in it.b. At 1:11 pm, Staff E, Licensed Practical Nurse (LPN) was in the hall outside Resident #54's room talking with another resident, then walked away.c. At 3:00 pm, Resident #54 continued to have the medication cup that contained the same medication on his night stand. During an interview on 5/4/26 at 3:00 pm, Resident #54 stated he could administer his own medication as he continued to hold the medication cup with the same medication in it. During an observation on 5/4/26 at 3:35 pm, after notifying Staff E, LPN that Resident #54 had medication on his night stand, Staff E took the medication cup, picked up the pill on Resident #54's blanket and stated, They are late, now I will have to see what they want me to do. Staff E left the room and Resident #54 shrugged his shoulders. During an interview on 5/4/26 at 3:35 pm, Staff E, LPN stated the medication in the medication cup was brought to Resident #54 earlier this morning. Staff E stated she then was asked to assist across the hall with a resident utilizing a mechanical lift. Staff E stated she had left the medication with Resident #54 and did not return to his room to see if he had taken them. The Medication Administration Record (MAR) dated May 2026 for Resident #54 revealed the following 6 am medications were administered and initialed by Staff E, LPN included:1. Allopurinol Oral Tablet 300 milligram (MG)(Allopurinol) Give 1 tablet by mouth in the morning for gout.2. Gabapentin Oral Capsule 300 MG(Gabapentin) Give 1 capsule by mouth in the morning for pain.3. Omeprazole Oral Tablet Delayed Release 20 MG (Omeprazole) Give 1 tablet by mouth in the morning for bile duct obstruction.4. Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth in the morning for depression.5.Sennosides Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth two times a day for constipation prevention.The Progress note dated 5/4/2026 at 3:45 pm revealed Resident #54 was requesting to only take the pills that are a necessity and was refusing to take the supplements. Staff E, LPN reached out to Nurse Practitioner to get a one-time order to administer Senna, Allopurinol, Omeprazole and Sertraline late. During an interview on 5/05/2026 at 1:59 pm, Staff I, Certified Nursing Assistant (CNA) reported observations of nurses leaving medications with resident's and walked away on multiple occasions. Staff I stated on 5/4/26 at 12 pm, Resident #54 was known for not taking his medication, noticed he still had his medication and notified Staff E, LPN.The VP of Clinical Operations provided a document titled Medication Administration Audit Report for Resident #54 dated 5/6/26 at 12:30 pm that revealed the Omeprazole, Allopurinol, Gabapentin, Sertraline and Sennosides were documented as administration date 5/4/26 at 9:03 am by Staff E, LPN. During an interview on 5/6/26 at 12:45 pm, The VP of Clinical Operations stated Resident #54 did not have an order to administer his own medication.

Based on clinical record review, resident and staff interviews, and resident council meeting, the facility nursing staff failed to notify the physician of a change of condition for 1 of 3 residents were reviewed (Resident #11). During a resident council meeting, Resident #11 reported having chest pain during the night to Staff J, Activities Director. Staff J filled out a grievance form and gave it to the Director of Nursing (DON) who failed to follow up and report the episode to the physician. The facility reported a census of 58 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #11 revealed the diagnoses of Parkinson's and was independent for activities of daily living. Resident #11 denied pain during the assessment. The Brief Interview for Mental Status (BIMS) score was 15 suggested an intact cognition.The Care Plan directed staff to monitor and document pain for probable cause of each pain episode and notify the physician if pain was a significant change from past experiences. During an interview on 5/4/26 at 1:26 pm, Resident #11 stated she had experienced chest pain during the night on 4/27/26, notified Staff G, Certified Nursing Assistant (CNA) and requested to see Staff H, Licensed Practical Nurse (LPN). Resident #11 stated the pain was a crushing pain that lasted about 15 minutes and she felt scared. Resident #11 stated the nurse did not respond, the pain subsided and she did not tell the nurse the next day. Resident #11 did inform staff in the Resident Council meeting on 4/28/26. A review of the Progress Notes for April/May 2026 revealed no documentation of Resident #11 had chest pain nor provider and family notification.During an interview on 5/04/2026 at 2:42 pm, Staff E, LPN stated she would believe Resident #11 if she would tell her anything, she was very believable. Staff E stated Resident #11 had not reported having chest pain. Staff E stated she would assess Resident #11 and give a report to the nurse practitioner tomorrow. During an interview on 5/7/26 at 8:38 am, Staff J, Activity Director stated on 4/28/26 was the first resident council she conducted. Staff J stated during the Resident Council meeting, Resident #11 stated she had chest pain overnight on 4/27/26 and the nurse did not come see her. Staff J stated she asked the Administrator what I do with the notes of concerns and was given grievance forms to fill out. Staff J stated she filled out a grievance form and gave it to the Director of Nursing (DON) the next morning on 4/29/26. During an interview on 5/07/2026 at 8:55 am, The Administrator stated when Staff J, Activity Director inquired what to do with the resident council concerns, she was given grievance forms to fill out and directed to give them to the responsible manager. The Administrator stated Staff J mentioned another resident's concern but couldn't remember if she was informed that Resident #11 having chest pain. The Administrator stated chest pain was a concern that would require immediate nurse assessment. During an interview on 5/06/2026 at 3:29 pm, The DON stated she was aware that Resident #11 complained of chest pain during a night shift and she told the CNA, who did tell the nurse but when they went back in to assess her she was asleep. The DON stated she was aware that Resident #11 filed a grievance that she complained of chest pain and the nurse did not come in to assess her. When inquired where it was documented that Resident #11 had chest pain, and the assessment and inquired if the provider was notified, the DON said no. The surveyor informed the DON that Resident #11 had the chest pain and informed Staff E, LPN on 4/4/26 who stated she would conduct an assessment and will notify the provider but there was no documentation of that assessment nor provider notification. The DON stated she would check on that but failed to provide a response to the survey team.During an interview on 5/7/26 at 8:26 am, Staff H, Licensed Practical Nurse (LPN) stated that he was the charge nurse on the over-night shift on 4/27/26. Staff H denied being informed of that Resident #11 had chest pain. Staff H stated if he was informed of that, he would have provided an assessment, notified the provider and provided pain management. Staff H verified he had worked on Resident #11's hall with Staff G, CNA and denied that the CNA had mentioned the chest pain episode.During an interview on 5/11/26 at 2:49 pm, The Administrator stated she was going to need to meet with the DON as the time lines did not make sense on the grievance form and the investigation of the grievance.During a follow up interview on 5/11/26 at 3:19 pm, The Administrator stated she had a conversation with the DON, who stated she had dated everything with the date of the grievance report, 4/28/26, due to her inability to remember what day she was notified of Resident #11's episode. The Administrator stated the DON reported that she told Resident #11 that she planned to discuss the situation with the LPN and the CNA involved.A document dated 4/30/26 a note to Staff F, LPN that revealed a directive from the DON to have a discussion with Staff G, CNA related to care expectations and reporting concerns. The document listed the complaint from Resident #11 regarding the chest pain episode that was not verified with Staff H, LPN as of yet. The document stated the report of concerns, especially chest pain, needed to be reported to the nurse immediately. The directive included to monitor Staff G for the next 3 shifts and notify the DON in writing if there were further concerns.

Based on record review and interviews, the facility failed to do the assessment for an initial Brief Interview of Mental Status (MDS), for Resident #34. The facility reported a census of 58 residents. Findings include:A Brief Interview of Mental Status (BIMS) dated 3/17/26 at 11:39 a.m., documented that Resident #34 was not assessed. On 5/7/26 at 12:41 p.m., the Administrator stated that the BIMS was not done with Resident #34's initial MDS. They had a PRN (as needed) traveling MDS person who worked on the MDS remotely. There was a miscommunication and it did not get conveyed to social services or anyone on the team in the facility that an MDS assessment needed to be done. A PRN BIMS was done today. A BIMS (PRN) dated 5/7/26 at 11:30 p.m., documented a score of 8 out of 15, which indicated moderately impaired cognition for Resident #34. A MDS 3.0 Completion policy dated 2025, directed the following:Policy:Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Definitions: OBRA Assessment refers to an assessment mandated by the Omnibus Budget Reconciliation Act of 1987, which specifies a Minimum Data Set (MDS) of core elements for use in assessing nursing home residents. PPS Assessment refers to an assessment used in the skilled nursing facility prospective payment system to classify residents into categories for payment purposes. ARD, or Assessment Reference Date, refers to the specific endpoint in the MDS assessment process ( last day of MDS observation period). Comprehensive Assessment refers to the completion of the MDS, Care Area Assessment (CAA) process, and development and/or review of the comprehensive care plan.Policy Explanation and Compliance Guidelines:According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State.Types of OBRA Assessments:Entry TrackingComplete and submit with every entry into the facility no later than entry date + 7 calendar days.The staff member who is completing the entry tracking enters his/her signature, title, and date completed.The Entry Tracking does not require an R.N. Coordinator's signature and may be completed and signed by any member of the interdisciplinary team.admission Assessment - completed within 14 days of admission counting the day of admission as day #1 when:The resident has no prior admission, orPrior admission was less than 14 days and no admission assessment was completed during the prior admission, orPrior admission ended with a Discharge Return not Anticipated; orPrior admission ended with a Discharge Return Anticipated and re-entry occurred >30 days after the discharge date .Annual Assessment - a comprehensive assessment completed using an ARD no >366 days from the most recent prior comprehensive assessment and no >92 days from the most recent quarterly assessment (counting ARD to ARD).Significant Change in Status Assessment (SCSA) - a comprehensive assessment completed within 14 days of the identification of a status change that meets the requirements outlined in Chapter 2 of the Version 3.0 RAI Manual.A significant change is a major decline or improvement in a resident's status that: (1) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting, if a decline); (2) impacts more than one area of the resident's health status, and (3) requires interdisciplinary review and/or revision of the care plan.A SCSA is required when a resident enrolls in a hospice program or changes hospice providers and remains in the facility, or a resident in the facility receiving hospice services discontinues those services (known as revocation of hospice care) and remains in the facility.A SCSA cannot be completed prior to the completion of an OBRA admission assessment.Quarterly Assessment - completed using an ARD no >92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD).Discharge Assessment - completed using the discharge date as the ARD. Must be completed within 14 days of the discharge date /ARD.Significant Correction of a Prior Comprehensive Assessment - a comprehensive assessment completed when the resident's overall clinical status was not accurately represented (i.e., miscoded) on the erroneous comprehensive assessment and the error has not been corrected via submission of a more recent assessment. Not to be confused with a Significant Change in Status Assessment. It must be completed no later than 14 days after the ARD and not later than 14 days after the determination was made that a significant error occurred.Significant Correction of a Prior Quarterly Assessment - completed when the resident's overall clinical status was not accurately represented (i.e., miscoded) on the erroneous quarterly assessment and the error has not been corrected via submission of a more recent assessment. Not to be confused with a Significant Change in Status Assessment. It must be completed no later than 14 days after the ARD and no later than 14 days after determining that the significant error occurred.Death Tracking Complete when a resident expires in the facility or when on LOA no later than discharge (death) date + 7 calendar days.The staff member completing the death tracking enters his/her signature, title, and date completed.The Death Tracking does not require an R.N. Coordinator's signature and may be completed and signed by any member of the interdisciplinary team.Types of PPS Assessments:5 Day/Initial Assessment The ARD must be set for days 1 through 8 of each Part A SNF covered stay.Must be completed within 14 days after the ARD (ARD + 14 days). If combined with the OBRA assessment, it must be completed by the end of day 14 of admission (admission date + 13 days). This assessment authorizes payment for the entire PPS stay (except in cases when an IPA is completed).Part A PPS Discharge Assessment - required under the Skilled Nursing Facility Quality Reporting Program.This assessment is completed on planned discharges when a resident's Medicare Part A stay ends, but the resident remains in the facility (unless it is an instance of an interrupted stay).If the End Date of the Most Recent Medicare Stay occurs on the day of or one day before the discharge date of a planned discharge, the OBRA Discharge Assessment and the Part A Discharge Assessment are both required and must be combined. When the OBRA and Part A PPS Discharge assessments are combined, the ARD must be equal to the discharge date .Must be completed within 14 days of after the End Date of Most Recent Medicare Stay.Interim Payment AssessmentThis is an optional assessment that authorizes payment for remainder of the PPS stay, beginning with the ARD.The assessment is completed as the SNF determines is necessary to account for changes in patient care needs. See Interim Payment Assessment (IPA) Policy.If performed, it must be completed within 14 days after the ARD (ARD + 14 days).Optional State Assessment - this is a standalone assessment required at the discretion of the state agency for payment purposes.Care Plan Team Responsibility for Assessment Completion:Interdisciplinary Responsibility for Completion of MDS Sections:The responsibility of all sections of the MDS will be clearly assigned. See MDS 3.0 Responsibility by Discipline supplemental document.Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections.The R.N. Coordinator signs, dates, and attests (in section Z0500A) to timely completion of the RAI, once all other disciplines have completed their sections.Coding of Assessment:All disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment.Within 7 days after completing a resident's MDS assessment or tracking record, the facility must encode the MDS data (i.e., enter the information into the facility MDS software).Assessment Reference Date:The assessment reference date is established as reference point for all staff participating in the assessment process. Although staff members may work on completing a resident's MDS on different days, establishment of the assessment reference date ensures the commonality of the assessment period.Observation should continue through the assessment reference date at midnight.Interviews such as the BIMS, PHQ-2 to 9, Pain Interview, and Preferences for Customary and Routine Activities should be completed on or before the ARD.Care Area Assessment (CAA's):The CAA process outlined in Chapter 4 of the RAI manual is designed to assist the assessor in systematically interpreting the information recorded on the MDS to facilitate decision making regarding the resident's plan of care.There are 20 CAAs. The responsibility for completion of each CAA will be clearly assigned. See CAA and Care Plan Division of Responsibility - Expectation List supplemental document.Based on the CAA review, key findings regarding a resident's status are documented, including the nature of the condition, complications and risk factors that affect the care planning decision, factors that must be considered in developing care plan interventions, and the need for referrals or evaluation by appropriate health professionals.Written documentation of the CAA findings and decision-making process may appear anywhere in the resident's record. Use the relevant columns on the CAA summary section of the MDS to document location and date of the information, and the decision to proceed or not to proceed to care planning.The CAA's are completed no later than 14 days after admission and each time a comprehensive MDS is completed.The R.N. overseeing the completion of the CAA's will sign the CAA Summary section at the Signature of R.N. Coordinator for CAA Process and Date Signed section. The date the process was completed will be entered beside the signature.The signature of the Person Completing Care Planning Decision can be any designated member of the care plan team or persons who facilitate the care planning decision-making process. The date entered here is the date the care plans for all triggered CAA's are complete.The care plan is completed no later than 7 days after the date in V0200C (CAA's completion date) as well as no later than 21 days from the date of admission in cases where the comprehensive assessment is an admission MDS.Correction of Errors on the Assessment:Errors identified prior to being submitted into iQIES or were submitted and rejected must be corrected. The facility has up to 7 days to encode and edit an MDS assessment after the MDS has been completed. (See the current RAI Manual Version 3.0 Chapter 5, 5.6 for details relating to significant errors vs. minor errors.)Errors identified in iQIES records must be corrected within 14 days after identifying the errors. Errors may include transcription errors, data entry errors, software product errors, item coding errors or other errors. Correction processes for MDS records that have been accepted into iQIES include Modification Requests, Inactivation Requests, and MDS 3.0 Individual Correction/Deletion or Move Requests.Modification Request:A Modification Request is used when an MDS record (assessment, entry tracking record, or death in facility tracking record) is in iQIES (already transmitted and accepted by CMS), but the information in the record contains clinical or demographic errors. It must be corrected within 14 days after identifying the errors. (See the current RAI Manual 3.0 Chapter 5, 5.7 for details relating to significant vs. minor errors.)The modification process is not permitted for certain items. The exceptions are listed in the current RAI Manual Version 3.0, Chapter 5.7.Inactivation Request:An inactivation request is used when a record has been accepted into iQIES but the corresponding event did not occur. An inactivation must be completed when specific items on the MDS are inaccurate. These items are listed in the current RAI Manual Version 3.0, Chapter 5.7.MDS 3.0 Correction, Deletion, and Move Requests:A few types of errors in a record in iQIES cannot be corrected with a Modification or Inactivation request. These errors are:The record has the wrong unit certification or licensure designation in Item A0410.The record has the wrong state code or facility ID in the control Items STATE_CD or FAC_ID.The record submitted was not for OBRA or Medicare Part A purposes.The record is a test record inadvertently submitted as production. If a record was submitted either with an error in Item A0410, not for OBRA or Medicare Part A purposes, or as a test record, the facility must complete the proper request within iQIES. The State Agency will review and either request, reject the request, or return the request and ask for additional information before approving or rejecting. (Refer to the iQIES Assessment Management: Assessment Submitter Manual for details.)In situations in which the state-assigned facility submission ID (FAC_ID) or state code (STATE_CD) is incorrect, an MDS 3.0 Manual Assessment Move Facility Request is required. The facility will complete the form and submit to the State Agency. (See the current RAL Manual 3.0 Chapter 5, 5.7 for details.)Reproduction of Data in the Resident's Record:The facility maintains 15 months of assessment data in the resident's active clinical record. The 15-month period is defined as 15 months following the completion date for all assessments and correction requests.Assessment data may be maintained electronically.If data is maintained electronically, and electronic signatures are not used, the facility must ensure hard copies of the MDS assessment signature pages are maintained for every MDS conducted in the resident's active clinical record for 15 months.Transmission Requirements:All assessments shall be transmitted to the designated CMS system (iQIES) within 14 days of completion.Each assessment must be accepted into the system, as verified by validation reports.Validation Edits:For each file submitted, the submitter will receive confirmation that the file was received for processing and editing by iQIES (initial submission feedback).Fatal File Errors - file structure is unacceptable (e.g., not in a ZIP file), the file will be rejected. These errors must be corrected and resubmitted.Fatal Record Errors - file structure was validated; however, errors exist such as out of range response or inconsistent relationships between items. These records are rejected and must be corrected and resubmitted.Non-Fatal Errors (Warnings) - file structure was validated and accepted but with errors. Non-fatal errors should be evaluated to identify necessary corrective action.References:Centers for Medicare & Medicaid Services, Department of Health and Human Services. State Operations Manual (SOM): Appendix PP Guidance to Surveyors for Long Term Care Facilities. (2025 Revision) F636-F638 and F640.Centers for Medicare & Medicaid Services. Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1. (October 2025) Chapters 2 & 5.

Based on record review, interview, and facility policy review, the facility failed to revise one of one resident's care plan (Resident #68) following a significant change in the resident's pain status, placing the resident at risk for uncontrolled pain and a diminished quality of life. The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #68 documented a [DATE] admission date to the facility from an acute hospital stay. Her diagnoses included dementia, difficulty in walking, unsteadiness on feet, repeated falls, and need for assistance with personal care. The MDS showed the Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident was cognitively severely impaired. The MDS documented the resident's health conditions included pain management with scheduled pain medications and that the resident had not received PRN (as needed) pain medications or non-medication interventions for pain. Resident #3's Pain Assessment Interview revealed she had not experienced pain in the last 5 days. The MDS further documented the resident had shortness of breath when lying flat and with exertion. The MDS documented the resident had 2 or more falls in the past 3 months. The MDS documented the resident's medications did not include any high-risk drugs. The Care Plan for Resident #68 dated [DATE] identified the resident was at risk for falls, had pain or the potential for pain related to a history of pain to her right shoulder and arm. The interventions for Resident #68's pain directed the staff to:a. Anticipate the resident's need for pain relief and respond as soon as possible to any complaint of pain. b. Monitor and record the resident's pain severity on the 1 to 10 scale (a standard 0-10 tool where 0 is no pain and 10 is the worst imaginable pain) every shift and as needed.c. Report to Nurse any s/sx [signs or symptoms] of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing).The care plan had not been updated to include the resident's right leg pain noted on [DATE] for which she was hospitalized from [DATE] to [DATE]. In an interview on [DATE] at 2:17 p.m. with Staff L, CNA stated she had worked at the facility for 10 months and usually worked the evening shift from 2 p.m. to 10 p.m. Staff L, CNA recalled caring for Resident #68 and stated the resident was in a lot of pain in late October to [DATE], but could not recall any specific event that had caused the pain. She stated that Resident #68 had pain every day in her right knee and that every time she was moved, she would vocalize her pain. She agreed that the staff would allow Resident #68 to remain in bed as transferring the resident had caused her pain. She stated that when she rolled the resident, the resident would hold on to the side rail while she changed the resident's incontinent pad and that rolling Resident #68 had caused her to experience pain. In an interview on [DATE] at 1:30 p.m. with the Director of Nursing (DON) she revealed she had worked at the facility for the past 4 years as their DON. She recalled Resident #68 had been hospitalized from [DATE] to [DATE] for her right lower extremity pain. The DON stated that after the resident's return from the hospital on [DATE] the resident experienced pain with movement. The DON agreed that Resident #68's care plan regarding her pain had not been updated after her return from the hospital on [DATE]. The DON stated that a significant change in status MDS assessment had been scheduled, and that the resident's care plan would have been updated with that assessment, but that assessment had been cancelled when she died on [DATE]. Review of the facility's policy Care Plan Revisions Upon Status Change, dated 2025 revealed the purpose of that policy was to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The policy directed staff to review and revise the care plan when a resident had experienced a change in status by having the MDS Coordinator and the Interdisciplinary Team discuss the resident's condition and collaborate on intervention options and update the resident's care plan with the new or modified interventions.The policy directed the Unit Manager or other designated staff member to communicate those new or modified care plan interventions to all staff involved in the resident's care.

Based on observations, interviews, and record review, the facility failed to provide grooming for 1 resident reviewed (Resident #34). The facility failed to trim resident's toenails which had grown long and were snagging on his socks. The facility reported a census of 58. Findings include:The 5-Day Minimum Data Set (MDS) Resident assessment dated [DATE] documented that Resident #34 (R34) required assistance from staff for the following; toileting hygiene, lower body dressing, shower/bathing, and putting on/taking off footwear. The MDS documented the R34's admission date as March 9, 2026. A care plan revised on 3/13/26, directed nursing staff that Resident #34 had a self-care deficit focus area evidenced by requiring assistance with ADLs (Activities of Daily Living).This resident was a 1 person assist. Staff were to encourage bathing 2x weekly, inspect skin during showers and alert charge nurse to any skin issues. Nursing staff were to check nail length and trim/clean on bath days and as necessary. On 5/5/26 at 9:56 AM, Resident #34 stated he would like his toenails clipped. He said that no one ever wants to trim them. Resident #34 stated his wife had her toenails trimmed recently. This resident said that when he asked why his toenails weren't trimmed, they told him he was not on the list. This resident said he didn't know how to get on the list. He repeated he just wants his toenails trimmed. On 5/6/26 at 11:15 AM, Staff K, Licensed Practical Nurse (LPN), when asked about whether or not Resident #34's toenails had been trimmed, Staff K stated that Resident #34 had not been at the facility very long. Staff K stated he initially admitted to the facility for skilled care with plans to return home. It was decided he was unable to go home. She stated this wasn't that long ago. She stated that his wife had her toenails trimmed by the podiatrist last week as she was on the list to be seen by the podiatrist. She didn't know if anyone had talked with him about being on the list. This LPN agreed to go look at his nails. She removed his socks and shoes. His large toes had approximately 1/4 inch growth from the tip of his toes. Resident #34 stated it had been difficult to put on his socks and shoes as they keep snagging on his toenails. He asked are you going to trim them. This staff person stated she would after breakfast. On 5/7/26 at 8:10 AM, Staff K stated that she did cut his toenails yesterday. She said she was able to trim all of them down. Staff K stated that Resident #24's son normally comes to pick up his laundry. She will talk with his son the next time he comes in and ask him if he wants to get on the podiatry list. She says she thinks (getting on the podiatry list) has something to do with what insurance a resident is on. Normally the Social Service Designee asks if this is a service the residents would like during the admission process. She stated that she believes it costs a little more for them to add this service on. This LPN stated the resident was happy to have his nails trimmed yesterday. On 5/7/26 at 8:44 AM, the Administrator stated that residents can get on the podiatrist list. The podiatrist comes to the facility at least every 3 months and sometimes more often. She stated that only clinical staff are able to trim nails and nurses are definitely able to trim them. They can ask if the resident would like to see the podiatrist and check if the podiatrist will be in the facility in the following week or so. If it would be awhile before the podiatrist would be in the facility, the nurses should go ahead and trim a residents nails. This administrator stated the facility is to trim residents nails no matter if they are skilled care or not. A Nail Care Policy dated 2025, directed staff:Policy:The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines:Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care, if possible.Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g., curling, color changes, separation from the nailbed, redness, bleeding, pain, odor, infection, etc.).Determine preferences regarding nail polish.Obtain history and preferences regarding podiatrist.Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke.Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis.Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises.The resident's plan of care will identify:The frequency of nail care to be provided.The type of nail care to be provided.The person(s) responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional).Principles of nail care:Nails should be kept smooth to avoid skin injury.Only licensed nurses shall trim or file fingernails of residents with diabetes. Toenails of residents with diabetes or circulation problems shall be filed only.If a resident has a toe infection, diabetes mellitus, neurologic disorders, renal failure, or PVD, toenail trimming should be performed by a physician or practitioner.Resident without complicating disease processes, may have their toenails clipped by staff who have received education and training to provide this service within professional standards of practice and as per facility policy.Each resident will have his/her own nail care equipment (e.g., clippers, emery boards, files, etc.). Equipment will not be shared between residents. Clean equipment after each use and before storing.Procedure:Perform hand hygiene and don gloves.Fill wash basin(s) with warm water. Soak hands/feet in wash basin for 10-20 minutes, unless resident has diabetes or circulation problems.Gently clean underneath nails with orange stick.If trimming is allowed, clip nails using nail clippers straight across and even with tops of the fingers/toes.Shape nails straight across using nail file, emery board, or the like.Dry hands/feet well with towel.Apply lotion to hands/feet. Remove gloves and perform hand hygiene.Document completion of task, any complications, or if resident refuses.

Based on observation, clinical record review, resident and staff interviews, the facility failed to provide an assessment and timely intervention for the necessary care and services for 2 of 3 residents reviewed (Resident #11 and Resident #45). Resident #11 reported having chest pain over night that lasted 15 minutes. The licensed nursing staff failed to provide an assessment after receiving the information. Resident #45 had a wound requiring a wound vac (medical device that uses negative pressure to promote healing in wounds). The licensed staff failed to maintain and provide interventions to ensure proper functioning of the wound vac. The wound vac was missing several changes and was not properly secured and functioning during wound clinic visits. The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #11 revealed the diagnoses of Parkinson's and was independent for activities of daily living. Resident #11 denied pain during the assessment. The Brief Interview for Mental Status (BIMS) score was 15 suggested an intact cognition. The Care Plan directed staff to monitor and document pain for probable cause of each pain episode and notify the physician if pain was a significant change from past experiences. During an interview on [DATE] at 1:26 pm, Resident #11 stated she had experienced chest pain during the night on [DATE], notified Staff G, Certified Nursing Assistant (CNA) and requested to see Staff H, Licensed Practical Nurse (LPN). Resident #11 stated the pain was a crushing pain that lasted about 15 minutes and she felt scared. Resident #11 stated the nurse did not respond, the pain subsided and she did not tell the nurse the next day. Resident #11 did inform staff in the Resident Council meeting on [DATE]. During an interview on [DATE] at 1:39 pm, Staff R, CNA stated Resident #11 was clear in thought and was believable. A review of the Progress Notes for April/[DATE] revealed no documentation of Resident #11 had chest pain. During an interview on [DATE] at 2:42 pm, Staff E, LPN stated she would believe Resident #11 if she would tell her anything, she was very believable. Staff E stated Resident #11 had not reported having chest pain. Staff E stated she would assess Resident #11 and give a report to the nurse practitioner tomorrow. Progress Notes review through [DATE] failed to document an assessment for Resident #11 or notification to the provider and family. Resident council meeting minutes on [DATE] revealed the following;Nursing: Resident #11 stated she was having pains in her chest last night, she reported this to Staff G, Certified Nursing Assistant (CNA) and the nurse failed to come to her room to assess her pain. During an interview on [DATE] at 8:38 am, Staff J, Activity Director stated on [DATE] was the first resident council she conducted. Staff J stated during the Resident Council meeting, Resident #11 stated she had chest pain overnight on [DATE] and the nurse did not come see her. Staff J stated she asked the Administrator what I do with the notes of concerns and was given grievance forms to fill out. Staff J stated she filled out a grievance form and gave it to the Director of Nursing (DON) the next morning on [DATE]. During an interview on [DATE] at 1:59 pm, Staff I, CNA stated Resident #11 did not report that she had chest pain and had a complete mind. Staff I stated the facility was short staffed and staff were not patient and ignored Resident #11. During an interview on [DATE] at 3:29 pm, The DON stated she was aware that Resident #11 complained of chest pain during a night shift and she told the CNA, who did tell the nurse but when they went back in to assess her she was asleep. The DON stated she was aware that Resident #11 filed a grievance that she complained of chest pain and the nurse did not come in to assess her. When inquired where it was documented that Resident #11 had chest pain, and the assessment and inquired if the provider was notified, the DON said no. The surveyor informed the DON that Resident #11 had the chest pain and informed Staff E, LPN on [DATE] who stated she would conduct an assessment and will notify the provider but there was no documentation of that assessment nor provider notification. The DON stated she would check on that but failed to provide a response to the survey team. During an interview on [DATE] at 8:26 am, Staff H, Licensed Practical Nurse (LPN) stated that he was the charge nurse on the over-night shift on [DATE]. Staff H denied being informed of Resident #11 having chest pain. Staff H stated if he was informed of that, he would have provided an assessment, notified the provider and provided pain management. Staff H verified he had worked on Resident #11's hall with Staff G, CNA and denied the CNA had mentioned the chest pain episode. During an interview on [DATE] at 8:55 am, The Administrator stated when Staff J, Activity Director inquired what to do with the resident council concerns, she was given grievance forms to fill out and directed to give them to the responsible manager. The Administrator stated Staff J mentioned another resident's concern but couldn't remember if she was informed that Resident #11 having chest pain. The Administrator stated chest pain was a concern that would require immediate nurse assessment. A document titled Grievance Form dated [DATE] revealed a summary of Resident #11's grievance. a. During the night on [DATE] Resident #11 experienced chest pain, reported the pain to the CNA and the nurse did not come to check on her. b. Investigation/Outcome revealed that education was provided to staff member related to communication with the nurse for complaints of pain. c. Signed by the DON, Grievance Officer and the Administrator. A document dated [DATE] a note to Staff F, LPN that revealed a directive from the DON to have a discussion with Staff G, CNA related to care expectations and reporting concerns. The document listed the complaint from Resident #11 regarding the chest pain episode that was not verified with Staff H, LPN as of yet. The document stated the report of concerns, especially chest pain, needed to be reported to the nurse immediately. The directive included to monitor Staff G for the next 3 shifts and notify the DON in writing if there were further concerns. During an interview on [DATE] at 3:29 pm, The DON stated she was aware that Resident #11 complained of chest pain during a night shift and she told the CNA, who did tell the nurse but when they went back in to assess Resident #11, she was asleep. The DON stated she was aware that Resident #11 filed a grievance that she complained of chest pain and the nurse on duty did not complete an assessment. When inquired where it was documented that Resident #11 had chest pain, and the assessment and inquired if the provider was notified, the DON said no. During an interview on [DATE] at 8:26 am, Staff H, Licensed Practical Nurse (LPN) stated that he was the charge nurse on the over-night shift on [DATE]. Staff H denied being informed of Resident #11 having chest pain. Staff H stated if he was informed of that, he would have provided an assessment, notified the provider and provided pain management. Staff H verified he had worked on Resident #11's hall with Staff G, CNA and denied the CNA had mentioned the chest pain episode. 2. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #45 included diabetes, infection of the foot, and open lesions. A BIMS revealed a score of 15 out of 15, which indicated intact cognition. This resident required applications of dressings to feet. A Census page documented that Resident #45 was admitted to the facility on 3//26/26. A Podiatry Clinic note dated [DATE], documentation included the following: Resident #45 is approximately 3.5 weeks post-op (post surgery). He has been placed at the facility for skilled care. Resident #45 reports that the dressing wasn't changed for the first 5 days he was there. Now changes are being performed every other day. The wound VAC was not applied correctly and the whole dressing was wet. The Assessment documented that this resident had a skin ulcer of left ankle with necrosis (death of cells) of bone. This was a postoperative examination at 3.5 weeks status post left ankle I&D (incision and drainage), hardware removal (removal of orthopedic (related to bone) implants that were initially placed to stabilize fractures, correct deformities, or support healing bones), external fixator (metal frame applied outside the body to stabilize broken bones in the ankle and lower leg) and wound VAC placement. Upon presentation the dressing was noted to be saturated and the wound VAC was not adhered to the wound and completely lifted and malfunctioning. No signs of pin sit infection. Antibiotics per infectious disease. This provider called the facility and discussed that Resident #45 was an hour late to his appointment, the wound VAC was not functioning, the dressing that was applied was completely saturated and there was no compression. A Podiatry Clinic note dated [DATE], documentation included the following: Resident #45 presented with a wound VAC battery dead and cannot reapply. Continue dressing changes Monday, Wednesday and Friday. Wound VAC to the medial wound (wound closer to the midline of the body) 125mmHg (unit of pressure) continuous, change canister once weekly. A Podiatry Clinic note dated [DATE], documentation included the following: Follow-up left lower extremity. Presents today for wound evaluation. Today is Wednesday, he reports the last VAC (wound vac) and dressing change was performed on Friday which goes against the podiatry clinic's provider's recommendations. Resident #45 stated the facility was now providing routine dressing changes. The provider did inspect his VAC prior to removing the dressing and it was set at 125 mmHg continuous, however the actual was 0 mmHg continuous. The provider did remove the dressing which was noted to be completely saturated in blood, the wound VAC was not adhered to the skin and not functioning. The surrounding tissue was macerated. Given the inability for the facility to maintain a VAC, the provider will stop VAC dressings at this time. Apply Betadine medially and laterally into the superficial heel wound. Cover with gauze, gauze roll and Ace bandage. Strict non-weightbearing to the left lower extremity. Antibiotics per infectious disease. On [DATE] at 2:07 PM, a podiatry clinic nurse stated that multiple times they had talked with the facility related to the wound vac not functioning or not applied properly. They ended up having to discontinue it. She stated that on [DATE] the battery was dead on the wound vac. On [DATE] it was presented that the facility was not doing routine vac changes. The wound vac was set at 0 instead of 125 like it should have been set. The wound vac was not functioning. The primary concern was that we want the staff to be educated and to be able to properly use wound vacs. A Treatment Administration Record (TAR) for the month of April, had the following order: The Left Lower Extremity (LLE) was to be kept clean and dry and intact. Wound VAC was to be connected and running at 125mmHg every day and night shift. The start date was [DATE]. The discontinued date was [DATE]. The TAR was missing several entries of the wound vac changes. The [DATE] Treatment Administration Record directed the following: Wound vac to left medial ankle 125mmHg continuous. Change 3 times a week. every day shift every Monday, Wednesday and Friday. The start date for this order was [DATE]. The order was discontinued on [DATE]. The TAR was signed by a nurse on the following days [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] this was signed as refused and on [DATE] it was signed as held. The TAR was not signed for the wound vac changes on [DATE], [DATE] and [DATE]. The wound vac was discontinued on [DATE]. The [DATE] TAR directed the following: Left foot: Apply adaptic (non adherent dressing) followed by betadine soaked gauze to lateral incision, Xeroform (non-adherent wound dressing) around pin sites and wrap with soft roll and ace. every day shift. The start date was [DATE]. The treatment was discontinued on [DATE]. The TAR was not signed for this treatment getting done on [DATE] and on [DATE]. On [DATE] at 2:00 p.m., an observation of wound care for both right and left lower legs was done by Staff S, Registered Nurse (RN). during wound care Resident #45 stated that this nurse always did his wound care the right way but not all the nurses did. During the wound treatment observation this resident stated that the wound vac really helped a lot and his wounds have improved greatly. On [DATE] at 2:50 PM, Staff S, Registered Nurse stated that she did not know of a time that the wound vac wasn't changed or that the settings were off. She stated the wound vac settings were preset. She stated the only thing she remembers is that they had sent this resident to the podiatry clinic and his wound vac was working when this resident left the facility. However, the battery had died by the time he was at his appointment and the podiatrist was not happy about it. She stated if there were missing entries on changing the wound vac, it was probably because they had to change it in between times and that would have started the 3 day change cycle over. She said she hated to see the wound vac go as it was so helpful. She stated they had a pretty good system down and it was working well. She stated the reason they were given for the discontinuation of the wound VAC was that Resident #45 was ready for a different treatment. On [DATE] at 1:05 PM, Staff T, Assistant Director of Nursing (ADON), RN, stated that she did work dayshift on [DATE], [DATE], and [DATE]. She stated that on a Friday she was busy and couldn't get to the wound VAC to change it, so she changed the wound vac on Saturday. She stated she obtained an order but forgot to put it into the electronic health record and she forgot to sign that she had changed the wound vac the next day. She stated another time the night nurse did the wound vac change. She wasn't sure what happened the 3rd time. On [DATE] at 8:39 AM, the Administrator stated she understood the concern with the management/documentation of the wound vac. A Negative Pressure Wound Therapy policy dated 2025, directed the following: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. This policy addresses the use of negative pressure wound therapy (NPWT) for the treatment and management of wounds. Definitions: Negative pressure wound therapy is an active wound care treatment that uses controlled sub-atmospheric (negative) pressure to assist and accelerate wound healing. The therapy may be gauze based, foam based, or peel and stick, and includes an evacuation tube and a computerized pump that applies the negative pressure. Policy Explanation and Compliance Guidelines: Negative pressure wound therapy will be provided in accordance with physician orders, including the desired pressure setting, continuous or intermittent therapy, and frequency of dressing change. Clean technique shall be utilized unless otherwise specified by the physician. Negative pressure wound therapy is considered an advanced wound therapy and is usually initiated when other modalities have proven unsuccessful or to prevent complications in high risk situations. Negative pressure wound therapy shall be used only when the goal is wound healing, the wound bed has minimal necrotic tissue, and treatment is underway for any wound infection. Indications for NPWT include: Acute and chronic open wounds with depth. Partial and full thickness wounds. Partial thickness burns. Surgical incisions. Enteric fistulas. Contraindications for NPWT include: Malignancy in the wound. Untreated osteomyelitis. Nonenteric and unexplored fistula. Necrotic tissue with eschar present. Exposed blood vessels or organs. Wounds with inadequate debridement. Untreated coagulopathy. Allergy to any component of the procedure. Precautions should be taken for residents with active bleeding, anticoagulant or platelet aggregate inhibitor use, and difficult wound hemostasis. Use and application of the therapy shall be in accordance with manufacturer's recommendations. General application process: Carefully remove the existing wound dressing and discard. Cleanse wound according to physician order. Cleanse and dry periwound skin. Prepare periwound skin with a skin preparation product, such as liquid barrier or transparent dressing/drape. Select foam type or gauze appropriate to the size and characteristics of the wound, and place gently into the wound. Fill the entire wound base and sides, tunnels, and undermined areas. Ensure edges of multiple pieces of foam are in direct contact with each other to achieve even distribution of negative pressure. Size and trim the adhesive drape to cover the foam or gauze, dressing and overlap onto intact periwound tissue. Apply the tubing to the dressing. Cut a hole in the drape large enough to accommodate the specific tubing assembly. Using the attached tubing adhesive drape, or additional dressing drape, seal the tubing assembly on top of the dressing and ensure that it will not lie on bony prominences. Connect tubing assembly to the canister tubing. Make sure canister is fully engaged into the pump. Initiate NPWT at the prescribed settings in accordance with pump/product specifications. Monitoring throughout the use of NPWT shall include, but is not limited to, the following: Pain associated with the therapy. Device is functioning. Settings as prescribed. Troubleshooting of any alarms, in accordance with pump/product specifications. Response of the therapy, including wound characteristics and progress towards healing. Whenever therapy cannot be resumed within two hours, remove the dressing and apply a moist wound dressing. Notify physician for specific orders. Therapeutic response of the therapy shall be documented in accordance with procedures for wound documentation. The physician shall be notified of any complications associated with the use of NPWT.

Based on observations, clinical record review, resident and staff interviews and policy review, the facility's licensed nursing staff failed to appropriately set and maintain oxygen devices for 1 of 2 residents reviewed for oxygen administration (Resident #20). The nursing staff reported adjusting the oxygen setting who were not licensed staff. The facility reported a census of 58 residents. The Minimum Data Set (MDS) dated [DATE] for Resident #20 revealed the diagnoses of asthma with dependence on oxygen delivery. The Care Plan for Resident #20 identified oxygen to be delivered at 2 Liters without further direction for nursing staff (Licensed Practical Nurse (LPN) and or Registered Nurse (RN)). The Physician Orders for Resident #20 revealed an order for 2 liters of oxygen and the direction for the nursing staff to change oxygen tubing every Wednesday. During an observation on 5/04/2026 at 2:33 pm, Resident #20 was in her bed with oxygen tubing dated 4/15/26 on tape that went into Resident #20's nose by a nasal cannula. The oxygen concentrator was delivering oxygen (O2) at 2.5 Liters through a dry humidifier bottle (bubblier) dated 4/25/26. During an interview on 5/4/26 at 2:33 pm, Resident #20 stated she felt dry in her nose and throat but had water to drink. Resident #20 stated she was not having respiratory distress and could feel the oxygen. During a second observation on 5/05/2026 at 8:00 am, Resident #20 was asleep in her bed. The oxygen concentrator continued to be delivering oxygen at 2.5 Liters with the humidification bottle dated 4/25/26 continued to be empty and the tubing dated 4/15/26 was not exchanged. During a third observation on 5/05/2026 at 12:25 pm, Resident #20's O2 tubing and humidification bottle had not been changed.During an observation on 5/5/26 at 1:25 pm, Staff E, Licensed Practical Nurse (LPN) walked toward Resident #20's room after the [NAME] President (VP) of Clinical Operations notified her that the O2 needed attention. Staff E entered Resident #20's room to discover the humidification bottle was exchanged and had fluid in it for the oxygen to flow through, not dated, and the tubing was not exchanged. Staff E checked the O2 meter to find it delivering 2.5 liters of oxygen and adjusted it to 2 liters. During an interview on 5/5/26 at 1:25 pm, Staff E, LPN stated she thought the oxygen tubing would be changed weekly, identified the night nurse to complete that task, and the humidification bottle would be changed when it became dry. During an interview on 5/05/2026 at 1:04 pm, The Administrator stated the O2 tubing should be changed weekly by the night nursing on night shift. During an interview on 5/05/2026 at 1:59 pm, Staff I, Certified Nursing Assistant (CNA) stated the CNA responsibility for oxygen was to make sure the tubing was on the resident and the humidification bottle that contained fluid. Staff I stated the CNA's would adjust the oxygen, turn it on and off, when the resident was transferred to a portable tank. Staff I stated that was the nurse responsibility, but when informed of the need to transfer to portable, the nurse would not respond. Staff I stated the CNA would be held responsible, but was aware that a CNA was not licensed to adjust oxygen. During an interview on 5/06/2026 at 2:00 pm, Staff N, CNA stated when a resident was off the concentrator and required a portable tank, she would turn the oxygen on and adjust the amount of oxygen to be delivered to the resident. Staff N stated it was expected that the CNA's perform this duty and had a key (the device to open the top of an oxygen tank to deliver the oxygen to the flow meter) attached to her name badge. During an interview on 5/06/2026 at 2:39 pm, Staff Q, CNA stated when she would transfer a resident from the oxygen concentrator to the portable tank, she would adjust the rate of oxygen flow but would not replace tubing or humidification bottles.During an interview on 5/06/2026 at 2:54 pm, Staff O, CNA stated she had the knowledge of how to change the water humidifier and would complete the task. The nurse will tell the CNA what the portable tank should regulated at and the CNA would set the delivery of oxygen when a resident was transferred. Policy titled Oxygen Administration dated 2025 revealed:1. Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists. 2. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.3. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification.

Based on interviews, record reviews, and policy review, the facility failed to obtain physician's orders for peritoneal dialysis, to provide initial and ongoing assessment and oversight of peritoneal dialysis (PD), and to provide consistent care and documentation per professional standards of practice for 1 of 2 residents reviewed that received peritoneal dialysis in the facility (Resident #69). Resident #69 received peritoneal dialysis in the facility which was connected and disconnected by her sons. The nurses did not provide these interventions. The facility was unable to produce provider's orders for the dialysis, documentation of assessments for this dialysis, documentation of the connecting and disconnecting of the peritoneal dialysis, and clarification for who was to turn on and shut off the dialysis. The staff at the facility allowed this to go on without seeking clarification. This resident required hospitalization related to avulsion of her external peritoneal dialysis tubing (a medical emergency when the external catheter or transfer set is forcibly torn, pulled or ripped from the body) resulting in a loss of a large amount of fluid and intervention to repair the avulsion. The facility had failed to assess the port sites or show they cared for or overall managed the PD in their facility. The facility reported a census of 58 residents. Findings include: A Minimum Data Set, dated [DATE], documented diagnoses for Resident #69 included End Stage Renal Disease (ESRD), dependence on renal dialysis, diabetes, malnutrition and non-Alzheimer's dementia. A Brief Interview for Mental Status revealed a score of 4 out of 15, which indicated severely impaired cognitive functioning. This resident received dialysis.Resident #69's care plan documented that she had a self care deficit as evidenced by requiring assistance with Activities of Daily Living (ADLs), impaired balance during transitions requiring assistance and/or walking, incontinence. She was a 1 person assist for transfers and toileting. This care plan was initiated on 12/31/25. A Census page documented that this resident was admitted on [DATE] and billing was discontinued on 1/13/26. The Medication Administration Record/Treatment Administration Record (MAR/TAR) for the month of December and the month of January lacked orders for hooking Resident #69 up or taking her off peritoneal dialysis (PD). There is no record of administration of dialysis that the facility was able to provide. Doctor's Orders since this resident was admitted through the day she was discharged did not include the solution that was to be used for dialysis. The only mention of peritoneal dialysis in this resident's doctor's orders was to apply gentamicin (antibiotic) cream to the PD exit site. The facility provided a hospital dialysis nurse note dated 12/25/25 at 7:00 p.m., from the hospital that she was at prior to coming to the facility. It documented that a CCPD (continuous cyclic peritoneal dialysis (home based dialysis)) initiation PD machine setup aseptically(minimizing contamination of microorganisms) per orders. Orders as follows : 1.5 % dialysate (fluid to remove waste products) 2.5 L(liter) fills x 4 exchanges= 10 L Number of hours: 9 Dressing aseptically changed. Site has drainage/redness with a spot at 11 o'clock open that's red and has drainage as well. Providers aware. Reported to dialysis RNA Care Plan initiated on 12/31/25, directed staff that Resident #69 required dialysis therapy and remained at risk for declines in alteration in renal status with the progression of this disease process. PD in the facility. It directed staff that a Dialysis flow sheet was to be completed daily to observe for shunt access site complications-report abnormalities to the physician. The facility could not produce this flow sheet. A Nurse's Progress note dated 12/31/2025 at 7:45 p.m., documented that Resident #69 arrived at the facility at 1:45 p.m. Resident arrived viaAmbulance service accompanied by EMS. Both sons were present when the resident arrived. Resident situated in room [ROOM NUMBER]. Educated about call light, assessments completed, vitals taken. Son stated that her blood pressure runs low all the time. Evidenced by the lower blood pressure obtained during vitals. Son brought a machine for PD from home, supplies brought in by the dialysis home company. The family was very helpful for obtaining information. No complaints of pain or discomfort noted at this time.Will continue to help this resident get settled and comfortable in the facility. Authored by Staff T, Registered Nurse (RN) Assistant Director of Nursing (ADON). A Daily Skilled Charting Note dated 1/2/26 at 2:53 a.m., documentation included that this resident was sleeping soundly in bed, son hooked up PD tonight before he left. Call light is in place, no acute nursing needs at this time, will continue with the current plan of care.A Daily Skilled Charting Note dated 1/3/26 at 12:35 a.m., documentation included that this resident was sleeping soundly in bed, son hooked up PD tonight before he left.A Daily Skilled Charting Note dated 1/4/26 AT 12:00 a.m., documentation included that this resident is hooked up to PD, currently watching videos on her phone. No c/o pain or discomfort. Spoke with son tonight and he prefers that he is the one to hook up and disconnect the PD machine. Will continue with the current plan of care.A General Progress Note dated 1/10/26 at 10:32 p.m., documented that resident's sons in facility and advised this RN that resident will be taking a break from dialysis tonight so did not need to begin cycle for this HS (hour of sleep) shift.Gastrointestinal: PD catheter present Metabolic: Reviewed and Normal/Negative. General: Awake, Alert, No Acute Distress, Calm, Cooperative, Gastrointestinal: Abdomen Soft, Non-Tender, Normoactive Appears Comfortable BS Eye: Pupils Normal Genitourinary: No TendernessA Resident Care Conference note dated 1/12/26 at 10:36 a.m., documented the resident's son- has been having issues. He has concerns with night nursing staff but loves the day staff. He mentioned that he was informed there was an RN able to unhook and do PD for this resident but now is having to come in himself or another family member and do it themselves. They are frustrated and disappointed. He mentioned that a machine was unplugged due to extensive beeping and lack of training for nursing staff for PD. He mentioned that there is a PD helpline phone number on the PD machine that should be utilized. He mentioned that he would be willing to see if the facility could change Resident #69's PD to be during day shift but have therapy come before 10 AM on PD days to still have therapies for her of course.A Nurse Practitioner's note dated 1/12/26 at 3:40 p.m, documentation included: Resident being seen today for c/o of pain in right big toe. No wound or open areas noted on exam. Has a hx of gout on a every other day dosing of allopurinol(medicine for gout). Will increase to daily.A General Progress Note dated 1/13/26 at 6:02 p.m., documented that the resident's family took the resident to the bathroom and PD began draining large amounts of pinkish drainage. Family here and requesting emergency room (ER). New order to send to ER for eval and treatment. Family followed.A Kidney Physician's Progress Note dated 1/15/26, documented the reason for visit was PD catheter dislodging. Patient (Resident #69) has been evaluated by vascular surgery, they felt to have avulsed her external extension tubing along with the titanium. Her PD catheter was fixed externally yesterday. Will plan to resume CCPD tonight. Son would like to know if patient needs to return back to the facility versus going home. This doctor had coordinated this with primary team, will request physical therapy to evaluate patient and make recommendations for discharge planning. Total time spent 38 minutes with more than 50% of the time to counsel patient and her son at bedside regarding above medical management including resuming CCPD tonight and coordinate care with internal medicine team.A Hospital Progress Note dated 1/15/26 at 8:37 p.m., documented that Resident #69 was admitted on [DATE]. The Assessment and Plan was PD catheter dysfunction status post external catheter revision. Patient was evaluated by vascular and recommended bedside external catheter revision which was completed on 1/14/26. Continue empiric (initiation of antibiotic for suspected microorganisms before the lab can identify which organisms) IV vancomycin and IV ceftazidime (antibiotics).On 5/5/26 at 4:46 p.m., Resident #69's son stated that staff were not properly trained for peritoneal dialysis. He stated the first day his mom got to the facility, the nurse on staff asked the family if she could have a refresher because she hadn't done the peritoneal dialysis in a while. Resident #69 was admitted on [DATE] at approximately 2:00 to 2:30 p.m. The CNAs were not trained to handle peritoneal dialysis. They were trying to maneuver her with the cord. Trying to understand the machine with the noises. Trying to disconnect her from the machine so that she could use the bathroom. Everything about it was evident they were not trained at all. The day shift care was okay. The night shift was absolutely terrible. The dialysis was supposed to go 9 hours. Resident #69's son stated that because the staff were untrained, this son and his brother hooked up and unhooked the peritoneal dialysis. This son the final thing that got his mom was she ended up having to go to the hospital. She had sat down in the restroom and said that she saw something running down her leg, then the tube was in her hand. This son said that his mom had carpal tunnel, so she didn't have the strength in her fingers to disconnect the tubing because it came apart at the clamp. This was around the same time the cord was wrapped around the bed. One time my brother got there and the machine was unplugged with the alarm going off. (The staff should have) called the 1-800 number. On 5/6/26 at 1:23 p.m., Staff V, Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON) stated the family took Resident #69 into the bathroom. They took her in there without staff assistance. They then came to report that the resident was leaking fluid all over the floor. Resident #69 was sent to the hospital. She did not return to the facility. Staff V didn't know what happened but if she had to guess, she'd say the family took this resident home because the family wanted her to go home in the first place, and did not want to bring her to the facility. The PD was not draining/leaking before this incident. On 5/7/26 at 11:20 a.m., the Home Therapies Manager (dialysis care partner) stated that she manages the home therapies. She stated they train this facility's staff to provide care. They have a contract with them. She stated the facility staff was trained. They gave a refresher course in December. In the contract we only have to train once, but for safety reasons and turnover she likes to go there and train annually. She had no issues with the facility staff. They did reach out that night to our nurse and this Home Therapies Manager fully believed they did what they needed to do. Everything was provided like it should have been. Only RNs and LPNs receive the training. The drain line goes into the toilet. Possibly the tubing could have been wrapped around the bed . She said that both of those sons, and Resident #69 had been trained to do the dialysis at home. She said that since they were in the nursing home the sons should not be doing anything with the dialysis. They had been educated on the fact that they were not to be doing anything with the dialysis while in the nursing home. On 5/07/2026 at 11:33 a.m., Staff T, Registered Nurse (RN), ADON- Staff were properly trained on PD. Resident #69 was down Hall 3 and the sons were primarily doing her PD. They were doing this at home. Most of the time we wouldn't even know they were hooking the PD up. They would just do it. They were very intimidating. One son argued with Staff T, saying it was his mom and they could do what they wanted. Staff T stated she was the one that took Resident #69 to the bathroom the night the stuff started gushing out. Staff T took her to the bathroom. It was a little after 7p.m. The daughter in law was in the room. Resident #69 was not hooked up to dialysis. Staff T never saw this resident's tubing kinked or wrapped around her bed. Nothing like that. Staff T always made sure it was straight. CNAs were all good with Resident #69 and knew what to do. Staff T had no concerns with them providing care, transferring her or toileting her. That evening Staff T and Resident #69 were in the bathroom. Staff T stated she was sorta picking up around the bathroom while Resident #69 was on the toilet. All of a sudden Staff T heard a [NAME] like the faucet was turned on. Staff T stated that Resident #69 was not a very big person and didn't know where all the fluid was coming from. Staff T clamped the tubing off. Staff T sent her out per the Nurse Practitioner's orders and the dialysis company the facility uses. Resident #69 told Staff T that the tube just started leaking. This resident said she hadn't pulled on the tubing or anything. There had been no problems with the tubing leaking or anything like that before this incident. On 5/7/26 at 1:32 PM, Staff V, Licensed Practical Nurse (LPN), ADON when asked why she documented and said that family was in the bathroom with resident when her tube came out, Staff V stated she just documented what staff had told her. She wanted to make sure something was in the chart. This nurse stated she never once heard that Staff T was in the room with Resident #39. She only heard that family was in the room, so she documented what she heard. She stated she couldn't say for sure that she documented that family was in the bathroom with the resident as it was a while ago and she isn't at the facility today to review the documentation. The entry was read to her. She stated that she documented what she was told. On 5/20/26 at 4:52 p.m., Staff H, LPN (6p.m. to 6 a.m. shift) stated there was one resident who the sons hooked up to dialysis. He stated he had not been trained on how to do the peritoneal dialysis prior to this resident coming to the facility. He said that he did get training on peritoneal dialysis after she had left the facility. He stated he has been at the facility about a year. He stated there have been other residents who required peritoneal dialysis, but other nurses would have to put them on and take those residents off dialysis because he couldn't do it. He stated there hasn't been a resident in the facility that has required peritoneal dialysis since he has been trained. He doesn't remember Resident #69's son asking him to hook his mother up to dialysis. He repeated he wouldn't have been able to because he hadn't been trained. On 5/20/26 at 6:55 p.m., Staff W, LPN (6p.m. to 6 a.m. shift) stated that Resident #69's family pretty much did everything with this resident's dialysis. This LPN didn't think it was set up for the family to do the dialysis. They actually just did it. She stated she would come in at 6 p.m., get report and then monitor the dining room until it was cleared out. By that time when she looked into this resident's room the family would already be in the process of setting her dialysis up. She would be taken off of it after Staff W left, it was usually 7 in the morning or so when they would disconnect the PD. Staff W would leave at 6/6:30 a.m. The family was trained with her PD because they had been doing it at home before she ever came to us. I think they said maybe a year they had been doing it at home. There were no issues with staff during the night, no issues with them toileting her and no issues with tubing getting wrapped around the bed that she knew of. Staff W said she sure doesn't remember that happening. She stated they all questioned if the family should be doing the PD. It was kind of an odd situation. Staff W said she had been trained in PD before that. We kept a close eye on her during the night. We never had any problems with the PD at night and never heard of anyone having problems with the PD during the night at all. The only time Staff W heard about a problem with the dialysis was when Resident #69 was sent to the hospital. The family kept in touch with the dialysis company and kept all of those records in a notebook. The dialysis solution was kept in this resident's room, but they normally carried it into the facility at night. One of the brothers kept the solution in his truck. One night they were setting her PD up and they came and asked if we had the longer tubing set because all they had was the shorter one. The family kept the solution. The family didn't want anyone doing anything for her as far as setting up the dialysis. Staff W believed one of the sons would come in just before breakfast to undo Resident #69 from the dialysis. The family had a lot of people in her room at night during the evenings. There would be from 4 people to 7 or 8 people in her room, just helping set things up. 05/07/2026 12:41 PM VP of Clinical Operations and the Administrator stated that they did not know why there was a discrepancy with documentation of this resident being sent out. Staff V, ADON documented the family had toileted their mom, and the other ADON, Staff T, stated she was with her in the bathroom when the event happened. They were going to look into this. acknowledged that there are no doctor's orders for peritoneal dialysis solution, no documentation of it being given or who started and stopped the PD. They will also look into this. Acknowledged that the sons were doing the PD instead of staff, and there was nothing care planned about the sons being the ones to manage the PD. They acknowledged that the Home Therapies Manager had reported that the sons should not have been handling the dialysis and that this manager had told the sons that. This VP and Administrator acknowledged that the facility should have been putting this resident on the peritoneal dialysis nightly and taking her off the peritoneal dialysis in the morning. On 5/11/2026 at 12:12 p.m., The Administrator stated that they were unable to find any further documentation for Resident #69's peritoneal dialysis. This Administrator stated she had talked with the DON and a binder keeps coming up, but no one can find the binder. This Administrator stated the Medical Director said he remembers the resident being here and said he only saw Resident #69 for the required visits. A State of Iowa Certificate of Death filed on 2/19/26, documented that Resident #69's date and time of death was on 2/8/26 at 11:14 a.m. at a Medical Center. The immediate cause of death was septic shock due to or as a consequence of respiratory failure and end stage renal disease. A Peritoneal Dialysis policy dated 2025, directed the following: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving peritoneal dialysis.Purpose:The facility will assure that each resident receives care and services for the provision of peritoneal dialysis consistent with professional standards of practice. This will include:The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at the facility.Safe administration of peritoneal dialysis in the nursing home provided by qualified trained staff/caregivers, in accordance with State and Federal laws and regulations.Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: andOngoing communication and collaboration with the dialysis facility regarding dialysis care and services.Definitions:Continuous Ambulatory Peritoneal Dialysis (CAPD) - A treatment in which dialysis solution is introduced through a catheter into the abdomen via gravity and the bag is disconnected. After a specific period of time, the catheter is reconnected and drains the solution containing wastes back into the bag. CAPD does not require a machine; the process uses gravity to fill and empty the abdomen. CAPD may be provided during three or four exchanges during the day and one overnight.Continuous Cycler-Assisted Peritoneal Dialysis (CCPD) - Uses a machine to fill and empty the abdomen three to five times during the night. In the morning, the last fill remains in the abdomen with a dwell time that is individualized according to the resident's needs. In some cases, an additional exchange is done in the mid-afternoon to increase the amount of waste removed and to prevent excess fluid absorption.End Stage Renal Disease - The stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life.Dialysis - A process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. The two types that are currently in common use are hemodialysis (HD) and peritoneal dialysis (PD).Dialysis Facility - Means an entity that provides outpatient maintenance dialysis services or home dialysis training and support services, or both.Home Dialysis - Home dialysis means dialysis performed at home by an ESRD patient or caregiver who has completed an appropriate course of training.Compliance Guidelines:The facility will inform each resident before or at the time of admission, and periodically thereafter during the resident's stay, of dialysis services available.Residents may receive chronic dialysis treatments through two options, if the facility allows it. This includes:In-Center Dialysis: This can involve either:Transporting the resident to and from an off-site or on-site certified ESRD facility for dialysis treatments; orTransporting the resident to a certified ESRD facility that is located within or adjacent to the facility.Home Dialysis: The resident receives dialysis treatments in the nursing home and can be administered by the resident, a family member or friend, dialysis facility staff or nursing home personnel. Any individual(s) that administers dialysis treatments must be trained, competent, and knowledgeable in all aspects of dialysis care before initiating treatments. The facility will ensure that staff who perform peritoneal dialysis in the nursing home are trained and qualified, receiving training and competency from a qualified dialysis trainer from a certified dialysis facility.The facility will coordinate and collaborate with the dialysis facility to assure that:The resident's needs related to dialysis treatments are met;Only trained and qualified staff/caregivers administer the dialysis treatments:The provision of the dialysis treatments and care of the resident meets current standards of practice for the safe administration of the dialysis treatments;Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team; andThere is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff.The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes.The facility will identify who is allowed to provide peritoneal dialysis treatments to residents, in accordance with State licensing rules. The facility will maintain documentation of completion of competency/training for staff or other individuals providing the dialysis treatments.The facility will establish, in collaboration with the nursing home medical director and the dialysis facility, dialysis specific policies/procedures based upon current standards of practice to include but are not limited to: The identification of all staff or contracted individuals who are allowed to provide peritoneal dialysis and the training required;The documentation of training and competency requirements for individuals providing dialysis treatments;If the facility allows a resident/family member or other individual to provide peritoneal dialysis treatments, documentation that training and competency was provided by the certified dialysis facility;Procedures for the initiation, administration and discontinuation of peritoneal dialysis treatments, types of monitoring required before, during and after the treatments, including documentation requirements;Procedures for methods of communication between the nursing home and the dialysis facility, including how it will occur, with whom, and where the communications and responses will be documented;The development and implementation of interventions, based upon current standards of practice, including, but not limited to documentation and monitoring of complications, weights, access sites, nutrition and hydration, lab tests, vital signs including blood pressure and medications; Management of dialysis emergencies including procedures for medical complications, and for equipment and supplies necessary;Provision of medications on dialysis treatment days;Procedures for monitoring and documenting nutrition/hydration needs;Assessing, observing, and documenting care of access site; Safe and sanitary care and storage of dialysis equipment and supplies;Responsibility for reporting adverse events, including who to report to, investigating the event and correcting identified problems;Response and management of technical problems related to peritoneal dialysis treatments such as power outages or:For peritoneal dialysis, how to recognize impaired flow and drainage or failure of the peritoneal dialysis cycler;For peritoneal dialysis, how and when to stop dialysis and/or seek help when there are significant issues.Dialysis specific infection control policies including but not limited to: Transmission based precautions including blood borne precautions, placement/location (cohorting), staff/visitor personal protective equipment (PPE) requirements, indications for the use of gloves, masks and hand hygiene;Potential health care associated infections (HAI) including Hepatitis B and tuberculosis;Restrictions for visitors/roommates, if any, during provision of peritoneal dialysis;Handling, using, and disposing of equipment/supplies, medications or other products in accordance with manufacturer's instructions, and in accordance with all applicable Federal, State, and local laws and regulations.Access to clean sink for hand washing, in addition, disposal needs to be addressed for dialysis by-products from the dialysis treatment;Housekeeping/laundry policies for cleaning/sanitizing the location(s) where treatments are provided, including linen handling and waste disposal;Peritoneal catheter care and dressing changes; andCleaning and disinfecting dialysis equipment, including procedures for spills and splashes of blood or effluent on furnishings, equipment, floors and supplies.The facility is responsible for the ongoing coordination of dialysis care in collaboration with the certified dialysis facility. The facility will establish specific written guidance for the provision of treatments, and handling complications and emergencies during the provision of peritoneal dialysis.The facility will have contact information available to staff assuring that dialysis qualified licensed professional staff are available by phone 24 hours a day 7 days a week, including who to communicate with regarding peritoneal dialysis related issues.Peritoneal dialysis may be performed by either the resident (if physically and cognitively capable) or an individual, such as a family member (if allowed by the facility), nursing home staff or a contracted caregiver who has completed training/competency by a qualified trainer from a Medicare certified dialysis facility.The facility will maintain documentation of the required ongoing dialysis training in order to assure qualified staff/caregivers are capable of providing peritoneal dialysis treatments. Training based upon current standards of practice must include, but not be limited to the following;Specific (step-by-step) instructions on how to use the resident's prescribed dialysis equipment (e.g. peritoneal dialysis cycler) and instructions in home dialysis procedures for peritoneal dialysis to facilitate adequate dialysis as prescribed by the practitioner;Training in proper storage and administration of Erythropoiesis-Stimulating Agents (ESAs), if applicable; How to identify/recognize medical emergencies, implement immediate responses/actions and methods for contacting emergency medical systems;How to recognize, manage, and report dialysis complications, including catheter, tunnel or exit site infection; peritonitis, catheter dislodgement; hypotension; hypokalemia; failure of sufficient dialysate to drain from the peritoneal space; protein malnutrition;Indications for the use of gloves, masks, and other personal protective equipment, methods for hand hygiene, peritoneal catheter care and dressing changes, cleaning and disinfecting dialysis equipment, cleaning and disinfection procedures for spills and splashes of effluent;How to properly dispose of needles, effluents, disposable items, and tubing and to minimize risks of infection or injury to self and others and to prevent environmental contamination (e.g. using impervious puncture resistant containers for disposal of sharps, placing empty dialysate bags and tubing in intact plastic bags before discarding.); andRecognizing, managing and reporting power outages, failure of the peritoneal dialysis cycler.Peritoneal dialysis may be provided by the following modalities:Continuous ambulatory peritoneal dialysis (CAPD) Continuous cycler-assisted peritoneal dialysis (CCPD)The physician's order for the individualized prescriptions must include at least the number of exchanges or cycles to be done during each dialysis session, the volume of fluid with each exchange, duration of fluid in the peritoneal cavity, the concentration of glucose or other osmotic agent to be used for fluid removal, and the use of automated, manual or combined techniques.Before, during and after receiving the peritoneal dialysis, the facility staff must, based on the physician's orders and professional standards of practice, do the following:Obtain vital signs, weights, assess the resident's stability, level of consciousness, and comfort or distress;Monitor for post-dialysis complications and symptoms such as, but not limited to dizziness, nausea, fatigue, or hypotension;Report identified or suspected complications immediately to the attending physician and dialysis staff to enable timely interventions;Documentation of ongoing evaluation of the peritoneal catheter, including assessment of catheter related infections and tunnel for condition, monitoring for patency, leaks, infection, and bleeding at the site;Monitor for complications such as peritonitis.The facility will communicate with the attending physician, dialysis facility and/or nephrologist of any canceled or postponed dialysis treatments and document any responses to the changes in treatment in the medical record. If dialysis is canceled or postponed, the facility and dialysis staff will provide or obtain ongoing monitoring and medical management for changes such as fluid gain, respiratory issues, review of relevant lab results, and any other complications that occur until dialysis can be rescheduled based on resident assessment, stability and need. In the event circumstances do not allow dialysis to be provided by the designated trained and qualified individual, the facility must immediately notify the dialysis facility in order to make arrangements to assure that no dialysis treatments are missed.Dialysis may be stopped, postponed, or delayed due to dialysis equipment failure. If this happens during dialysis, the staff and practitioner must assess the resident immediately to as[TRUNCATED]

Based on record review, staff interviews, resident representative interviews, and policy review the facility failed to provide medically-related Social Services in assisting and obtaining Medicaid applications and Power of Attorney documents for 1 of 1 Residents (Resident #57) reviewed. The facility reported a census of 58 residents. Findings include:Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #57's admission to the facility on 2/6/26 and a Brief Interview for Mental Status (BIMS) assessment completed on 2/23/26 resulting in a score of 6 indicating severe cognitive impairment. Resident #57's diagnoses included urinary tract infection, diabetes, COPD, respiratory failure, anxiety, depression, and requiring substantial/maximal assistance with the use of a wheelchair. Review of Resident #57's Care Plan initiated 2/13/26 documented impaired cognitive function and thought processes. The Care Plan documented that the resident used a walker in the bedroom with assist of one staff member, and used a wheelchair for distance mobility with assist of one staff member.Review of Resident #57's admission Record- Facesheet revealed private pay as primary payer. Review of Resident #57's Electronic Health Records (EHR) revealed admission Agreement and documentations signed by Resident #57 on 2/4/26 and signed witness Staff D, Social Services/Admissions. admission Agreement documents indicated Resident #57's expected primary payor source Medicare/Medicaid. Further documentation titled Advance Directives Policy and Record failed to indicate Resident #57 having a Power of Attorney. Review of a Progress Note- Resident Care Conference dated 4/15/26 at 10:24 AM noted Resident #57's Family Representative attended the care conference and the facility Business Office Manager to call on 4/17/26 to check Medicaid status. In an interview on 5/5/26 at 2:38 PM, Resident #57's Contracted Representative stated contracted hire started in the fall of 2025 to assist Resident #57 with Medicaid applications. This application had been completed December 2025, pending further bank statement documentation to finalized approved coverage. During this time Resident #57 was hospitalized with a UTI and the pending bank statements had not been submitted as a result voiding any Medicaid coverage. Contracted Representative explained after Resident #57's admission to the facility communication attempts had been made to the facility to discuss the Medicaid applications with no response. Resident #57 communicated with the Contracted Representative that facility staff had been asking her for the needed documents to complete this application and requested the Contracted Representative assist the facility. The Contracted Representative again tried to communicate with the facility to provide and discuss needed documents to complete the Medicaid application, with refusal from the facility to communicate with her. The Contracted Representative further explained, per the facility, due to Resident #57's cognitive status, Resident #57 was not able to make these decisions for herself so the facility had contacted a lawyer to implement an emergency conservator to control Resident #57's financials. At this time the Contracted Representative informed the facility Resident #57 does have a Medical Power of Attorney and this person should be contacted to be appointed Resident #57's financial representative. Review of provided Email communication between Resident #57's Contracted Representative and Facility's Business Office staff revealed the following communications:a. 4/16/26 at 12:19 PM Contracted Representative notified Staff A, Corporate Director of Business Office Services, providing consent and documents for Resident #57 and notifying Contracted Representatives will be at the facility later this day to assist with the Medicaid Application. b. 4/17/26 at 9:02 AM Contracted Representative provided bank statements for Resident #57 for December 2025 to March 2026 and noted charges on Resident #57's bank statements that would need clarification and follow-up to meet requirements of the Medicaid process. c. 4/21/26 at 12:48 PM, Resident #57's POA communicating to the facility his communication with the Contracted Representative and his request for the Contracted Representatives assistance with Resident #57's care. d. 4/30/26 at 7:00 PM Resident #57's POA communicated in the email thread, regarding recent actions taken concerning Resident #57. As POA, he was not notified the facility was pursuing an Emergency Conservatorship or bringing in legal counsel. POA stated, this is extremely concerning , he should have been contacted immediately regarding any decisions of this nature and expects to be included in all discussions going forward and requested contact information for the Emergency Conservator and/or legal representative. e. 5/1/26 at 4:39 PM, Resident #57's POA responded to the email thread to follow up on the request sent on 4/30/26. POA formally requested immediate release of all records related to Resident #57's care, evaluations, and any actions taken by the facility to include any conservatorship efforts. Lack of response was not acceptable, continued request for contact information of any attorney or legal representative as well as written clarification of any steps that had been taken for the conservatorship without his knowledge. f. 5/4/26 at 10:22 AM Staff B, Corporate VP of Revenue Cycle Management, responded to the email introducing herself and her position with the Corporation. Staff B indicated the facility did not have a copy of the POA paperwork and requested these be provided. g. 5/4/26 at 11:18 AM, Contracted Representative responded to Staff B's email stating she would be at the facility to assist Resident #57 with bank account matters so a Medicaid application could be submitted with hopes for approved coverage starting June 1, 2026. The Contracted Representative also requested cognitive testing be done for Resident #57 as her interactions with Resident #57 did not indicate the severe cognitive impairment status as previously scored on admission. h. 5/4/26 at 2:20 PM, Staff B's email response included an overview of phone conversation with the Contract Representative documenting, the facility will redo the BIMS assessment to determine Resident #57's cognitive status, Contract Representatives have agreed to restart the Medicaid application process and noting the facility does not have Resident #57's POA paperwork on file. i. 5/4/26 at 2:47 PM, Contracted Representative replied, a BIMS assessment was completed with Resident #57 scoring 15/15 (indicating cognitively intact), this is an issue as Staff A was planning on forcing Resident #57 into a designated conservatorship without discussing with Resident #57 or family. Contracted Representative had been in the facility a couple week prior and provided Staff A, a black binder containing all of Resident #57's paperwork. Today when requesting the return of this binder, Contracted Representative was told we don't have it. Contracted Representative informed yes, you do. I handed it to you when we were standing in your office. Following, Staff C, Business Office Manager, Staff C walked into her office to the filling cabinet, pulling out the binder and provided to Contracted Representative. j. 5/4/26 at 2:54 PM, Staff B replied stating the facility's need for a copy of Resident #57's POA paperwork. k. 5/5/26 at 8:42 AM Staff B responded receiving Resident #57's POA paperwork. l. 5/5/26 at 9:57 PM, Resident #57's POA replied to email thread requesting clarification regarding the facility not having a copy of the POA paperwork prior to receiving yesterday. Over the past several months, POA had received multiple calls and communication from facility staff providing updates, discussing Resident #57's care and documentation and information requests directly from POA. It appeared the POA role had been recognized and was relied on, but POA is unable to understand how these communications were taking place if the facility did not have the POA documents on file. m. 5/5/26 at 10:57 AM, Staff B responded, thanks for the email, the facility has been provided the documents by the Contracted Representative. Thank you for the follow up. In a provided phone conversation on 4/30/26, Staff A, informed Contracted Representative, she had found an attorney to do a temporary conservatorship for Resident #57 to get the Medicaid application done. During a phone conversation on 5/4/26, Staff B informed Contract Representative at that time the facility does not have Resident #57's POA documentation. The Contract Representative reiterated to Staff B, Resident #57's documents had previously been provided to Staff A and the Medicaid application could have been started. Staff B responded, this was missed steps on our part.During an interview on 5/7/26 at 12:30 PM Staff D, Social Services/Admissions, stated she had never completed an admission on a confused resident and has never had to request POA paperwork on an admission and confirmed the facility was seeking conservatorship for Resident #57 due to low BIMS score and poor cognition. In an interview on 5/7/26 at 2:46 PM, Facility Administrator and VP of Clinical Operations acknowledged the miscommunications between facility staff, Contracted Representatives, POA and Resident #57 and agreed the Medicaid Application process should have been initiated on Resident #57's admission as well as obtaining POA documentation for Resident #57's records on admission to the facility. Facility Administrator informed the Medicaid application for Resident #57 had been completed and submitted in the past couple of days and was pending. Review of Facility provided Resident Rights policy, revealed the following:1. The resident has the right to exercise his or her rights as a resident of the provider and as a citizen of the United States. 2. In the case of a resident adjudged incompetent the rights of the resident devolve to and are exercised by the resident representative appointed under state law to act on the resident's behalf. 3. In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative. 4. The resident or resident representative has the right to access personal and medical records pertaining to him or herself and shall have access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual. 5. Residents have the right to manage their own money and financial affairs or to choose someone to manage their money and financial affairs for them, including prior notice of any charges the Provider may impose against a resident's personal funds.6. The Provider will provide the Resident with needed social services including counseling, help solving problems with other residents, help in contacting legal and financial professionals and discharge planning.

Based on observations, resident and staff interviews, and policy review, the facility staff failed to ensure Enhanced Barrier Precautions (EBP) were in place for residents with multidrug-resistant organisms (MDROs) (Resident #24), failure of staff to wear appropriate personal protective equipment (PPE) when providing care to residents on EBP (Resident #8), and failure to follow proper infection control practices to prevent the transmission of infection with blood sugar monitoring. The facility reported a census of 58 residents.Findings include:1. Review of MDS dated [DATE] revealed Resident #24 BIMS of 11 indicating moderate cognitive impairment with diagnoses of Multidrug-Resistant Organism ((MDRO) bacteria that have become resistant to three or more classes of antibiotics) and Urinary Tract Infection, and incontinent of bowel and bladder with need for substantial/maximal assistance with ambulation and use of walker or wheelchair. Review of Resident #24's Care Plan initiated 1/23/26 documented incontinent of bladder and risk for UTIs with interventions to provide peri-care with each incontinence episode, monitor/document for signs and symptoms of UTI, and obtain labs as ordered and notify physicians of results. Observation of resident #24's room on 5/4/26 at 12:28 PM failed to indicate EBP. Review of Resident #24's lab results revealed the following: a. 1/10/26 Urine Culture: >100,000 Proteus mirabilis/penneri. Multi-Drug Resistant Gram-Negative Rod. (Indicating growth of MDRO bacteria in urine) (Isolation required)b. 1/16/26 Urine Culture: 50,000-100,000 Proteus mirabilis- ISOLATION IS REQUIRED. (Indicating growth of MDRO bacteria in urine) (Isolation required)c. 4/9/26 Urine Culture: >100,000 Klebsiella pneumoniae, 10,000-49,000 Proteus mirabilis. (Indicating growth of MDRO bacteria in urine) (Isolation required) During an interview on 5/7/26 at 2:46 PM, VP of Clinical Operations, reviewed Resident #24's urine cultures and acknowledged due to MDRO results resident #24 should have been and should be under EBP with incontinent cares. Review of facility provided Enhanced Barrier Precautions dated 3/25/24 revealed the following: 1. Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.2. EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with CDC-targeted MDROs. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #8 revealed the diagnoses of cerebral palsy, benign prostatic hyperplasia (BPH is an enlargement of the prostate gland that squeezes the urethra effecting the urinary system) and required maximal assistance from staff for personal hygiene and was dependent for toilet. The MDS identified indwelling catheter. The Care Plan for Res #8 directed staff to utilize Enhanced Barrier Precautions (EBP) related to the presence of a catheter. During an observation on 5/6/26 at 11:35 am, Staff P, Certified Nursing Assistant (CNA) provided catheter care for Resident #8. Resident #8 had a urinary leg bag attached to his left leg. Staff P placed a barrier on the floor with a container to contain the drained the urine (a graduate). Staff P put gloves on but failed to practice the EBP by putting the gown on as directed on the EBP sign on Resident #8's door. The PPE storage outside the door contained gowns, gloves and masks if needed for splatter. Staff P paced the graduate onto her knee to stabilize it instead of releasing the straps from around Resident #8's leg and bring the bag to the graduate when she emptied it. Infection Control Policy revealed: Standard Precautions:a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.e. Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department. Isolation Protocol (Transmission-Based Precautions):A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.Residents will be placed on the least restrictive transmission-based precaution for the shortest duration possible under the circumstances. 3. On 5/6/26 at 11:13 AM, Staff U, Certified Medication Aide (CMA), stated she was going to check a resident's blood sugar. She went into Resident #41's room and obtained a blood sample. After obtaining the blood sample, Staff U picked up the supplies and walked out of the room. When asked if she should have done anything differently, Staff U replied that she should have removed her gloves after obtaining the blood sample and sanitized her hands (prior to touching other objects). On 5/6/26 at 12:15 PM, the [NAME] President of Clinical Operations stated that Staff U had let her know what happened. This [NAME] President of Clinical Operations stated that she had no questions and understood the infection control concerns. Policy: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. Definitions: Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected, then the meter will not be used for multiple residents. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Procedure: Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. Wash hands. Explain the procedure to the resident. Provide privacy. Put on gloves. Obtain capillary blood glucose sampling according to facility policy. Remove and discard gloves, perform hand hygiene prior to exiting room. Reapply gloves if there is visible contamination of the device or if the resident is HIV or Hepatitis B or C positive. Retrieve (2) disinfectant wipes from container. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. Discard disinfectant wipes in waste receptacle. Perform hand hygiene.

Based on record review, observations, staff interviews and facility policy review the facility failed to complete an accurate Minimum Data Set (MDS) for 1 of 4 residents (Resident #2) reviewed. The facility reported a census of 68 residents. Findings include:According to the Discharge-Return Not Anticipated MDS assessment tool with reference date of 11/24/2025 documented Resident #2 was admitted to the facility on [DATE] and discharged home/community on 11/24/2025.The Care Plan Focus Area with a revision date of 11/24/2025 documented Resident #2 and responsible party choose long-term placement. Review of Resident #2's progress notes from 11/12/2025-12/1/2025 revealed no documentation of her being discharged from the facility. On 12/30/2025 at 11:45 AM Resident #2 was observed to be sitting in the dining room with her peers. On 12/30/2025 at 11:57 AM the Director of Nursing (DON) verified Resident #2 was in the building and not discharged . While reviewing the MDS that was completed on 11/24/2025 she acknowledged it documented Resident #2 was discharged but that was not accurate. At 1:30 PM she stated the corporate staff was fixing the MDS. During the exit meeting at 2:03 PM she indicated the MDS fixed the issue. The Assistant Director of Nursing (ADON) stated around that time there was talk of Resident #2 discharging home but the family realized that was not going to be an option.The facility provided a document titled Conducting an Accurate Resident Assessment. The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status).Policy Explanation and Compliance Guidelines:2. Qualified staff who are knowledgeable about the resident will conduct an accurate assessmentaddressing each resident's status, needs, strengths, and areas of decline. The assessment will bedocumented in the medical record. 7. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. Whether the MDS assessments are manually completed, or computer-generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status.

Based on clinical record review, staff interviews, and facility policy review the facility failed to ensure 1 of 4 residents' (Resident #1) care plan was updated to include interventions to offload her heals while in bed. The facility reported a census of 68 residents. Findings include:According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 11/29/2025 Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. Resident #1 had one pressure ulcer present upon admission/entry. She had a pressure reducing device for her bed and chair, utilized nutrition or hydration interventions to manage skin problems and received pressure ulcer care. Record review revealed wound care orders from a local hospital dated 11/21/2025. One order included to float Resident #1's heels with heel protectors at all times. The Care Plan Focus area with a revision date of 12/11/2025 documented she has the potential for impaired skin integrity and is at risk for pressure ulcers related to her diagnoses of incontinence, debility, and Alzheimer's disease. Resident #1 had an area to her sacrum and deep tissue area injury to her right heel. The care plan lacked interventions to prevent the worsening of the deep tissue injury area to her right heel.On 12/26/2025 at 12:38 AM Staff A Registered Nurse (RN) stated Resident #1 did have boots on her feet but would not always keep them on. On 12/26/2025 at 1:38 PM Staff B Licensed Practical Nurse (LPN) verified Resident wore booties on her foot and had treatments to her bilateral heels. On 12/30/2025 at 11:00 AM Staff C Certified Nursing Assistant (CNA) acknowledged Resident #1 wore booties on her feet to help with offloading her heels.On 12/30/2025 at 11:57 AM the Director of Nursing (DON) stated when Resident #1 returned to the facility from the hospital in November she had pressure injury to her heel. Initially they tried heel protectors that cupped her heels and had a single strap across the front her foot. The resident was able to easily remove them so they got pressure reducing boots. They are soft [NAME] boots with Velcro to help secure them and they were able to stay on better for her. When asked if this intervention should be included on Resident #1's care plan she indicated she would have to look at the care plan. She added she would think it should be, so yes. She indicated they have had some staffing change over with over looks the care plans being completed. The facility provided a document titled Comprehensive Care Plans. It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility provided a document titled Pressure Injury Prevention and Management. This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. 4. Interventions for Prevention and to Promote Healinga. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with interventions will be documented in the weekly summary charting. 6. Modifications of Interventions b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: i. Changes in resident's degree of risk for developing a pressure injury. ii. New onset or recurrent pressure injury development. iii. Lack of progression towards healing. iv. Resident non-compliance. v. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.

Based on observations, clinical record review, staff interview and policy review, the facility failed to supervise residents at risk for elopement for 1 of 3 residents reviewed (Resident #9). This failure resulted in the resident eloping from the facility, his whereabouts unknown for approximately an hour and 30 minutes and sustaining fractures of five ribs, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as ofMay 8, 2025, on August 18, 2025 at 1:15 PM. The Facility Staff removed theImmediate Jeopardy on August 20, 2025 through the following actions: Resident assessed and sent to the hospital 100% Headcount of all Residents on 6/4/2025 100% Elopement Risk assessment review completed by DON for accuracy and current on 6/5/2025. The three residents verified at risk for elopement, and wearing wanderguard devices, had all care plan interventions reviewed and confirmed in place for supervision on 6/5/2025. 100% Care plan, TAR, placement of device, elopement binder, and device functioning audit for all residents determined to be at risk for elopement completed by MDS on 6/5/2025 Facility conducted 100% audit of all external doors to ensure they are in proper working order and checked all windows for security on 6/4/2025 Facility conducted elopement drills x 3 shifts 6/5/2025-6/7/2025 Facility conducted Ad Hoc QAPI to address this alleged deficient practice on 6/5/2025 Elopement binder reviewed and noted as up-to-date on 6/5/2025 with reviews daily and weekly as part of our quality assurance program, 8/18/2025, and ongoing Staff in-service on Elopement Policy began 6/4/2025, to include, promptly answering sounding door alarms, not resetting alarm until the source of the alarm is discovered and/or 100% resident presence is verified Resident placed on 15-minute checks upon return from hospital and continued until discharged Current resident at risk for elopement, noted effective 3/21/2025, has a wanderguard in place on her ankle with every shift checks for placement and functioning, distract from wandering by offering pleasant diversions, structured activities, food, conversation, tv or book. Care plan revised and updated 5/29/2025, 8/18/2025 as part of our ongoing compliance. As of 6/5/25, and ongoing as part of our quality assurance, all current and new admissions to the facility have had and will continue to have an elopement risk assessment done on admission, quarterly and as needed. If determined to be at risk for elopement, the new resident's individualized care plan will be developed for safety based upon their preferences and routines related to ensuring adequate supervision for safety. New hire staff receive education upon hire related to elopement, and all direct care staff have access to the resident's Kardex/care plan and are expected to be familiar with individualized needs for supervision. The scope lowered from a J to D at the time of the survey after ensuring the facilityimplemented education and their policy and procedures. In addition, the facility failed to provide for safe transfer for Resident #10 by not using adequate staff during the transfer for 1 of 3 residents reviewed for transfer. The facility reported a census of 68 residents. Findings include: 1.The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The resident had diagnoses to include medically complex conditions, hyperlipidemia, Alzheimer's disease and anxiety disorder. The resident had wandering behavior that occurred 4 to 6 days, but less than daily, which significantly intruded on the privacy or activities of others. The Care Plan for Resident #9, with an initiation date of 4/24/25, included a focus area: potential for elopement risk/wanderer risk. The resident wanders aimlessly, WanderGuard bracelet (a wearable security device, worn by residents at risk of wandering that alerts staff when the resident approaches a monitored exit or enters an unauthorized area) in use for safety. The goal included: safety will be maintained through the review date and interventions included:Assess for elopement/wander risk (created 4/24/25)Observe location frequently. Document wandering behavior and attempted diversional interventions in behavior log (created 4/24/25) On 5/31/25 resident took his wander guard off his lower extremity in his room. WanderGuard (WG) replaced on right wrist hoping that resident might not be able to take it off with his left hand (created on 6/5/25) Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes (created 4/24/25)Every 15 minute safety/location checks upon readmission from hospital (created 6/13/25)Resident noted to remove wander guard bracelet-reapplied by staff (created 5/1/25)Room change upon readmission to new private room on different unit to decrease environmental stimuli (created 6/13/25)WG alert, replaced bracelet right wrist, expires 1/12/28 (created 4/24/25) Review of the Electronic Health Record (EHR) revealed Resident #9 scored at risk for elopement on Elopement Risk Evaluations completed on 4/24/25, 5/4/25, 6/5/25 and 6/12/25. Review of the EHR revealed Resident #9 admitted to the facility on [DATE]. The resident was placed in a room on Hall 6 (Ambassador). Review of the EHR for Resident #9 revealed Progress Notes which documented wandering behavior:Progress note dated 4/24/25 at 3:33PM, nurses note: resident noted to be wandering hallways looking for his wife. Easily directed. Spoke with wife in regards to safety and she gave permission to place WG on resident and will reevaluate as needed. Placed on RT(right) ankle.Progress note dated 4/24/25 at 3:455PM nurses note: resident was up to Royal walking down hall 2 looking to leave. assisted by 2 staff to return to ambassador. He did not want to go but after much talking from staff he did begin to walk with staff to ambassador.Progress note dated 4/24/25 at 4:52PM, nurses note: resident continues to walk up and down hallways and has been taken out of the therapy room [ROOM NUMBER] times and redirected. Spoke with DON was instructed to call wife and ask her to sit with him for awhile. Spoke with wife explained situation. Wife will be here at building in a few minutes.Progress note dated 4/25/25 at 4:49AM, nurses note: resident has been resting quietly in the lounge, at beginning of shift he was redirected multiple times from going in and out of other residents rooms and hallways he would go to his room and only stay in room for a very short time. Progress note dated 4/28/25 at 8:27PM nurses note: found resident coming out of room [ROOM NUMBER], resident in room [ROOM NUMBER] was yelling out help Walked resident back to Ambassador and gave him to staff. 10 minutes later resident was back looking in rooms on hall 2. Walked back to Ambassador again.Progress note dated 4/29/25 at 9:57AM nurses note: resident in and out of resident rooms on hall one. redirected back to his room.Progress note dated 4/29/25 at 12:42PM nurses note: found wandering around hallways on royal and into resident rooms. directed out and then stood at the front door. assisted by CNA back to ambassador.Progress note dated 4/29/25 at 2:30PM nurses note: resident has been on Royal side of building for the past couple hours walking up and down the hallways. He does attempt to open door but only tries once before moving on.Progress note dated 4/29/25 at 3:41PM nurses note: resident pushing on door until they sound. staff responded and redirected resident. He attempted this on 2 different doors.Progress note dated 4/30/25 at 12:35AM nurses note: resident on Royal side of the building wandering throughout the evening. Made several attempts to open the front door and doors at end of hallways. Wandered into other resident rooms several times. escorted back to his room by staff many times. Resident very pleasant with staff.Progress note dated 4/30/25 at 12:32PM nurses note: resident has been up and about wandering down all 3 halls standing and pushing on doors trying to go outside to get in his car. Staff have redirected him several times, I just walked him down to his room to rest resident is confused and disoriented of where he is.Progress note dated 5/1/25 at 3:03AM nurses note: resident is currently awake and wandering about ambassador side of building no set location or explanation as to where he is going is noted to become agitated with redirection as he has been trying to go in and out of other residents room Certified Nurses Aid (CNA) reports that he swung at her while trying to redirect him out of the therapy room this nurse was able to get resident back into his room.Progress note dated 5/1/25 at 9:33AM nurses note: resident noted to cut off WG this am with his butter knife. New WG put in place. DON made aware. Progress note dated 5/5/25 at 12:49PM Risk Note: IDT review of attempted elopement finds that all facility processes/systems working correctly. Resident was stopped at the base of the ramp outside the exit door by staff responding to alarm sounding. No injuries. He was able to be redirected back into the building. Wander guard bracelet remains in place to rt ankle et functioning properly. RCA: wanderer with dementia et confusion. Wander guard in place to rt ankle as ordered. Alarm systems working. Resident allowed staff to walk back into the building and enter through the patio door. Resident stated that the noises the alarms made needed to be fixed not to go off when he went out through doors. INTERVENTION: 15 minute safety checks implemented. Referrals already in progress for a dementia unit placement. N.O. for prn Xanax for increased anxiety from PCP. Psych provider referral requested 5/5/25.Progress note dated 5/8/25 at 12:21PM at 4:52PM nurses note: resident wandering up and down halls. easily redirected when attempting to go in others rooms or trying to push on doors.Progress note dated 5/8/25 at 12:28PM nurses note: resident tore of WG this am, was immediately replaced. Progress note dated 5/8/25 at 4:52PM nurses note: resident continues to wander trying to go out the doors. He is easily redirected. Progress note dated 5/9/25 at 8:17AM risk: IDT review of removal of wander guard 5/8 et fall notes 15 minute safety checks and alternative placement attempts con't. Wander guard in place to left ankle et functioning. No injuries r/t fall from side of bed, 72 hr fall f/u w/neuro checks in place. Staff are encouraging resident to lie down in bed or recliner when observing s/sx tiredness however res is resistive to this, wandering throughout facility continues. Progress note dated 5/10/25 at 9:24AM nurses note: resident wandering in and out of residents rooms. easily redirected but continues to do it over and over.Progress note dated 5/29/25 at 12:23PM risk: IDT review of care/needs notes COC (change of condition) for increased edema noted to BLEs this week. labs per NP w/visit. See orders. No c/o pain. No new falls. Res con't to wander throughout facility during waking hours. Does not comprehend/remember education/enc to sit et rest to elevate extremities r/t edema. Appetite poor today. Res noted to be unwilling to remain in dining room for meal at times et does not consume from room trays provided. Progress note dated 5/30/25 at 7:41PM nurses note: resident noted to be being aggressive with staff trying to hit and shove staff also noted to be trying to leave building spoke with PCP new order obtained for alprazolam 0.5 mg po q 8 hours prn mar updated pharmacy notified and wife aware.Progress note dated 5/31/25 at 2:21PM nurses note: resident roommate brought this resident leg-alarm to this nurse at the nurse's station and he said he observed this resident taking his leg alarm out with his right hand in their room. as such, the alarm is now placed on right wrist hoping that resident right might not be able to take it out with his left hand. Progress note dated 6/5/25 12:13AM nurses note: This writer asked at 9:44PM if anyone had seen Resident. This writer went to Residents room, then started a building search with ALL staff. When Resident was not found in the building outside search started 2 staff out front door, this nurse and CNA went out therapy door and started outside search. Resident was found at 9:40 pm sitting on his bottom, legs in front and left (Lt) arm leaning against cement wall in the back of building between hall 6 wing and assisted living. DON was called and notified of elopement. Asked Resident if he was ok, he stated his right (RT) ribs and RT hip hurt. Attempted to assist to his feet and Resident was unable to stand with assist of 2. Assistance was requested outside and wheelchair (W/C). 4 staff to assist Resident to W/C. Noted dirt to back RT shoulder, lifted shirt and noted light purple discoloration. Emergency Medical Services (EMS) was called for assistance. (late entry, incident occurred on the night of 6/4/25) During an interview 8/5/25 at 2:30 PM, Staff J, Licensed Practical Nurse (LPN), stated she was working the night of 6/4/25, the night of the incident with Resident #9. Staff J stated the night of the 4th of June was not the first time the resident was able to get out of the building, she thought it happened maybe two other times, however stated she was not working on the other occasion(s). Staff J stated Resident #9 admitted to the facility in April of 2025, he had a room on Hall 6. The therapy room is at the end of hall 6, and the resident liked to walk down to the end of that hall by the therapy room and open the door in the therapy room. He also liked to walk to the front of the building, by halls 1, 2 and 3 and spend time in that front dining hall. Staff J stated the resident walked around the building daily, he walked fast and did not use a walker or any device. He could present initially as though he was intact cognitively, he would talk often. The resident had taken his WG off, he took it off at least 2-3 x's prior to the night of June 4, 2025. Staff J stated she was working on the night of the 4th of June on the Ambassador halls, where Resident #9 had a room, starting at 6:00 pm. Staff J stated the door alarm did go off around 7 pm that night when the smokers went outside to smoke. Staff J stated she never heard another alarm go off that night. Staff J stated a staff member at the Assisted Living (AL), which is connected to their building by a passageway, down Hall 6 and Hall 5, past the nursing station, told Staff J she saw the resident outside smoking with an AL resident that night in the AL courtyard, in the evening, not sure what time exactly. Staff J stated on the night of the 4th she gave Resident #9 an as needed (PRN) anti-anxiety medication at around 6:30-7:00 PM due to agitated behaviors. He was ripping pictures off the wall and became aggressive with staff. Staff J stated she then went to check on the resident at 9:00 PM and could not find him. She did not see him in between giving him his medication at around 6:30-7:00 PM until she went to check on him at 9:00 PM. She started looking for him at 9:00 PM, then included the whole building in the search for him. They searched the entire building until 9:30 PM, then they went outside to look for him, she went outside to look for him with another staff member, a CNA. They found him at 9:40 PM. He was outside sitting on the ground, in a grassy area in between the back of Hall 6 and the AL building. He was sitting next to a cement wall, with his left arm leaning on the cement wall. He was wearing a plaid shirt, a bluish colored ball cap, sweat pants and tennis shoes. They tried to get him to stand up, he yelled out in pain so they got a wheelchair and assisted him up with a gait belt. Staff J stated she raised up the resident's shirt and noted purple colored bruising to the left side of his back. He yelled out in pain when they moved him but he could not say what happened or what was hurting him. Staff J stated prior to finding the resident, they were outside yelling his name, he did not respond to this. It was dark outside, they used their flashlights on their phones while looking for him outside. They called the physician and got an order to take him to the hospital. Staff J stated she talked to all of the staff working that night and no one saw him since around 7:00 PM. Staff J stated the resident was not on 15 minute checks and staff were supposed to know of his location frequently. No staff stated they heard the WG alarm go off that night. Staff J stated the smokers went outside at around 7:00 PM to 7:20 PM and the door alarm went off at that time. Staff J stated the resident had his wander guard on when they found him outside. Staff J had checked his wander guard earlier due to him being so agitated. Staff J stated the resident did go to the doors often, especially the therapy door at the end of hall 6. Staff J stated the door to get to the AL side is not alarmed. It has a code box, but no alarm. Staff J stated they did have an oxygen tank delivery that day (unsure of the exact time), the delivery guy went from their side to the AL side through the door at the back of Ambassador (halls 4, 5 and 6). Staff J stated the resident was an independent walker and would talk to people, he could present as though he was not a resident. Staff J wonders if the delivery guy let him through the AL doors, which take you into the dining room of AL and then through there there are doors to take you outside, one of the doors leads to the area where the resident was found. During an observation 8/5/25, beginning at 3:00 PM, with the Administrator present, observed the area where Resident #9 was found outside on the night of 6/4/25. Going out the door the smokers used to go outside to smoke, by the dining room, this leads to a courtyard that is not fenced in, there is a sidewalk that leads to a side parking lot and a ramp that goes up to the door leading to hall 6 by the therapy rooms. The courtyard where residents smoke is not enclosed. Walking around the ramp on the grass, down the side of the building by hall 6, going to the back of the building there is a short (approximately 3 feet tall cement wall). There is a grassy area in between the back of Hall 6 and the AL portion, with a door to the basement of the SNF building. The resident was found in this grassy area between the back of Hall 6 and the AL building. There was a door at the back of the AL building that was an exit door, out this door there is a sidewalk then a steeper grassy hill, which is connected to the area where the resident was found. With the Administrator present, the door alarms were tested in the SNF building. Each door is alarmed to go off if the door is opened more than 15 seconds, the doors are not locked, other than the front door which has a key pad. The doors sounded an alarm when pushed open more than 15 seconds. A WG was then tested on the doors, when the door was opened holding the WG the alarm went off immediately, this was the same alarm sound as the door alarm, however it went off immediately when the door was opened. The alarms are turned off by a key pad next to the doors, which also resets the alarms, including the WG alarm. The WG alarm is the exact same sound as the door alarm. While testing the alarms, observed AL residents going from the SNF over to AL through a door with a key pad, the door is at the back of the Ambassador hall. With the Administrator present, walked to the AL side, going through a door which connects their SNF with AL, at the back of Ambassador hall (halls 4, 5 and 6). This door is accessible to all of the residents, it is locked with a key pad next to the door. There is no alarm on this door, and the door is accessible from the SNF side by walking down a short hallway off the living room and nurses station of the Ambassador side. Once going through the door, there was a short hallway into the AL side, going through another door which was not locked or alarmed, this entered into the dining room of AL. The Administrator stated the exit doors on the AL side have alarms, however they only sound at the nurses station, there is one nurses station in AL. Going down the hallway to the left of the dining room, there is an exit door at the end of the hallway, this exit door was the door closest to where Resident #9 was found. We opened the door, it was not locked, an alarm did not sound. Going to the nurses station, AL Staff K, Certified Medical Assistant (CMA) was sitting at the nurses station and said an alarm did not go off. Staff K stated an AL resident just came back from the SNF side after playing Bingo on the SNF side. The Administrator stated they encourage AL residents to go to the SNF side for activities and they can come and go as they please, they all have the code to get back into AL from the SNF side. The Administrator opened another door in AL, the door closest to the nurses station, and the alarm did not sound. The Administrator opened another door to the back of the nurses station, and the alarm did not sound. Staff K stated the alarms should sound at the nurses station when an exit door is opened, other than the door to the SNF side, and the front entry door and side door by the nurses station. The side and front entry door are not alarmed, they get locked at 10 PM every night. Staff K stated he is not sure why the alarms did not sound today when the other doors were pushed open. Staff K checked a panel on the wall and noted the alarms had been turned off, he said they should never be turned off. Staff K turned the alarm on from the panel and the Administrator opened an exit door, the alarm did sound at the nurses station. During an interview on 8/5/25 at 3:30 PM, Staff K stated he was working at AL on the night of the 4th of June, 2025. Staff K recalled seeing a person he did not know outside in the courtyard with an AL resident who was in the courtyard smoking. Staff K described what the person he did not know was wearing, stated the person had on a gray/blue colored ball cap, a plaid shirt and sweat pants. Staff K believed this was around 5:30 PM. He did not see this person again. Staff K stated he worked until 10 PM on the night of the 4th of June. He stated no one told him they were looking for a resident who was missing from the SNF side. Staff K stated they did have a delivery person who came over to the AL side from the SNF side on the 4th of June, he thought this was around 4 pm or so. During an interview 8/5/25 at 3:45 PM, the Administrator stated they followed up with AL regarding the visitor Staff K saw in the courtyard that day, and they do not believe it was Resident #9 as Staff K was shown a picture of the resident and he did not believe it was him. An AL resident did have a visitor that day. The Administrator stated all of the door alarms on the SNF were working the night of the 4th of June, she had the Assistant Director of Nursing (ADON) check and had her check the windows. They completed a facility investigation with interviews of staff working that day. Staff stated they did not believe a door alarm went off again that night other than the alarm for the smokers when they went out to smoke. The Administrator stated if a door alarm goes off, it has to be turned off and reset at that door, staff cannot turn off the door alarm from another door. They began education that night on elopement procedures and did elopement drills after the incident on the 4th. During an interview 8/6/25 at 10:45 AM, Staff L, Certified Medication Aid (CMA), stated she recalled the day of June 4th, she worked a day shift, leaving at 6:00 PM. Staff L stated Resident #9 was initially on Hall 6, then he moved to Hall 3 after getting back from the hospital. Staff L stated Resident #9 was a wanderer, and he loved to talk and joke around. The resident liked to walk around the facility. He would walk around at all times of the day and he was an independent walker before that night, he was not after he returned from the hospital right away, he used a walker. Staff L stated Resident #9 did try to open the doors to go outside and they would redirect him. The resident was always looking for his white SUV in the parking lot, from the front dining room. He would punch in random codes in the front door, however he never got out the front door. He would try to get out the door by the front dining room, the door off the side of the dining room. This door was alarmed. Staff L stated the resident never got out when she was working. Staff L stated the resident was not overly agitated that day, before she left he was not agitated, but he was going to the doors. During an interview 8/6/25 at 11:00 AM, Staff M, CMA, stated she recalled Resident #9. He was a resident who liked to wander and he would go to the doors and try to open them. Staff M stated the resident would try all the doors, he never got out up front that she is aware of, on the Royal side. Staff M stated Resident #9 would walk up to the doors on Royal, there are doors at the end of each hallway and the front door and the dining room door, however the resident never got out these doors, he would push on them and they would redirect him. Staff M stated on the 4th of June, she worked 6:00 PM to 6:00 AM, on the Royal side. Staff M stated she only saw the resident once, around dinner time, he was up here just briefly, then he went back to his hallway and she did not see him again. Staff M stated when the smokers go out to smoke, the door alarm does go off sometimes, when they hold the door open. Staff M stated she never heard the wander guard alarm go off, ever, that night, or any door alarms. Staff M stated staff up front on the Royal side were told that Resident #9 was missing and to search for him in the building. This was later at night, she was not sure what time, it was dark outside. Staff M stated all of the staff checked the rooms and the resident was not located anywhere on the Royal side. During an interview 8/6/25 at 11:20 PM, staff H, Certified Nursing Assistant (CNA), stated she did work the day of the 4th of June, from 2:00 PM to 6:00 PM, on the Royal side. Staff H recalled Resident #9, he was pleasant to be around. Staff H stated the resident would look for his wife and wander around routinely. Staff H stated the resident had a WG on. He was independent with walking. Staff H stated he was on hall 6 when he admitted in April of 2025. The resident would try to get out the doors often, especially the door at the end of hall 6, by the therapy room. The resident also liked to come up to the front and sit in the dining room. He would sometimes get agitated when he was redirected, but more frustrated than aggressive. Staff H stated she did not remember any alarms going off on the 4th of June. Staff H stated the door alarms do sound when they go out to smoke sometimes, she stated the door alarm sound is the same as the WG alarm sound. Staff H stated she did not recall any time the resident set off the door alarms or the WG alarm. During an interview 8/6/25 at 12:19 PM, Staff N, CNA, stated she worked on the 4th of June, 2025. Staff N stated she recalled Resident #9, he was a resident that liked to walk around the building. There were a few times he was violent with other CNA's, however he was never with her. He would get frustrated during redirection, but not physically aggressive toward her. Resident #9 liked to walk around and would walk to doors, they would redirect him. The resident wore a WG. He would try to take it off sometimes. Staff N stated they would always be sure the resident had his WG on. Staff N stated she worked from 2:00 PM to 10:00 PM on the 4th of June, on the Ambassador side. Staff N stated the last time she recalled seeing the resident that day was around supper time in the dining hall. Staff N stated she does not recall an alarm sounding that night. There have been times when she has worked that the door alarm has gone off when the smokers go outside. She cannot recall if the door alarm went off that night when the smokers went outside. Staff N stated she does not recall seeing the resident after supper that night. Staff N did not recall the resident trying to get out that night or trying to push a door open. He did like to go to the doors, especially in hall 6, at the end, by the therapy room. Staff N was told later that night on the 4th, before 10 pm, that the resident was missing. They all started looking for him, they looked all over in the building. After looking in the building, she is not sure for how long and not finding him, she and Staff J went outside to look for him. She and Staff J found him outside, he was found in the grass, in between the back of Hall 6 side and AL. He was awake, he said he could not stand on his own because he was in pain. Staff N stated it was dark outside, the resident was fully dressed. The resident did have some scrapes/marks on his back and rib area. He had on a flannel/plaid shirt and pants. His shoes were not on his feet, they were near him on the ground. The Administrator had them check every window and door alarm and review the elopement book for residents who were an elopement risk. During an interview 8/6/25 at 12:55 PM, Staff O, Licensed Practical Nurse (LPN), stated she works on the Royal side normally. Staff O stated she was aware Resident #9 had a WG and he liked to wander the building. Staff O stated he liked to go to the doors, and he would be redirected when he went to a door. On the night of the 4th of June, 2025, Staff O stated she worked, her shift began at 6:00 PM, on the Royal side. She did not recall seeing the resident at all that night. She recalled at around 9:00 PM being told that the resident was missing. They looked for the resident inside and could not find him on the Royal side. Other staff went outside to look for him and he was later sent out by ambulance. Staff O stated she does not recall any alarms going off that night. During an interview 8/6/25 at 4:00 PM, Staff P, CNA, stated she recalled working on the 4th of June, 20205. She worked on the Ambassador side, on hall 5, the 2:00 PM to 10:00 PM shift. Staff P recalled Resident #9 had wandering behaviors that day, as he did every day. He would wander the halls and would go in and out of resident rooms. He would be redirected during these times. At times, he would become aggressive or agitated when redirected. Resident #9 would walk up and down the halls and go to doors. Staff P stated the resident never went out a door when she was working, she heard he did get out a door one other time, but she was not working then and only heard that he did. On the 4th of June, she believed she last saw Resident #9 at around 7:00 or 7:30 PM, he was in the 5 hallway, walking. Staff P recalled hearing a door alarm at around 7:00 PM, she thought this was the smokers going out or coming in. When she heard the door alarm, she checked the door at the end of hall 5 and by the AL entryway, and did not see any residents, the alarm was shut off, not by her. Staff P stated she was told at around 9:00 PM that the resident was missing. They looked all through the building for approximately 30 minutes and then staff went outside to look for him. He was found outside in between AL and the back of hall 6. Staff P stated she does not know how the resident got outside. Staff P stated the resident liked to go to the door at the end of hall 6, through the therapy room. She believed the door at the end of hall 6 is coded and not alarmed. During an observation 8/6/25 at 4:20 PM, observed the door at the end of hall 6, the door was alarmed. The door is located through the therapy room, at the back of the therapy room.During an interview 8/11/25 at 6:50 AM, Staff Q, LPN, stated she did work the night of 6/4/25, from 6:00 PM to 6:00 AM. She worked on the Ambassador side, the back halls. Staff Q stated Resident #9 was a resident who wandered, he would wander through the building the majority of the day. He was not aggressive, but he would get frustrated when redirected and would be verbally aggressive. He would wander into other resident's rooms and up and down the hallways, he would go to the doors to try to get outside. There were numerous times he would go into the therapy room at the end of hall 6 and try to get out the door in the ther[TRUNCATED]

Based on clinical record review and staff interviews, the facility failed to accurately complete a Minimum Data Set (MDS) Assessment for 4 of 8 residents reviewed (Resident #6, #7, #9 and #12). The facility reported a census of 68 residents. Findings include: 1. The quarterly MDS assessment dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) Score of 4, indicating severe cognitive impairment. The MDS included diagnoses of medically complex conditions, non-Alzheimer's dementia, seizure disorder, anxiety disorder and depression. The MDS documented a wander/elopement alarm was not used. The Care Plan for Resident #6, with an initiation date of 6/5/23, included a focus area: the resident is having adjustment issues to admission. An intervention for this focus area included Wander guard in place to the left lower leg. Functioning will be checked QS (twice daily). This was initiated on 8/13/24. Review of the Electronic Health Record (EHR) Elopement Risk Evaluation for Resident #6 completed on 8/7/24 revealed the resident at risk for elopement. Review of the EHR order summary for Resident #6 showed an order to check placement and function of wanderguard each shift, left ankle every day and night shift for wandering, with a start date of 10/25/2024, and a discontinue date of 8/04/2025. The annual MDS assessment dated [DATE] for Resident #6 documented a wander/elopement alarm was not used. The quarterly MDS assessment dated [DATE] for Resident #6 documented a wander/elopement alarm was not used. 2. The annual MDS assessment dated [DATE] documented Resident #7 had a BIMS score of 3, indicating severe cognitive impairment. The resident had diagnoses to include medically complex conditions, hyperlipidemia, thyroid disorder, non-Alzherimer's dementia, anxiety disorder, depression and psychotic disorder. The MDS documented the resident had not exhibited wandering behavior and documented the resident did not use a wander/elopement alarm. The MDS documented the resident did not have indicators of hallucinations or delusions. The Care Plan for Resident #7, with an initiation date of 3/21/25, included a focus area: potential for elopement risk/wanderer risk. Interventions included: assess for elopement/wander risk and wander alert, left ankle device. The Care Plan further included the focus areas: the resident uses antidepressant medication related to depression, the resident has level 1 PASRR with mental health diagnoses of major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, and psychotic disorder with delusions, the resident uses antipsychotic medications related to disease process of dementia and the resident had a mood problem related to dementia. Review of the EHR Elopement Risk Evaluation for Resident #7 completed on 3/20/25 revealed the resident at risk for elopement. Review of the EHR order summary for Resident #7 showed an order to check wander guard functioning Q shift, two times a day for wander guard, with a start date of 3/20/25. Review of the EHR for Resident #7 revealed Progress Notes which documented wandering and other behaviors:Progress note dated 3/20/25, nurses note, documented Resident was packing her room stating she needed to go home her friend was waiting for her. Resident redirected several times. Progress note dated 3/21/25, nurses note, documented resident has had no attempts to leave facility, just wandering in hallways non intrusive. Progress note dated 3/24/25, nurses note, documented resident came out to the nursing station numerous times between 2030 and 2200. Progress note dated 3/27/25, nurses note, documented late entry for 3-26-25 resident went from room to dining room in excess of 10 times within a 30 minute time frame. Progress note dated 4/6/25, nurses note, documented resident refused upper meal, after meal resident was noted to be wandering down other hallway. Progress note dated 5/15/25, SBAR summary for providers, change in condition reported were behavioral symptoms, agitation and psychosis, resident is having auditory and visual hallucinations/delusions, is wandering facility. Progress note dated 5/16/25, nurses note, Resident has been up last 2 hours wheeling up and down hallways talking to an invisible being, Demanding Show yourself loudly as well as There you are manically going the other directions. Resident is not redirectable. When you ask her questions she states mind your own business I am dealing with them.Progress note dated 5/21/25, nurses note, resident has been up and propelling self up and down hallways was noted to be standing up at water fountain near nurses station, the wandering of the building has been an ongoing habitual behavior, resident also continues with visual and auditory hallucinations and well as wandering behaviors. 3. The discharge MDS assessment dated [DATE] documented Resident #9 was rarely/never understood and a BIMS score was not conducted. The resident had diagnoses to include medically complex conditions, Alzheimer's disease and anxiety disorder. The MDS documented the resident did not exhibit wandering behavior and did not have any alarms used. The admission MDS assessment dated [DATE] documented Resident #9 exhibited wandering behavior 4-6 days, but less than daily and indicated the wandering did not place the resident at significant risk of getting to a potentially dangerous place, but did significantly intrude on the privacy or activities of others. The MDS documented a wander/elopement alarm was not used. The Care Plan for Resident #9, with an initiation date of 4/24/25, included a focus area: potential for elopement/wander risk, resident wanders aimlessly, wander guard bracelet in use for safety. Interventions included: Assess for elopement/wander riskObserve location frequentlyOn 5/31/25 resident took his wander guard off his lower extremity, wander guard replaced on right wrist On 5/1/25 resident noted to remove wander guard bracelet, reapplied by staffWander alert, initiated 4/24/25 Review of the EHR Elopement Risk Evaluations for Resident #9, completed on 4/24/25, 5/4/25, 6/5/25 and 6/12/25, revealed the resident to be at risk for elopement. Review of the EHR order summary for Resident #9 revealed an order to check placement and functioning of wander guard in place to right ankle every morning and at bedtime, with a start date of 4/24/25. 4. The Medicare-5 Day MDS assessment dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had diagnoses to include medically complex conditions and paroxysmal atrial fibrillation. The MDS did not include a diagnosis of Diabetes Mellitus. The MDS revealed the resident was on high risk drug classes to include insulin and had received insulin injections 5 days of the 7 day look back period. The admission MDS assessment dated [DATE] documented Resident #12 had diagnoses to include medically complex conditions, atrial fibrillation and orthostatic hypotension. The MDS did not include a diagnosis of Diabetes Mellitus. Review of the Electronic Health Record (EHR) admission papers for Resident #12 revealed the resident admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus. The admission medication list for the resident included the medications Empagliflozin (used to manage type 2 diabetes) 10 mg tablet one time each day and Metformin (used to treat type 2 diabetes) 500 mg tablet two tablets two times a day with meals. Review of the Medication Administration Record (MAR) for July of 2025 revealed Resident #12 was given the following medications and had the following orders:1. Empagliflozin Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth in the morning for DM2 (Diabetes Mellitus type 2) -Start Date 07/10/2025.2. Check Blood Glucose BID two times a day for Blood Glucose -Start Date 07/29/2025 -D/C Date 08/06/2025.3. HumaLOG KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 141 - 180 = 2 units; 181 - 220 = 4 units; 221 - 260 = 6 units; 261 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units >400 14 units and call provider, subcutaneously before meals and at bedtime for diabetes -Start Date 07/30/2025. Review of the MAR for August of 2025 revealed Resident #12 was given the following medications and had the following orders:1.Empagliflozin Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth in the morning for DM2 -Start Date 07/10/2025.2. Check Blood Glucose BID two times a day for Blood Glucose -Start Date 07/29/2025 -D/C Date 08/06/2025.3. HumaLOG KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 141 - 180 = 2 units; 181 - 220 = 4 units; 221 - 260 = 6 units; 261 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units >400 14 units and call provider, subcutaneously before meals and at bedtime for diabetes -Start Date 07/30/2025.4. 472=16 units as one time order. one time only for high blood sugar until 08/06/2025 23:59 -Start Date08/06/2025 1245 During an interview 8/19/25 at 1:30 PM, the Director of Nursing (DON) stated when a resident has a diagnosis of diabetes, she would expect this to be in the MDS as a diagnosis. During an interview 8/20/25 at 11:30 AM, the MDS coordinator acknowledged the alarm section of the MDS for Residents #6, #7 and #9 should have been marked for using the wander alarm, as all three residents had a wander guard. The MDS coordinator acknowledged she did not mark this section accurately. The MDS coordinator stated Section E for behaviors is completed by the Social Worker, the facility has a newly hired social worker. During an interview 8/20/25 at 12:35 PM, the DON acknowledged the MDS assessments should have been coded for alarms for Resident #6, #7 and #9, and should have been marked for behaviors if they were exhibited. The DON stated the facility follows the Resident Assessment Instrument (RAI) Manual for completing the MDS and follows standards of practice. The facility does not have a specific policy for MDS assessments.

Based on observations, clinical record review, resident interviews, staff interviews, and facility document review, the facility failed to ensure adequate staffing levels to meet the residents' needs safely and timely. The facility reported a census of 68. Findings include: During an observation 8/5/25 at 9:00 AM in the back hallways (Ambassador halls), observed one Certified Nursing Assistant (CNA) in the 5 hallway, one CNA in the 6 hallway and one CNA giving residents showers in the 5 and 6 hallway. A CNA was not observed in the 4 hallway. During an interview 8/5/25 at 9:50 AM, Staff F, CNA, stated to be fully staffed in Ambassador halls (halls 4, 5 and 6) they should have 2 CNA's on hall 5, two CNA's on hall 6 and then they split hall 4 with a floater CNA, they need 5 to 6 CNA's to be fully staffed on Ambassador halls. Staff F stated the back hallways are not normally staffed fully as they get more call ins back there, it is a more stressful area to work as residents have more care needs and there are more residents back there. Administration will try to find staff to replace the staff who call in, but sometimes they cannot. In the front halls (halls 1,2 and 3), Staff F stated they are able to answer call lights within 3-5 minutes and residents do not wait longer than 15 minutes for a call light response as the facility is staffed fully in the front halls more routinely. In the back halls, when Staff F has worked back there, residents have waited longer than 15 minutes for a call light response. Staff F stated there have been several times when the back (Ambassador) does not have enough CNA's. During an interview 8/5/25 at 10:45 AM, Staff I, CNA, stated to be fully staffed in the back hallways (Ambassador), they should have two CNA's for hall 5, two CNA's for hall 6, and then share hall 4, with an additional floater CNA. Today, there is just one CNA for the entire hall 6, which has 24 residents and one CNA for the entire hall 5, which has 19 residents, and these two CNA's are sharing hall 4, which has 4 residents. Staff I started a shift today at 6 AM, and the back halls have been staffed with just 2 CNA's and a floater to assist with showers all morning. Staff I stated this is the 3rd time in 3 weeks that there has been only one CNA for hall 6 and one CNA for hall 5, sharing hall 4 as well. There are 6 residents on hall 6 that are a two person lift as well as residents on hall 5 that are a two person lift. Staff I stated earlier this morning, two residents had to wait 45 minutes for a call light response, Residents #11 and #12. Resident #12 had to wait 45 minutes to use the bathroom and Resident #11 had to wait 45 minutes to be cleaned in the bathroom after having a bowel movement, this was upsetting to the resident and the resident was embarrassed and upset. Staff I stated oral care for residents have not been done this morning as there has not been time to complete this task with lack of sufficient staff. During an observation 8/5/25 at 11:00 AM, in the back hallways, (Ambassador halls), observed one CNA in the 5 hallway, one CNA in the 6 hallway and one CNA giving residents showers in the 5 and 6 hallway. A CNA was not observed in the 4 hallway. The quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #11 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The resident required substantial/maximal assistance for toileting hygiene and partial/moderate assistance for toilet transfer and shower/bathe. The resident required setup or clean-up assistance for oral and personal hygiene. The resident used a manual wheelchair. During an interview 8/5/25 at 12:35 PM, Resident #11 stated he has had to wait longer for call lights sometimes, usually waiting longer on the weekends and at night. Resident #11 stated he has waited a half hour at times. Resident #11 stated he waited longer this morning for a call light response. The resident stated he can transfer independently onto the toilet, however needs staff assistance for toileting hygiene. Resident #11 stated he had a bowel movement this morning and did have to pull the call light to get cleaned up. The resident stated it did seem like a long time this morning before someone came to answer the call light to clean him up after his bowel movement on the toilet. Inquired as to how long, the resident stated he did not have a watch, but felt he waited a long time, over 15 minutes. Resident #11's roommate yelled out it was an hour Resident #11 waited this morning after pulling the call light. During the interview, observed Resident #11's fingernails to be very long and dirty. Resident #11 stated he cannot say when the last time it was that he had his nails trimmed, staff trim them for him after showers. While asking Resident #11 about his fingernails, he tried to hide them from view. Resident #11 stated it had been a while since staff trimmed his fingernails. The MDS dated [DATE] documented Resident #12 had a BIMS score of 15, indicating intact cognition. The resident required partial/moderate assistance for toileting hygiene, sit to lying, chair/bed to chair transfer and toilet transfer. The resident required substantial/maximal assistance for sit to stand. The resident used a manual wheelchair and a walker. During an interview 8/5/25 at 12:55 PM, Resident #12 stated she had a fall recently, she fell on her way back to her bed from going to the bathroom. She said at that time, she could go to the bathroom on her own, now that she has fallen, they have told her she needs to use her call light to use the bathroom. Resident #12 stated now that she has to use her call light, she waits a very long time sometimes for a response. Resident #12 stated this morning she waited about an hour for a response to use the bathroom, she had to urinate. The resident stated she did urinate in her briefs while waiting for a call light response. Resident #12 stated she also waited a long time for her breakfast this morning, they brought her a whole tray of food and she did not order this, she had asked for cereal. Staff removed the tray and then Resident #12 stated she waited for about an hour before someone came and told her they did not have the kind of cereal she wanted. The resident said she just had milk for breakfast. Resident #12 stated she did not believe the facility had enough staff. During an interview on 8/5/25 at 1:35 PM, Staff C, Registered Nurse (RN), discussed staffing is the most challenging from 2:00 PM to 6:00 AM given the increased number of staff call-ins. It is not unusual for the facility's RNs or Licensed Practical Nurses (LPN) to specifically cover open CNA positions for part or all of a shift. Licensed nursing staff will also pick-up the 6:00 to 10:00 PM Certified Medical Assistant (CMA) position as well. Staff C noted a specific resident voiced to them an increased call light response times recently. During an interview 8/5/25 at 1:45 PM, Staff H, CNA, stated they have been under staffed today, with just two CNA's and a shower aid for the back 3 halls (Ambassador). Staff H stated they should have 2 CNA's for hall 5 and 2 CNA's for hall 6, a shower aide and a float to help with hall 4. They should have 6 aides for the back, they only had 3 today. Staff H stated residents have waited longer for cares and call light response today given how they are short staffed. Staff H stated residents have waited 20 minutes for a response to call lights on hall 5. Staff H stated this has happened before, where they have been short staffed in the back three hallways, where they have only had two CNA's to cover the 3 hallways. Things will go okay for a while, and then it will get bad with people calling in or just not showing up for work. Review of the facility Matrix for the week of 8/4/25 revealed 46 residents in the Ambassador halls, halls 4, 5 and 6 During a confidential resident interview on 8/6/25 at 2:30 PM, the resident voiced waiting approximately 45 minutes for bathroom assistance two weeks ago. This occurred mid-afternoon. In another incident, the resident voiced yelling out for help off the bed pan as staff was not responding to the call light. During an interview on 8/7/25 at 9:55 AM, Staff D, CNA, explained staffing can be good at times. When other staff start to call-in, the nursing units work bare-bone and work short. Resident cares may be delayed. Staff will do what they can with the resources available. During an interview on 8/7/25 at 12:00 PM, Staff B, CNA, explained there is typically a total of 2-3 staff for the Ambassador nursing unit during the evening shift. When there are only 2 CNAs, one will take Hall 5 and the other will take Hall 6. Both will then share Hall 4. Many residents on the Ambassador nursing unit require 2 staff for assistance, specifically those needing a mechanical lift for transfers. Staff B acknowledged a CNA may float over from the Royal nursing unit to assist, as they are available, or another CNA may be called in to help out for part of a shift. Staff B noted residents have complained to them regarding the wait times for evening/bedtime cares. One resident will cry when getting to bed late. Staff B explained there have been times when they are unable to provide the necessary personal cares to residents (incontinent brief changes/pericares). When this occurs, Staff B will inform the in-coming CNAs on the night shift. Staff B acknowledged they completed a slide board transfer on Resident #10, who resides in the Ambassador nursing unit, individually on 7/24/25. Staff B reported they explained to Resident #10 another staff member was needed to help with the transfer. Staff B called out for assistance to a CNA working another hall. The request for assistance went unanswered. Resident #10 verbalized it was OK for Staff B to complete the slide board transfer without the other staff member. Resident #10 experienced a fall during this transfer as the wheelchair brakes were not fully engaged. During an interview on 8/7/25, at 12:30 PM, Staff E, CNA, noted unit staffing is good some days and a struggle others. Staff E believes it takes longer to get to residents and provide the requested cares. During an interview on 8/7/25 at 1:35 PM, the DON explained they will go through the monthly schedule to monitor for needed coverage. The facility's scheduler oversees the daily staffing sheets and will make necessary calls to cover any open positions. The DON noted the Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) Assessment nurse will cover both nursing and non-nursing areas, such as a CNA position, to ensure resident needs are met. Facilty RNs and LPNs will also cover non-nursing areas as needed. The DON voiced the facility is adequately staffed with the number of available positions. Facility staff have voiced concerns regarding the number of call-in's. The DON noted no resident concerns have been brought to their attention with regards to staffing. Review of the facility document Fall Scene Investigation, completed 5/15/25 at 8:05 PM, detailed Resident #1's fall. The document explained Resident #1 had been sitting in a wheelchair in the Ambassador Dining Room. When the CNA was ready to assist the resident to bed, the wheelchair Resident #1 was sitting in was empty and the resident was no longer in the Dining Room. Resident #1 was found on the floor in their room on Hall 4. The document noted the root cause of the fall was limited staff (2 CNAs for 51 residents). On 8/4/25, the facility reported an in-house census of 68 (22 residents on the Royal nursing unit and 46 residents on the Ambassador nursing unit). The DON indicated a total of 9 residents in the Royal nursing unit require a mechanical lift (3 on Hall One, 2 on Hall Two, and 4 on Hall Three). The DON indicated a total of 18 residents in the Ambassador nursing unit require a mechanical lift (0 on Hall Four, 9 on Hall Five, and 9 on Hall Six). Two staff members are required to be present when utilizing a mechanical lift to transfer residents. During an interview 8/19/25 at 1:30 PM, the Director of Nursing (DON) stated she does not believe a resident has waited longer than 20-minutes for a call light response. The DON stated the expectation for staff to respond to call lights is as soon as possible and within 15 minutes. The DON stated for the facility to function minimally and meet resident needs they would need during the day at least 2 CNAs, 1 nurse and 1 CMA for the up front halls (halls 1, 2 and 3) and at least 3 CNA's and two nurses for the back halls (halls 4, 5 and 6). The DON stated on 8/5/25, they did have staff call ins for the back three halls and had 1 CNA for hall 6 and 1 CNA for hall 5 with a floater aid to assist with showers and cares, the two CNA's would split hall 4. From 6 am to right around lunch time, they only had the 2 CNA's and the float, the DON then found another CNA to assist in the back halls. The DON does not believe any resident waited longer than 20 minutes for a call light response that day. The DON stated the facility does not have a policy for staffing or call lights, the facility follows standards of practice for call light response time, which should be within 15-minutes. The facility document titled Regency Care Center Facility Assessment 2025, revised 11/2024, outlined the following staffing guidelines: 2-4 nurses working 12-hour shifts on the day shift or a combination of nurses and Certified Medication Aides (CMA)2 nurses are scheduled on the night shift with additional staff for treatment and medication pass from 6:00 PM to 10:00 PM3 Certified Nurses Aide (CNA) for the Royal nursing unit and 4-5 CNAs for the Ambassador nursing unit during the day shift (6:00 AM to 2:00 PM). A bath aide and restorative aide may be additional2-3 CNAs for the Royal nursing unit and 4-5 CNAs for the Ambassador nursing unit during the evening shift (2:00 PM to 10:00 PM)No staffing assignments documented for the night shift (10:00 PM to 6:00 AM)

Based on clinical record review, staff interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 12 residents reviewed (Resident #12). The facility reported a census of 68 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS revealed the resident was on high risk drug classes to include insulin and had received insulin injections 5 days of the 7 day look back period. Review of the Electronic Health Record (EHR) admission papers for Resident #12 revealed the resident admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus. The admission medication list for the resident included the medications Empagliflozin (used to manage type 2 diabetes) 10 mg tablet one time each day and Metformin (used to treat type 2 diabetes) 500 mg tablet two tablets two times a day with meals. Review of the hospital record dated 7/25/25 revealed Resident #12 was seen in the emergency department for a fall. Lab work was performed and the resident was found to have Hyperglycemia (high blood sugar). Review of the hospital record dated 7/29/25 revealed Resident #12 was seen in the emergency department for dizziness. Lab work was performed and the resident was found to have Hyperglycemia (high blood sugar). Diagnoses related to the emergency department visit included Hyperglycemia, history of Diabetes Mellitus and lightheadedness. Review of the Medication Administration Record (MAR) for July of 2025 revealed Resident #12 was given the following medications and had the following orders:1. Empagliflozin Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth in the morning for DM2 (Diabetes Mellitus type 2) -Start Date 07/10/2025.2. Check Blood Glucose BID two times a day for Blood Glucose -Start Date 07/29/2025 -D/C Date 08/06/2025.3. HumaLOG KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 141 - 180 = 2 units; 181 - 220 = 4 units; 221 - 260 = 6 units; 261 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units >400 14 units and call provider, subcutaneously before meals and at bedtime for diabetes -Start Date 07/30/2025. Review of the MAR for August of 2025 revealed Resident #12 was given the following medications and had the following orders:1.Empagliflozin Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth in the morning for DM2 -Start Date 07/10/2025.2. Check Blood Glucose BID two times a day for Blood Glucose -Start Date 07/29/2025 -D/C Date 08/06/2025.3. HumaLOG KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 141 - 180 = 2 units; 181 - 220 = 4 units; 221 - 260 = 6 units; 261 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units >400 14 units and call provider, subcutaneously before meals and at bedtime for diabetes -Start Date 07/30/2025.4. 472=16 units as one time order. one time only for high blood sugar until 08/06/2025 23:59 -Start Date08/06/2025 1245 Review of the EHR, MAR and Treatment Administration Record (TAR) for July and August of 2025 for Resident #12 revealed a lack of monitoring and documentation for signs and symptoms of hyperglycemia and hypoglycemia. The Care Plan for Resident #12, with an initiation date of 7/11/25, lacked a focus area, goals and interventions for Diabetes Mellitus. During an interview 8/19/25 at 1:30 PM, the Director of Nursing (DON) stated when a resident has a diagnosis of Diabetes Mellitus, she would expect this to be in the care plan with a focus, goal and interventions. The DON stated the diagnosis of Type 2 Diabetes Mellitus did not get put in the EHR under the diagnosis section until 8/12/25, however it should have been in there from the time of the resident's admission. The DON stated there should have been an entry in the MAR to monitor and document any signs and symptoms of hyperglycemia and hypoglycemia, and acknowledged this was not in the MAR or the EHR. Review of the facility policy Comprehensive Person-Centered Care Plan, with a review date of 10/23/19, documented each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Contains services provided, preference, ability, and goals for admission, desired outcomes, and care level guidelines.

Based on clinical record review and staff interviews, the facility failed to ensure staff completed an accurate and timely resident assessment as necessary for 1 of 3 residents reviewed for elopement (Resident #7). The facility reported a census of 68 residents. Findings include: The annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #7 had a BIMS score of 3, indicating severe cognitive impairment. The resident had diagnoses to include medically complex conditions, hyperlipidemia, thyroid disorder, non-Alzherimer's dementia, anxiety disorder, depression and psychotic disorder. The Care Plan for Resident #7, with an initiation date of 3/21/25, included a focus area: potential for elopement risk/wanderer risk. Interventions included: assess for elopement/wander risk and wander alert, left ankle device. Review of the Electronic Health Record (EHR) Elopement Risk Evaluation for Resident #7 completed on 3/20/25 revealed the resident at risk for elopement. Review of the EHR for Resident #7 revealed Progress Notes which documented wandering behavior: Progress note dated 3/20/25, nurses note, documented Resident was packing her room stating she needed to go home her friend was waiting for her. Resident redirected several times. Progress note dated 3/21/25, nurses note, documented resident has had no attempts to leave facility, just wandering in hallways non intrusive. Progress note dated 3/24/25, nurses note, documented resident came out to the nursing station numerous times between 2030 and 2200. Progress note dated 3/27/25, nurses note, documented late entry for 3-26-25 resident went from room to dining room in excess of 10 times within a 30 minute time frame.Progress note dated 4/6/25, nurses note, documented resident refused upper meal, after meal resident was noted to be wandering down other hallway. Progress note dated 5/15/25, SBAR summary for providers, change in condition reported were behavioral symptoms, agitation and psychosis, resident is having auditory and visual hallucinations/delusions, is wandering facility. Progress note dated 5/21/25, nurses note, resident has been up and propelling self up and down hallways was noted to be standing up at water fountain near nurses station, the wandering of the building has been an ongoing habitual behavior, resident also continues with visual and auditory hallucinations and well as wandering behaviors. Progress note 6/11/25, nurses note, resident has been up this evening. Manic state. [NAME] self up and down hallways looking for invisible people. Talking to voices in the walls and vents. Redirection attempted numerous times. Unsuccessful. Review of the EHR revealed an Elopement Risk Evaluation for Resident #7 was not completed after 3/20/25 until 8/18/25, however this was not placed in the EHR until 8/20/25. The Elopement Risk Evaluation on 8/18/25 showed the resident at risk for elopement. During an interview 8/20/25 at 11:30 AM, the MDS coordinator stated she is the one to complete some of the elopement evaluations, however it can also be the Director of Nursing (DON) or the floor nurse. The MDS coordinator acknowledged the last Elopement Risk Evaluation for Resident #7 was in March of 2025. The MDS coordinator stated the resident should have had another Elopement Risk Evaluation completed in May of 2025, with her annual review. The MDS coordinator stated she would have expected another one for the resident in May. The Elopement Risk Evaluations are completed upon admission, quarterly and as needed. During an interview 8/20/25 at 12:35 PM, the DON pointed out where in the EHR the Elopement Risk Evaluations are stored, and pointed this out specifically for Resident #7. The DON acknowledged there was not another Elopement Risk Evaluation for Resident #7 after the one completed in March of 2025. The DON stated she completed an audit of the Elopement Risk Evaluations on the 5th of June, including an audit for Resident #7. During this audit, she thought the last evaluation was in May, she read the date incorrectly she believed. The DON stated Elopement Risk Evaluations are completed upon admission, quarterly and as needed. The DON acknowledged the Elopement Risk Evaluation for this resident should have been completed by or around the 20th of June 2025, and acknowledged this was not completed at that time. The DON stated they follow the Resident Assessment Instrument (RAI) Manual for completing the MDS and follow standards of practice for the Elopement Risk Evaluations. The DON stated she started another elopement risk evaluation for Resident #7 on 8/18/25 and will submit this today, 8/20/25.

Based on observations, interviews and record review the facility failed to accurately assess and intervene in a timely manner for resident with change in condition for 3 of 3 residents reviewed, (Resident #82, #83 and #5). On December 4, 2022, Resident #82 was experiencing shortness of breath and coughing symptoms, nursing staff failed to provide timely assessments and on December 5th the resident passed away with cause of death being respiratory failure. This failure resulted in the death of one resident, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. Resident #83 had an unwitnessed fall and staff failed to provide neurological assessments and Resident #5 had edema and an order for daily leg wraps, staff failed to apply the wraps. The facility reported a census of 75 residents. The State Agency informed the facility of the IJ that began as of December 4, 2022, on April 13, 2023 at 9:45 AM. The facility staff removed the Immediate Jeopardy on April 13, 2023 through the following actions: a. Completed 100% audit on change of condition 4/13/23. b. Completed 100% audit on neuro check completed per policy on 4/13/23. c. Completed the following in-service with licensed nursing on 4/13/23; 1. Change in Condition, nursing assessments. 2. Notification of Change in condition policy. 3. Neuro checks completed per policy. d. Facility Nurse Practitioner evaluated residents with change in condition on 4/13/23. e. The facility will monitor the following through the facility audit tool 5x a week for 4 weeks then monthly; 1. Resident with change in condition for assessment and intervention. 2. Neuro check completed per policy. f. Education will be incorporated in orientation of new hire during on boarding effective 4/13/23; 1. Change in condition, nurse assessment and intervention, 2. Notification of change policy, 3. Neuro check per policy. The scope was lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #82 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). The resident required extensive assistance with the help of two staff for bed mobility, transfers, dressing and toileting. A Care Plan initiated on 10/5/22 showed that Resident #82 had a self-care performance deficit and required assistance of one staff with walker and noncompliant with asking for assistance. The resident had a history of falls and fall with fracture on 9/6/22. The resident stated that he would not ask for assistance if he didn't feel that he needed help. Observe for new onset of signs and symptoms of Covid-19 infection and communicate with the physician. Monitor for pocketing choking coughing, monitor for malnutrition, Resident was on diuretics increased risk of falls and report pertinent lab results. Diagnosis reflux, repeated falls chronic kidney disease chronic bronchitis, cognitive communication deficit, muscle wasting. According to an Incident Report dated 12/4/22 at 9:07 AM Resident #82 was found in front of his bathroom door with the wheel chair in front of him and the wheels were not locked. The resident stated that he was trying to go the bathroom and slid out of the wheel chair. The nursing note indicated that immediate action had been taken that included neurological evaluation per protocol. A Neurological (Neuro) Check List Form found in the electronic chart under the Assessments tab included the following vital signs that were taken on 12/4/22 at 9:31 AM; Temperature 97.8, Heart Rate, 116 beats per minute, Respirations of 18 per minute and a Blood Pressure of 98/78. a. 1st Neuro check times 6:36 AM and signed on 12/4/22 at 1:37 PM b. 2nd Neuro check timed 6:40 AM and signed at 1:38 PM c. 3rd Neuro check timed 7:00 AM and signed at 1:39 PM d. 4th Neuro check timed 7:00 AM and signed at 1:40 PM e. 5th Neuro check timed 8:00 AM and signed at 1:40 PM f. 6th Neuro check timed 9:00 AM and signed at 1:40 PM g. 7th Neuro check timed 9:32 AM and signed at 9:35 AM h. 8th Neuro check timed 10:06 AM and signed at 1:41 PM i. 9th Neuro check timed 11:00 AM and signed at 1:42 PM The following documentation was found in the Nursing Notes: a. On 12/1/22 at 11:15 PM resident complaining of nausea with dry heaves and given as needed Zofran medication b. On 12/2/22 11:05 PM physician note the resident had complaints of nausea with temperature of 97.5 and heart rate of 68 beats per minute. c. On 12/3/22 at 10:33 PM Green emesis and Zofran given. d. On 12/3/22 at 2:30 PM increased malaise and nausea prompted Covid test and test was negative. e. On 12/3/22 at 5:30 PM continues to complain of nausea, fluids encouraged. A Nutritional assessment dated [DATE] at 3:00 PM showed that the resident required 2100-2200 milliliters of fluids daily. According to the Activities of Daily Living documentation flow sheet for December included the following milliliters (ml) of fluid per day: a. December 1st 500 ml b. December 2nd 720 ml c. December 3rd 720 ml e. December 4th 720 ml A Nursing Note dated 12/5/22 at 5:54 AM showed that Resident #82 was taken to the emergency room by ambulance at that time. A follow up nursing note on 12/5/22 at 1:32 PM indicated that the facility received a call from the hospital that the resident had passed away at 12:45 PM on that day. According to the hospital report on 12/5/22 at 6:25 AM, Resident #82 arrived in the emergency room with a chief complaint of shortness of breath and a clinical impression of dehydration with dry mouth and cracked lips. Upon arrival to the emergency room his oxygen saturation was 75%, blood pressure was 97/46, heart rate 104 beats per minute, respirations 32 per minute and a temperature of 101 Fahrenheit. The hospital report dated 12/5/22 at 1:00 PM indicated that the time of death was 12:55 with cause of death being acute or chronic respiratory failure and viral sepsis as result of Covid-19. At 4/12/23 at 10:16 AM the Medical Director (MD) said that he did not remember that the resident had a fall on 12/4/22 and said that the fall would not have had any relation to the sepsis on 12/5/22. However, if the resident had experienced a change in condition on 12/4/22 more sets of vitals and lung assessments would have been helpful for the on-call doctor to have known sooner. On 4/11/23 at 5:48 AM Registered Nurse (RN) Staff V said that she mostly worked overnights and she had been working with Resident #82 the night before he went out to the hospital. She said that he had been restless and agitated the night before he went to the hospital. He was yelling at staff and refused his medications and had even refused his pain medication which he rarely did. She said that he did have a cough through the night but she didn't remember if she had assessed his lungs. The Assistant Director of Nursing (ADON) had come in the next morning and tested him for Covid-19 and that was when he tested positive and they send him to the hospital. On 4/11/23 at 8:30 AM a family member for the resident said that the resident presented to the emergency room with a bowel obstruction and Covid-19. He said that he had visited the resident on Sunday 12/4/22 because he had gotten a call about the fall. When he came in to visit, the resident was out of it, very confused and didn't feel well. He said that the resident had spilled a soda on him and Certified Nursing Assistant (CNA) Staff R got the resident cleaned up and back in bed. The resident was struggling to breathe so the CNA elevated that head of the bed that seemed to help him breathe a little better. While he was at the facility he did not see a nurse do a lung assessment or take any vitals. On 4/11/23 at 9:15 AM RN Staff W said she remembered having found the resident on the floor by the bathroom with the wheel chair in front of him on 12/4/22. She did not remember him having a cough or rattily lungs. She said that it was an unwitnessed fall and the facility policy is to do neurological assessment so she would have completed that task. She said she would not use previous vitals for each assessment. On 4/13/23 at 10:15 AM CNA Staff R remembered working with Resident #82 on 12/4/22, it was a Sunday, and she said that she had been working every other weekend. Staff R remembered the family being at the facility while she got the resident cleaned up after he had spilled some soda on himself. Staff R said he looked like death, his legs and abdomen were swollen and she could hear his lungs were rattling as soon as she walked in the room. She put the head of the bed up because he was having trouble breathing and she went and told the nurse that he wasn't doing very well. The nurse told her that he had just tested positive for Covid-19 and the symptoms that he was experiencing were to be expected. Other staff members told her that the resident hadn't eaten for at least two days. Staff R did not see a nurse go in and assess his lungs or take any vitals. She said that the nurses would often dismiss the concerns of the CNA's and not listen to them when they have a concern about residents. 2) According to the MDS dated [DATE], Resident #83 had a BIMS score of 0 (severe cognitive deficit). The resident was totally dependent on two staff for bed mobility, transfers, dressing and toileting needs. A Care Plan revised on 10/31/22 showed that Resident #83 was at risk for unmanaged pain, staff were directed to observe for signs of pain such as facial grimacing, hesitancy with movement, and refusing to move or transfer. The resident was at risk for fractures and injuries related to a history of pathological femur fracture, osteoporosis and osteoarthritis, osteopenia, and had hip and knee joint replacements. Resident #83 required the Hoyer mechanical lift with 2 staff assistance for all transfers staff were to use caution with all transfers related to extremities due to risk for injury and fractures. A Nurse Note dated 9/29/22 at 2:06 PM noted Resident #83 was discovered on her floor mat beside her bed. She was in the seated position with back resting on side of the bed. She was soiled with BM at that time. Bed was in lowest position. Resident was assisted back to bed x3 assist, BM cleaned, care provided, assessed for injury. Director of Nursing notified. Power of Attorney notified. Fall follow up initiated per facility protocol. The Nursing Notes included one set of vitals taken on 9/29/22 at 2:06 PM and the chart lacked documentation of a neurological evaluation. According to the policy titled Neurological Evaluation dated 3/28/23, A neurological evaluation will be performed by a licensed nurse when a residents status warrants; an unwitnessed fall to identify a change in condition related to a possible head injury. According to a facility policy titled: Notification of Change in Resident Condition reviewed on 4/28/21 the attending physician and resident's representative would be notified of change in condition per standards of practice. The guidelines for notification of physician include a signification change on condition. 46513 3. The MDS assessment tool for Resident #5 dated 2/24/23 revealed residents BIMS score of 14 which indicated cognition intact. Diagnosis included coronary artery disease, peripheral vascular disease, heart failure, diabetes mellitus and localized edema. The Treatment Administration Record (TAR) for Resident #5 dated April 2023 directed staff to apply ace wraps to bilateral extremities. A check mark and Staff #C initials on 4/6/23 indicated the treatment was completed when TAR was reviewed on 4/6/23 at 1:50 PM. Record review of Resident #5 Kardex (a note system for the nursing assistants directing care) dated as of 4/10/23 did not address ace wraps. During interview/observation on 4/6/23 at 2:00 PM Resident #5, voiced I need help to get my legs wrapped. Observed no wrapping to the lower legs that were edematous (meaning swollen related to excess fluid). Resident #5 relayed my legs are supposed to be wrapped every day, I cannot do it myself. I do not always get them wrapped, some days it is very late, as late as 4:00 PM and some days not at all. Interview on 4/6/23 at 2:10 PM with Registered Nurse (RN), Staff C reported on her process,Staff C stated she signed all treatments and wrote down the treatments to later ensure during the shift. All treatments were signed as completed at this time. Staff C relayed she trusts the nursing assistants to do non-medicated treatments, within their scope and she had signed completed. Staff C relayed the nursing assistants know the treatments to do since is listed on the Kardex . Staff C stated she did not need to follow up since she trusts the nursing aid staff. Requested to review the nursing assistant Kardex that did not list Resident #5 ace wrap treatment. Staff C acknowledged initialing as completed even though was not completed. During interview on 4/6/23 at 2:35PM the facility Administrator acknowledged a nurse should not sign off on a procedure including a medication or a treatment should not be signed as being completed before it is done. Interview with Director of Nursing (DON) on 4/10/23 at 11:50 AM confirmed a nurse should not sign ahead for any treatment, medication or procedure. DON acknowleged should not sign if did not complete. The DON stated the nurse should ensure the treatment and ideally at that time a nurse assesses for changes and reports to the doctor if needed. Confidential interview on 4/12/2023 at 9:50 AM with another family member, daughter of a resident stated to surveyors in conference room visit of repeated notifications needed to staff that her family member is suppose to have specialized hose on daily for treatment of edema , relayed is repeatedly missed. Facility policy provided titled Medication Administration, Preparation and General Guidelines section 7.2, Part D, 1. revealed recording of the process directly is after completion.

Based on clinical record review, observation and staff and family member interviews, the facility failed to provide care to prevent the development of pressure ulcers for one of three residents reviewed with pressure ulcers (Resident #1). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #1 had [DIAGNOSES REDACTED]. Resident #1 scored 4 out of 15 points on the Brief Interview for Mental Status (BIMS) cognitive assessment, indicating indicated severe memory and cognitive impairment. The resident required the assistance of one with bed mobility, the assistance of two with transfers and used a wheelchair for mobility. The assessment documented she had no risk of pressure ulcer development and no ulcers at the time of assessment. The resident's care plan documented she had the potential for impaired skin integrity problem related to decreased mobility, incontinence and poor circulation problem and showed an initiation date of 10/21/14. The care plan instructed to provide supplementation as directed by the dietician, to handle Resident #1 carefully due to fragile skin and to float her heels on pillows as tolerated when in bed. Staff care planned an actual impaired skin integrity problem related to immobilizer leg braces on 10/29/18. The care plan directed staff to assess the areas to both (bilateral) lower extremities and initiate skin sheets, initiate treatments per physician orders, and measure the areas per facility guidelines. A hospital Discharge and Transfer Form dated 8/8/18 revealed the resident transferred to the facility under Hospice care with bilateral femur fractures and a [MEDICAL CONDITION] 5th digit (finger). The resident did not walk or bear weight and had no skin breakdown identified. The Hospice Comprehensive Assessment and Plan of Care Report for the 8/8/18 to 10/6/18 period revealed the resident as bedbound with bilateral leg immobilizers in place. Review of a Skin Assessment form dated 9/27/18 revealed a 5 centimeter (cm) by 1.5 cm area noted on the right ankle and an old scab noted to the right inner ankle with redness that surrounded the scab. A Physician order [REDACTED]. On 10/19/18, the weekly wound assessment described the area as a Stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed) that measured 3.2 cm by 3 cm, without depth, with 80 percent slough tissue in the wound, and interventions that included floating her heels and application of sheep's wool to the areas under the immobilizer brace. On 10/29/18, staff documented the right inner ankle wound had worsened Stage 3 pressure ulcer that measured 3.5 cm by 4 cm, with 85 to 90 percent slough in the wound bed, and odorous. A Physician order [REDACTED]. Observation of wound care performed by Staff F, LPN (Licensed Practical Nurse) on 11/15/18 revealed a circular shaped open wound on the resident's right inner ankle that measured approximately 3 cm wide, with approximate 0.3 - 0.4 cm depth, slough tissue at the wound bed, tan wound drainage, and a margin of 0.4 - 0.5 cm of redness that surrounded the edge of the wound. Staff F stated at that time the condition of the wound had greatly improved. During interviews on 12/6/18, the Administrator and Consultant Nurse stated Resident #1 was on bed rest with full length bilateral leg immobilizers with metal bars worn 24 hours per day since her return from the hospital on [DATE]. Staff turned the resident at least every two hours and the facility had not implemented other skin interventions specific to the leg immobilizers before identification of the pressure ulcer on 9/27/18.

Based on clinical record review, observation, and resident, family and staff member interviews, the facility failed to ensure that staff performed safe resident transfers which resulted in serious injury for one of six residents reviewed (Resident #1). The facility reported a census of 66 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #1 had [DIAGNOSES REDACTED]. Resident #1 scored 4 out of 15 points on the Brief Interview for Mental Status (BIMS) cognitive assessment, indicating indicated severe memory and cognitive impairment. The resident required the assistance of one with bed mobility, the assistance of two with transfers and used a wheelchair for mobility. The resident's care plan documented a focus area of self care deficit, initiated 8/18/16, which directed two staff were required to transfer the resident, the resident did not walk and she used a wheel chair for mobility. The pocket care plan utilized by the certified nursing assistants (CNA's) last revised on 7/23/18 revealed Resident #1 required the assistance of two staff for transfers. The facility's self-reported incident dated 8/2/18 documented that staff found the resident with multiple bruised areas that morning, the resident said yes when asked if someone had hurt her, had pain upon movement of her left leg and sent to the hospital emergency room (ER) for further assessment. X-rays performed in theER on [DATE] revealed a comminuted impacted [MEDICAL CONDITION] right femur and an impacted comminuted [MEDICAL CONDITION] left femur (upper leg bones, the areas near the knee). The facility's investigative summary revealed Staff A, agency CNA, had been assigned to the resident on the 2:00 p.m. to 10:00 p.m. shift on 8/1/18 and she stated she knew the resident required two staff assist to transfer and had the pocket care plan that stated the resident required two for transfer, Staff A stated she transferred the resident from the bed to the wheel chair by herself and lowered the resident to her knees on the floor prior to the evening meal on 8/1/18. She then lifted the resident back to the bed and to the wheel chair, also by herself. Staff A did not report the incident to any staff as required. On 12/17/18 at 2:55 p.m., Staff A stated she transferred the resident to bed with Staff B earlier in the shift. She stated the agency she worked for didn't provide her with a gait belt and she didn't have the pocket care plan. Staff A thought everyone transferred Resident #1 by themselves. Staff A stated when she got the resident up for supper she locked the wheel chair, attempted to transfer the resident by herself from bed and the wheel chair scooted back. She lowered the resident to her knees on the floor, her legs were bent under her, she was able to lift her off the floor to her bed, then transferred her to the wheel chair. She stated if a resident falls or is lowered to the floor staff are supposed to report it to the nurse, but she didn't report the incident because she didn't think it was that serious. When questioned the following day by the Administrator, she didn't admit she lowered the resident to the floor because she heard the resident was injured and felt scared of what would happen to her. During an interview on 11/7/18 at 1:41 p.m., Staff B, CNA, stated she worked on 8/1/18 from 2:00 p.m. - 10:00 p.m. Staff B stated she transferred Resident #1 to bed with Staff A between 2:30 p.m. and 3:00 p.m. without incident. Staff A had asked her to help transfer her from bed for supper and when she got to the room the resident wasn't ready. She asked Staff A to get her when the resident was ready for transfer. Staff B did not assist with the transfer, but Staff A may have had another staff member help her. Staff B saw the resident in the dining room for supper that day. The next day, everyone had to write statements because the resident's legs were broken, Staff A approached her and said she already spoke to the Administrator and told her that she (Staff B) assisted with her transfer for supper on 8/1/18. Staff B informed Staff A that wasn't true and she wasn't going to lie for her. On 11/7/18 at 1:53 p.m., Staff C, CNA, stated she worked on 8/1/18 from 2:00 p.m. - 10:00 p.m., she assisted Staff A to transfer Resident #1 from her wheel chair to bed after supper with a gait belt and without incident. The resident needed 2 staff to transfer, the agency CNA's had pocket care plans accessible and available to them, and if they had questions they could ask the nurse questions about a resident's care requirements. During interview on 11/7/18 at 4:34 p.m., Staff E, CNA, stated she worked on 8/1/18 from 10:00 p.m. until 6:00 a.m. At approximately 5:15 a.m. on her last rounds, she turned the lights on to provide care and prepare the resident for day shift and noted a bruise on the resident's left hand. Staff E reported it to the nurse and assisted the nurse when she examined the resident. There were more bruises, the resident had not fallen, got out of bed or indicated pain prior to that on her shift. On 11/8/18 at 10:21 a.m., Staff D, licensed practical nurse (LPN), stated she worked on 8/1/18 from 10:00 p.m. until 6:00 a.m. Staff E called her to the resident's room approximately 5:45 a.m. and asked if she was aware of the resident's bruises. No injuries had been reported by the previous shift. Staff D assessed the resident with another nurse present, noted multiple bruises that she measured and recorded. The resident grimaced with pain and yelled when her left leg was moved. She called the Director of Nursing and the physician, she received orders to transfer the resident to the ER. During an interview on 11/14/18 at 3:45 p.m., the resident's husband stated he visited Resident #1 every afternoon and saw Staff A transfer the resident alone from the wheel chair to her bed three or four days before the incident. He told Staff A at the time Resident #1 was a two person transfer.

Based on clinical record review, staff interviews, observations and facility policy review, the facility failed to provide immediate interventions to prevent multiple falls for one of three residents reviewed (Resident #1). The facility reported a census of 71 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] recorded Resident #1 had [DIAGNOSES REDACTED]. The resident's BIMS (brief interview for mental status) score of 10 out of 15 rated Resident #1 with a moderately impaired memory and cognition. The MDS noted Resident #1 had unsteady balance when moving from a seated to a standing position and could stabilize without staff assistance. The resident used a walker and a wheelchair as mobility devices, walked independently in her room and walked with the support of one in the corridor. The assessment documented Resident #1 had frequent episodes of urinary incontinence and occasional episodes of bowel incontinence. The MDS also recorded Resident #1 received daily antianxiety and diuretic (which can cause frequent urination) medications. The resident's 11/27/17 revised Care Plan noted Resident #1's risk for falls related to her cognition, unawareness of safety needs and deconditioning. The Care Plan also noted the resident's generalized muscle weakness. Staff provided the following interventions related to falls on 6/19/17 - Anticipate and meet the resident's needs, encourage the resident to call for assistance and wear appropriate footwear, follow therapy recommendations for transfers and mobility and place the call light within reach. On 3/30/18, staff added the intervention of a high/low bed. On 4/2/18, staff documented adding a drop seat to the resident's wheelchair. On 4/5/18, staff documented the resident had a bolster mattress with a plastic cover. On 4/1/18, they documented installation of anti-roll back brakes to her wheelchair. Under an Activities of Daily Living deficit focus, staff added the resident was independent with toilet use on 9/5/17 and transferred independently in her room on 9/7/17. The facility's Falls Management Guidelines, revised 7/14/17, directed staff on what to do when a resident fall occurs. According to the policy, the licensed nurse should assess the resident for injuries prior to moving them. The policy also instructed the licensed nurse to complete the risk report in Point Click Care (an electronic health record) and the 24 hour report. Nurses are to communicate all resident falls to the attending physician and the resident's family and document on the Incident and Accident form. The IDT (interdisciplinary team) will review all falls within 24-72 hours at the morning IDT meeting to evaluate the circumstances and probable causes of the fall. Finally, the IDT modifies and implements a care plan and treatment approach to minimize repeat falls and the risk of injury related to the fall. The resident's 2/19/18 Fall Scale-Morse assessment rated Resident #1 at a high risk for falling. A Nurses Note dated 3/19/18 at 3:35 a.m. documented Resident #1 presented with behaviors. The resident propelled her wheelchair up and down the hall and within the facility looking for her apartment and her daughter in the hospital. The nurse also noted that Resident #1 continued antibiotic therapy for a UTI (urinary tract infection). A Nurses Note dated 3/19/18 at 10:16 a.m. documented that Resident #1 received her last dose of an antibiotic for the UTI. The nurse recorded a new order to follow up with a UA (urinalysis) on 3/22/18 if indicated. A Nurses Note dated 3/25/18 at 9:56 a.m. documented staff notified the resident's doctor of the lab results and obtained a new order for antibiotic therapy for 10 days. A Nurses Note dated 3/27/18 at 2:13 a.m. documented that Resident #1 continued on antibiotic therapy for a UTI. The nurse noted that the resident as alert and oriented times 1 - 2 with baseline dementia/[MEDICAL CONDITION] process. A Nurses Note dated 3/28/18 at 2:48 a.m. documented that Resident #1 continued on antibiotic therapy for a UTI with continued orientation x 1 - 2 with baseline dementia/[MEDICAL CONDITION] process. A Nurses Note dated 3/29/18 at 9:57 a.m. documented that Resident #1 continued on antibiotic therapy for a UTI. The nurse noted the resident as alert with confusion an without behaviors. An Incident Report dated 3/29/18 at 2:55 p.m. revealed they found Resident #1 sitting on the floor in front of her recliner; assessment revealed no injuries. The nurse described the resident as alert with confusion and indicated the resident slid out of her recliner while trying to get into her wheelchair. The nurse named confusion, incontinence, UTI and a recent change in medication as predisposing factors to the fall. An update on 3/30/18 documented Resident #1 had orders for PT (physical therapy) to evaluate and treat because the resident said her legs felt weaker at the time of the incident. A Nurses Note dated 3/29/18 at 3:41 p.m. documented that a new order had been obtained for PT to evaluate and treat for weakness. A Nurses Note dated 3/30/18 at 1:13 a.m. documented Resident #1's as alert with confusion. Resident #1 declined supper and required the assistance of one as needed. The resident went to bed early because she stated she did not feel well and continued on antibiotic therapy for a UTI. A Nurses Note dated 3/30/18 at 9:51 a.m. documented Resident #1 as alert with confusion. Resident #1 stated she still felt weak and staff educated her on the need to call for assistance with transfers. The nurse also noted the resident's forgetfulness and/or denial that she needed help; the resident continued on antibiotic therapy. A Nurses Note dated 3/31/18 at 1:21 a.m. documented Resident #1 as alert with confusion and she continued antibiotic therapy for a UTI. The resident misplaced her TV remote, staff could not find it and the resident stated it was a plot to kill her. Attempts at redirection did not work. The Incident Report dated 3/31/18 at 2:50 a.m. recorded staff heard yelling at 1:45 a.m. and found Resident #1 on her knees beside the bed with her head on a pillow and her feet twisted in a blanket. The nurse described the resident as confused and that she said she pushed me out of bed because of papers. The resident complained of her right foot hurting; her range of motion was within normal limits and she walked without grimacing or limping. The nurse named confusion, incontinence and a current UTI as predisposing factors to the fall. An update on 4/2/18 documented a scoop mattress as placed on the resident's bed as a fall prevention intervention as she told the CAN (certified nursing assistant) she slid off her bed. The Incident Report dated 4/1/18 at 7:56 a.m. revealed that as a result of being called to the resident's room, the nurse saw Resident #1 lying on the floor on her left side next to the bed with her walker tipped over at her feet. The resident denied injury and moved all extremities without pain or discomfort. The Resident #1 stated the wheelchair rolled out from under her as she transferred from her recliner to the wheelchair; the wheels were not locked. The nurse noted confusion, UTI and gait imbalance as predisposing factors to the fall. An update on 4/2/18 documented a request to maintenance to place an anti-roll back device on Resident #1's wheelchair as a safety intervention. A Nurses Note dated 4/1/18 at 8:41 a.m. documented Resident #1 continued on antibiotic therapy for a UTI. The nurse noted that the resident as alert and oriented x 1 - 2 with baseline dementia/[MEDICAL CONDITION] process. An Incident Report dated 4/1/18 at 11:20 a.m. documented when called to the resident's room, the nurse saw Resident #1 sitting on the floor with her legs extended in front of her and her back resting on the front of her recliner. The resident denied injury and could move all extremities without any problems. Resident #1 told her the wheelchair rolled away because the wheels were not locked as she tried to transfer to it. The nurse noted confusion, UTI, gait imbalance and impaired memory as predisposing factors to the fall. Additional notes dated 4/2/18 documented that lab work had been ordered as an intervention. A Nurses Note dated 4/2/18 at 6:16 a.m. documented that Resident #1 continued on antibiotic therapy for a UTI and the resident was alert and oriented x 1 - 2 with baseline dementia/[MEDICAL CONDITION] process. A Social Services note dated 4/2/18 at 10:16 a.m. and authored by the Administrator documented that at 10:11 a.m., he heard a yell down hall 4 and found Resident #1 on the floor. The Incident Report dated 4/2/18 at 2:31 p.m. recorded staff found Resident #1 lying on her right side at 10:15 a.m. The resident bled from a small area on the right side of her head. Resident #1 denied pain as staff rolled her onto her back for further assessment and the [MEDICAL CONDITION] stopped bleeding. Staff assisted the resident to a sitting position; at which time she complained of some dizziness that resolved quickly. After standing, the resident continued to deny pain and had no apparent signs of other injury. The nurse documented the resident slipped out of the chair as she bent over to take her shoes off. The nurse documented confusion, incontinence, UTI, gait imbalance and impaired memory as predisposing factors to the fall. An additional note documented that Resident #1 had been sitting in her wheelchair at the time she bent over to take her shoes off and she went head first out of the wheelchair. Staff documented they changed out the resident's wheelchair applying an anti-roll back device and a drop seat. A Nurses Note dated 4/2/18 at 1:25 p.m. documented that Resident #1 complained of right hip pain during transfers or movement. Staff obtained a new order for a right hip X-ray. A Nurses Note dated 4/3/18 at 12:11 a.m. documented that X-ray results showed Resident #1 sustained a mid-displaced subcapital [MEDICAL CONDITION] hip. The nurse notified the on-call doctor who gave orders to send the resident to the ER (emergency room ) and the resident left the facility at 10:00 p.m. The ED Provider Notes dated 4/2/18 at 11:13 p.m. documented Resident #1 arrived at the ER due to increasing pain over her right hip and the inability to walk since being found on the floor at 10:15 a.m. today. The resident had a 3 cm (centimeter) laceration over her right temple with mild bleeding. Resident #1 was confused and reported pain over her right hip, right knee and right ankle. The final result of a hip X-ray dated 4/3/18 at 3:59 a.m. revealed Resident #1 sustained an impacted, non-displaced right femur fracture. A Nurses Note dated 4/3/18 at 4:44 a.m. documented Resident #1 admitted to the hospital with [REDACTED]. An interview on 4/5/18 at 3:25 p.m. with Staff D, CAN revealed she went to the basement before Resident #1 fell on [DATE]. Staff D said the resident's call light was off when she left about 3:20 p.m. and on when she returned about 3:30 p.m. Staff D saw Resident #1 sitting on the floor between her recliner and walker. She asked the resident, but she denied being in pain. Staff D reported it to the nurse. Staff D said the nurse did vital signs and they helped Resident #1 into her wheelchair. Staff D believed Resident #1 required the assistance of one for transfers and she only used her call light when she was in bed. Staff D said Resident #1 fell twice more in the next couple days. They told her to keep an eye on Resident #1 and provide help even if she did not ask for help. Staff D stated she did not know Resident #1 had a UTI until after she fell the third time at this point, they told her to keep a closer eye on the resident. Staff D said their pocket care plans do not let them know if residents have UTIs, although they should. Staff D said the nurses should tell them that stuff without having to ask. Communication is a real problem. An interview on 4/9/18 at 9:40 a.m. with Staff C, CAN revealed when she returned from lunch break on 4/2/18 she learned that Resident #1 needed a shower because there was blood in her hair. Resident #1 had just fallen in her room. Staff C said they told her at shift change to keep a close eye on Resident #1 because she had a couple falls recently. Staff C believed Resident #1 required the assistance of one but the resident had a problem with using her her call lights or asking for help. An interview on 4/9/18 at 2:05 p.m. with Staff A, CAN revealed that she found Resident #1 after both falls on 4/1/18. The resident fell first before breakfast. Resident #1 yelled for help as she helped another resident across the hall, Staff A saw her lying on the floor on her left side in front of her recliner and the resident seemed to be fine. Resident #1 told her she fell while transferring from the recliner to the wheelchair and it slid away from her because the wheels were unlocked. Staff A stated she told the nurse what happened and the nurse stayed with the resident while she went to find someone to help get her up. Resident #1 fell again before lunch. Staff A responded to Resident #1's call light and found her sitting on the floor. The resident told her she slid out of the chair while trying to self-transfer. Before the falls, Resident #1 was supposed to call for help to transfer, but she would not use her call light most of the time. Staff A said she told Resident #1 after the first fall she needed to lock her wheelchair and call for help. The CAN said she was late for work and the overnight shift had already left by the time she got there that morning. Staff A said the overnight shift should have told someone on the day shift the resident fell during the night; that information should have been relayed to her, but it was not. Staff A also said she had not asked and nobody told her anything about what was going on with her residents before she started her shift. Staff A said she told the next shift that Resident #1 fell twice during her shift and staff should keep a close eye on her. Staff A said she did not know that Resident #1 already fell twice that weekend. An interview on 4/9/18 at 2:40 a.m. with the Director of Nursing (DON) revealed she worked on Saturday (3/31/18) and Sunday (4/1/18). With the first fall, the CAN told her she found Resident #1 on the floor about 8:00 a.m. The DON said she saw Resident #1 lying on the floor on her side. The resident told the DON her wheelchair slid out from under her as she tried to transfer from her recliner to her wheelchair. The DON saw the wheelchair about a foot away from the resident and the brakes were not on. The DON said that although the resident was not in any distress, she got upset because she fell . The resident squirmed around and got herself up on her knees at her chair. At that point, Resident #1 let them help her up into the recliner. They transferred her back into her wheel chair shortly after to go down for breakfast. Staff made sure to keep the brakes on her wheelchair locked and to keep it far enough away from her so she would not be tempted to self-transfer again. The resident had a history of [REDACTED].#1 fell again about 11:20 a.m. The DON said the same CAN told her she found Resident #1 on the floor again. The DON went in there and saw the resident sitting on the floor perpendicular to her recliner with the wheelchair a couple of feet away. The DON said she asked what happened and the resident went off on a tangent about something that seemed irrelevant. The resident finally said something about the wheelchair falling out from under her. The DON said her assessment determined the resident did not have any injuries. The DON said that although the resident was independent to transfer in her room, they had been trying to give her assistance and encourage her to use her call light since she had a UTI but the resident continued to self-transfer. The DON said they had already implemented the installation of an anti-roll back device on her wheelchair as an intervention, but maintenance was not there to do it. The DON said she could not think of what else they might have done to try to prevent her from falling. The DON said information about a resident's change in status gets relayed by word of mouth and the 24 hour report. An interview on 4/10/18 at 8:09 a.m. with Staff B, LPN (Licensed Practical Nurse) revealed he worked the overnight shift on 3/31/18 when Resident #1 fell . Staff B and a CAN met in the hallway about 2:30 a.m. on their way to find out the source of a yell they heard. They entered Resident #1's room together and found her on her knees with her head on the bed and her feet twisted up in a blanket. Staff B completed as assessment. Resident #1 complained about her right ankle, but he did not see any apparent signs of injuries. The CAN got the resident up to take her to the bathroom and he did not notice any problems as he watched the resident walk. Staff B asked the CAN later if Resident #1 complained about her ankle anymore and she said no. Staff B saw Resident #1 at about 8:00 p.m. shortly after the beginning of his shift as he had to give her an antibiotic for a UTI. Staff B said the resident was alert and very confused per her normal. Staff B said Resident #1 told him the woman pushed her out of bed because she wanted the papers but Resident #1 did not have a roommate. Staff B recalled a time when Resident #1 misplaced her TV remote. Resident #1 told people staff took her remote because they wanted to steal her social security check. Staff B said nobody reported anything unusual about Resident #1 at shift change and he last worked on 3/27/18 before she fell that night. Resident #1 had been independent in her room before the falls, but he did not know her transfer status now because she had moved up front. An interview on 4/10/18 at 9:35 a.m. with the PT (physical therapist) revealed that she was told on 4/6/18 that they expected Resident #1 back from the hospital on [DATE] and she should be prepared to come in on 4/8/18 to evaluate her needs. The PT said she talked to staff and they said Resident #1 had been doing pretty well after surgery, but was confused as normal. The PT said they changed the resident's room to keep her closer for safety due to the fact that she had several falls. An interview on 4/10/18 at 10:30 a.m. with the MDS Coordinator revealed she thought everyone should know what every resident needs and what cares should be provided to them 24/7. Falls and changes in status should be entered into the 24 hour/communication book. When asked, the MDS Coordinator verified that nobody entered anything in the communication book related to Resident #1's falls prior to hospitalization or her transfer status upon being readmitted from the hospital. An interview on 4/10/18 at 1:50 p.m. with the Administrator regarding post fall interventions revealed they usually have IDT meetings on Monday mornings to discuss falls, what interventions were implemented and what needs to be changed. The Administrator said every fall is different and they try to determine the root cause of the fall and go from there. Regarding PT, it should be implemented as soon after a fall as possible which depends on when they obtain the order and consult with family, etc. When asked about implementation of a scoop mattress as an intervention after one of Resident #1's five falls, the Administrator said he did not know when they put the scoop mattress on the resident's bed and would speak with the old DON. The Administrator said spare mattresses are kept downstairs, including scoop mattresses. When asked how he could be sure they had a spare scoop mattress to use, the Administrator said he believed they had a spare because nobody asked him to rent one or obtain one. The Administrator would have expected maintenance to install the anti-roll back device specified as an intervention on Resident #1's wheelchair on the Monday morning following the falls and he saw the antirollback bars installed on Monday 4/2/18. He did not think labs ordered over the weekend would have been picked up Sunday and the facility would have to store them. When asked who decides which post fall interventions should be implemented on the weekends in the absence of the IDT, the Administrator said nursing staff. The Administrator said he expected them to make good clinical decisions to keep the residents safe. The Administrator offered he though staff did everything they could do at that time considering the circumstances. Another interview on 4/10/18 at 4:15 p.m. with the Administrator revealed they did not get lab results back before the resident's fifth fall with fracture. The Administrator also acknowledged he could not find any documentation or information to know when the scoop mattress was placed on the resident's bed. A subsequent interview on 4/11/18 at 11:40 a.m. with the Administrator revealed they did not bill Resident #1 for the scoop mattress because they had one in storage. An interview on 4/11/18 at 8:20 a.m. with the Maintenance Assistant revealed a nurse asked him to put an anti-roll back device on Resident #1's wheelchair when he came in on the Monday morning after Easter. The Maintenance Assistant said Resident #1 sat in her wheelchair in the dining room when the nurse asked him and that wheelchair did not have an anti-roll back device on it at the time. The Maintenance Assistant said he asked an aid to transfer Resident #1 out of the wheelchair so he could work on it. The Maintenance Assistant went about his business, returned to work on the wheelchair and saw Resident #1 on the floor with about 4 other people in her room. The Maintenance Assistant said this was the first request for him to install the device. An interview on 4/11/18 at 9:00 a.m. with the Maintenance Supervisor revealed that nobody had submitted a request to have an anti-roll back device installed on Resident #1's wheelchair. The Supervisor said they apparently just asked his assistant to do it when they saw him. Additional interview on 4/11/18 at 11:55 a.m. with the PT revealed they notified her at some point after a fall that Resident #1 would need to be evaluated and treated pending payment verification. The PT said she could not recall exactly when they first notified her, but she did not work with the resident until after she readmitted after surgery.

Based on record review, observation and resident and staff interviews, the facility failed to provide adequate supervision and assistive device to ensure against an injury (Resident #1). The sample consisted of 4 residents and the facility reported a census of 71 residents. The resident had a history of [REDACTED]. The facility failed to provide enough assistance to assist the resident once unsteady, leading to a fall occurrence with a fracture of the left ankle. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1, identified a Brief Interview for Mental Status (BIMS) score of 12. A score of 12 indicated the resident had moderate cognitive impairment. The MDS identified the resident had no signs or symptoms of delirium. The assessment indicated the resident required extensive physical assistance of 1 person for transfers and bathing. The MDS coded the resident as not steady, only able to stabilize with staff assistance during surface-to-surface transfers and moving from a seated to standing position. The MDS documented the resident had [DIAGNOSES REDACTED]. The Rehabilitation Screen RehabCare signed by a therapist on 7/15/16, documented a quarterly review. The therapist wrote under comments the resident needed the assistance of 1 (person) with ADL (activities of daily living) transfers. The Care Plan focus area, initiated on 7/22/16, identified a risk for falls related to gait/balance problems, history of falls, and incontinence. The Care Plan directed staff to follow therapy recommendations for transfers and mobility. The Care Plan focus area initiated on 8/18/16 identified a self-care deficit related to: late effects of a stroke as evidenced by requiring assistance with ADL's; impaired balance during transitions; and functional limitation of range of motion to one upper extremity. The Care Plan informed the staff members that Resident #1 used a wheelchair, non-ambulatory and required extensive 1 person assistance with bathing and transfers. The Fall incident report documented by Staff B, Registered Nurse (RN), on 8/27/16 at 7:50 a.m. and revised 8/29/16 at 8:44 a.m., recorded the resident fell in the shower room. The report recorded Staff B found the resident sitting on the floor in front of the whirlpool fully dressed. The report documented the resident stated his/her knee buckled and she/he went down. Staff B wrote the incident witnessed by the shower aid who stated the resident only landed on his/her knee then the aid had the resident sit down until assistance arrived. The report documented the resident's mental status as oriented to person, place, and time. The Progress Note documented by Staff B on 8/27/16 at 8:52 a.m., recorded the resident in the shower in the a.m. The note documented the resident stood up to transfer to the wheelchair and the resident stated his/her knee buckled. Staff B wrote the aid was unable to hold up the resident alone, so had the resident kneel down, then sit on the floor until assistance arrived. Staff B recorded the resident denied pain, however stated his/her knee felt stiff. The Progress Note documented by Staff B on 8/27/16 at 2:52 p.m., recorded at 11:00 a.m. the resident's left ankle noted to be swelling, the resident complained of pain, and a PRN (as needed) Rx (medication) provided. Staff B recorded she received an order for [REDACTED]. The Radiology Report dated 8/27/16 at 1:32 p.m. documented the results of the ankle x-ray indicated an acute distal fibular fracture (distal designated the end of the bone near the ankle junction). The Final Report of the x-rays dated 8/27/16 at 4:15 p.m. documented: severe degenerative change left knee; degenerative changes in the ankle and foot; mild-moderately displaced oblique acute Weber type B fracture distal fibula (this meant a shifted, diagonal break of the bone at the top of ankle); and overlying soft tissue swelling. The Progress Note dated 8/27/16 at 8:39 p.m. documented the resident returned to the facility and wore a cam boot (a controlled ankle motion walking boot used for treatment and stabilization of fractures). The Major Injury Determination Form, signed by the ARNP (Advanced Registered Nurse Practitioner) on 8/30/16, documented the ARNP felt the acute distal fibular fracture was a major injury. The facility investigation note documented by the Director of Nursing (DON) on 8/27/16 recorded the DON spoke to Staff A, certified nurse aide (CNA), at approximately 1:00 p.m. The DON reported Staff A stated she transferred the resident back to the wheelchair and right before the resident was going to sit, his/her knee buckled. The DON noted Staff A had to lower the resident to the floor. The DON documented Staff A said the wheelchair was right up next to the shower chair and the space small, so the resident had to sit on his/her leg/ankle. The DON recorded Staff A admitted she did not use a gait belt (a device used to transfer people who have a problem with balance to increase security and safety).When asked why, Staff A told her she forgot it at home and did not think to ask the other aides for a gait belt. The DON documented Staff A received her certification in June 2016 and trained during certification to use a gait belt for all transfers except when using mechanical lifts. In an interview on 10/3/16 at 12:00 p.m., the DON reported Resident #1 interviewable but fluctuated. The DON stated the resident reported she/he went down when stood and his/her left leg went under. The DON stated Staff A admitted she did not use a gait belt. The DON acknowledged she expected a gait belt to be used for any assist of 1 or 2 transfers. The DON stated she educated Staff A on that expectation after the incident. In an interview on 10/3/16 at 1:00 p.m., Staff B, RN, stated no gait belt on the resident when she entered the shower room to assess the resident. Staff B stated the resident reported she/he couldn't stand any longer so went down on a knee. Staff B stated Staff A reported she could not hold the resident because she/he was too big and weighed approximately 300 pounds. Staff B commented Staff A should have been able to transfer the resident on her own and would have expected the resident to receive assistance of 1 person and a gait belt. Staff B reported the resident stated to her nobody used a gait belt. Staff B stated she did not know if that was the resident's preference or if the resident was reporting that information. In an interview on 10/3/16 at 1:30 p.m., the DON responded that other than the gait belt policy signed upon hire, there was no additional documentation of transfer training for Staff A. The DON stated she expected Staff A to follow the training received for (CNA) certification by the state. In an interview on 10/3/16 at 2:45 p.m., Resident #1 recalled the fall incident in the shower room. Resident #1 stated she/he put a hand on the high part of the wheelchair, turned to sit in the wheelchair, and his/her hand slipped because knee gave out. The resident reported the knee had given out before but no injury occurred. The resident commented she/he felt the leg crack and the foot went under his/her butt. The resident stated his/her butt broke the leg. Resident #1 stated she/he knew they (the facility) said she/he should have the thing around the waist (indicated gait belt) but it happened to fast. Resident #1 stated she/he never refused to wear the gait belt and had never been asked in the shower to use the gait belt. Resident #1 commented she/he had returned on 10/3/16 from the doctor where they removed the cast and only had to continue to wear a boot for 4 to 6 weeks. In an interview on 10/3/16 at 3:50 p.m., Staff C, CNA, stated she always used a gait belt during shower transfers. Staff C stated Resident #1 had refused the belt in the past but she could usually get the resident talked into using it after educating the need to use it for safety. In an interview on 10/4/16 at 7:45 a.m., Staff D, CNA, stated she was familiar with Resident #1's care. Staff D said the resident required the assistance of 1 person, was non-compliant with transfer assistance, and the resident would say it was not needed. Staff D reported the resident had an unusual squat stance and moved his/her butt in a shimmy while turning then would plop down. Staff D stated the resident transferred like that since her date of hire in May 2016. Staff D stated the resident's knees gave him/her trouble and she could see the knees buckle or wobble. Staff D stated when that happened, she needed to hold the pants to assist but even then the resident refused the gait belt. In an interview on 10/4/16 at 7:50 a.m., Staff E, CNA, stated she had worked for the facility for 5 years and familiar with Resident #1's cares. Staff E stated the resident never refused the gait belt but didn't like it. Staff E stated it took extra time to explain the importance of the belt. In an interview on 10/4/16 at 10:00 a.m., Staff A stated she worked at the facility since June 2016. Staff A stated she went thru an orientation by job shadowing only while not certified. Staff A reported once she received certification at the end of July, she just worked on her own. Staff A stated she was never observed for transfers. Staff A stated she knew how to use a gait belt but not trained by the facility. Staff A reported she had only helped Resident #1 a few times. Staff A commented she felt the resident was not a safe transfer and should have been assisted by 2 persons. Staff A reported she did have other staff available to assist but did not ask for help because mornings are hectic. Staff A stated she offered the gait belt to the resident when she assisted the resident out of bed and the resident refused. Staff A said she did not offer the gait belt in shower room because the resident had already refused when getting out of bed. Staff A reported she assisted during the transfer by holding under the resident's left arm. Staff A stated she felt the resident moving down on the left side because the knee buckled, then the leg caught. Staff A said she released the wheelchair brake to push the wheelchair out of the way because she could not see which leg was caught and the left knee almost to the ground. Staff A reported she did not know what was putting pressure on the resident's leg so she wanted to move the wheelchair. Staff A then lowered the resident all the way to the floor and moved the wheelchair completely. Staff A reported she had never told the facility the resident refused the gait belt because she figured it was nothing new. In an interview on 10/4/16 at 2:10 p.m., the DON confirmed Staff A did not have a transfer audit completed prior to the incident on 8/27/16. The DON verified the facility record contained no orientation or CNA skills checklist. The DON confirmed Resident#1's clinical record lacked documentation of the resident's refusal to allow the use of a gait belt.

Based on record review and staff interviews, the facility failed to protect one (1) of ten (10) residents against environmental hazards. Record review and staff interview established Resident #1 required his/her walker when walking in his/her room. Staff interviews revealed resident ' s walker had been in the hallway for cleaning when he/she fell and sustained a pelvic & left hip fracture. The facility reported a census of 67 residents. Findings include: 1. According the Minimum Data Set (MDS) assessment tool with a reference date of 03/13/16, Resident #1 had active [DIAGNOSES REDACTED]. Resident #1 demonstrated severe cognitive impairments with a score of 5 out of 15 on the Brief Interview of Mental Status (BIMS) cognitive test. The MDS identified Resident #1 independent for bed mobility, transfers, ambulation and eating; however the resident required extensive assistance of one staff member to physically assist with toilet use and dressing. The MDS documented the resident normally used mobility devices of a walker. The MDS indicated the resident balance during transitions and walking as steady when walking with assistive device (walker). The MDS indicated the resident had no functional limitation in range of motion. The Care Plan dated 08/07/2014, identified the resident self-care deficit, needs assist with activities of daily living (ADL's). The Care Plan listed interventions/approaches that directed staff to: 1. Provide assist with ADL's, morning and at hour of sleep. 2. Assist of one staff with ambulation and (at times) resident is independent with ambulation. The resident preferred to hold staff/family's arm and staff should encourage independence with ambulation. 3. Allow resident to do as much as possible for him/her (self). 4. Ensure call light is available. Staff is to attempt to anticipate needs. Review of the Progress Nurse's Notes dated 03/29/16 at 2:26 a.m., indicated the nurse had been called to the resident's room by Certified Nurse Aide (CNA) who heard resident yelling. Resident #1 found sitting on floor, on buttocks with knees up and feet flat on the floor, in bathroom doorway. The nurse completed a head to toe assessment and the resident had a skin tear to left elbow with no complaints of pain with ambulation.The resident's physician notified via facsimile of resident's fall and status. At 8:37 a.m. Nurse assessed the resident and he/she complained of pain in the pelvis and left hip. Staff administered pain medication as ordered, and the physician ordered x-rays of pelvis and hip. At 11:00 a.m. x-ray at facility and x-rays completed. At 3:00 p.m. the resident's physician called regarding x-ray results and orders received to send the resident to the emergency room for further evaluation and treatment. Resident transferred to the emergency room via ambulance transport. Review of the facility's Verification of Investigation and Fall Incident Report, both dated 3/29/16 indicated the CNA (Certified Nurse Aide) heard Resident #1 yelling and found resident sitting on the floor in the bathroom doorway. Nurse completed assessment and applied dressing to left elbow. Two staff assisted the resident up from the floor with a gaitbelt. Resident #1 stated he/she could not find her/his walker and was ambulating to the bathroom at the time of the fall. The form identified the resident had been independent with transfers and ambulation in his/her room with the walker prior to the fall. Review of the History and Physical dated 03/29/16 revealed Resident #1 presented to the hospital on [DATE] with left hip pain status [REDACTED]. The X-rays showed a left femur/pelvis fracture. The resident admitted for pain management and orthopedic plan of care. No surgical repair, rehab and weight bearing with walker. The resident discharged back to facility on 4/2/16 to skilled care for rehab therapy. During an interview with Staff A, Licensed Practical Nurse (LPN) on 4/19/16 she stated the CNA, agency staff summoned her to the resident's room. The CNA had been in the next room and heard Resident #1 calling for help. Staff A stated she found Resident #1 on the floor and the resident stated he/she could not find the walker when attempting to go to the bathroom. Staff A reported the resident's walker had been in the hallway for cleaning. Staff A stated the resident is independent with ambulation with walker and staff is well aware of that. Staff A reported the resident always used his/her walker, all the time. Staff A stated the walker should have been washed and returned right away from the CNA for the resident's use. During an interview with the Director of Nursing (DON) on 4/19/16 at 2:00 p.m. she stated prior to the fall staff were aware Resident #1 ambulated independently with use of a walker. The DON stated the resident's walker should never been taken out of the resident's room for cleaning without another walker replacing it.

Based on observation, record review, and staff and resident interviews, the facility failed to ensure Resident #8 received services to prevent pressure ulcers. Staff placed a bed pan under the resident ' s buttocks and did not return to check the resident. The resident went to sleep with the bed pan under buttocks which resulted in an avoidable pressure ulcer. The resident lacked pressure relieving devices for both heels and had pressure ulcers on each heel. The sample consisted of 8 residents and facility reported a census of 76 residents. Findings include: 1. Resident #8 had an admission Minimum Data Set (MDS) assessment with a reference date of 10/01/15. The MDS identified the resident had no memory problem and some difficulty in new situations only. The MDS reflected the resident did not ambulate and depended upon staff of more than 2 people for transfers and required assistance of 1 staff person for bed mobility. The MDS identified active [DIAGNOSES REDACTED]. The MDS identified the resident at risk for the development of pressure ulcers. The MDS reflected the resident did not have any pressure ulcers, venous or arterial ulcers. The preventive items listed for prevention identified a pressure reducing device for the chair and bed. The MDS reflected no turning or repositioning program or preventive intervention care for heel ulcers. The MDS identified the following descriptions of Pressure Ulcers: Stage I is intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching and only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough. May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss, subcutaneous fat may be visible but bone tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable is when the wound bed cannot be observed. The admission Braden Scale (pressure sore risk assessment) dated 9/24/15, 9/30/15, 10/23/15 and 11/6/15 identified scores of 13 and 14. A score of 12 or less indicated high risk. The Interim Plan of Care dated 9/24/15 identified the resident had pressure areas noted on the left heel, left toe and the coccyx area. The Interim Plan of Care did not identify preventive care for pressure ulcers and only had an approach to provide wound care as ordered. The Interim Plan of care reflected on 10/6/15, the staff added compression socks to the right lower extremity with approaches to apply in the A.M. and remove in the P.M. The Resident Care Plan dated 10/13/15 identified the resident to have impaired physical mobility related to [MEDICAL CONDITION]([MEDICAL CONDITION]- stroke). The approaches included and directed staff to provide assistance as needed for transfers and mobility, assist/encourage resident to reposition in bed as needed, turn schedule, cushion in wheelchair and heel protection with float boots. Review of Non-Pressure Skin Condition reports dated 9/24/15 on admission revealed the resident had an abrasion noted on the right buttock and scabbed areas on the toes of the left foot. Treatment consisted of [MEDICATION NAME] (anticeptic) to tips of the toes and zinc oxide 20% ointment on buttock twice daily. An additional Pressure Ulcer Record also dated 9/24/15 revealed a blood filler blister noted on the left heel. Treatment consisted of [MEDICATION NAME] to the left heel. During a group interview on 1/27/16 at 10:00 AM with four residents (#8, #9, #10, and #11) deemed cognitive by staff, Resident #8 stated he/she was admitted 4 months ago into the facility for rehabilitation care and his/her goal was to return home after becoming stronger. Resident #8 stated about three months ago he/she had been left on a bedpan overnight and developed a pressure ulcer on his/her right buttock which was identified by staff 1-2 days later. Resident #8 stated after placed on the bed pan, he/she fell asleep and the staff did not return to check on him/her or remove the bed pan from underneath him/her. Resident #8 stated the staff did not remind him/her to reposition self prior to the identification of the wound. The resident stated he/she currently goes to the wound clinic for treatment of [REDACTED]. Review of a facsimile sent to the physician dated 10/14/15, identified the nurse notified the physician of an identification of an 8 centimeter (cm) by 4.3 cm. The fax reflected the staff questioned if the blister was from the bed pan. The area is open, steri striped. The nurse requested an order for [REDACTED]. Review of a Non-Pressure Skin Condition Report dated 10/13/15 noted the identification of the blister on the resident ' s right upper buttock. Review of a Weekly Pressure Ulcer Record revealed on 10/27/15 the wound was identified as an unstageable pressure ulcer and documentation was changed from a non-pressure flow sheet to the Weekly Pressure Ulcer Report. The wound measured 7.2 cm by 4.2 cm with scant amount of drainage and a brown/black center. During an attempt to observe wound care on 1/28/16 at 9:00 AM Resident #8 refused to allow observation of wound care for the pressure ulcer located on his/her upper right buttock. The resident stated he/she would allow observation of the dressing and pulled down his/her pajama pants. A 4 inch by four inch dry and intact dressing was noted on the right upper buttock. The resident ' s bedpan was noted to be plastic with a 14 centimeter upper lip which tapered down to a front lip of .5 cm in width. The resident stated the night he fell asleep on the bedpan, the bedpan was placed by a CNA with the wide upper lip under his/her upper buttocks. The CNA had told the resident he/she would return shortly to remove the bedpan. The resident could not recall the CNA ' s name and stated the CNA was no longer employed at the facility. On 1/28/16 at 9:10 AM, Staff H, Licensed Practical Nurse (LPN), was interviewed and stated a CNA came to her on 10/13/15 and stated she noticed a skin tear on the buttock of Resident #8 while assisting the resident off of the bedpan. Staff H assessed the resident ' s s skin issue and determined it was an 8 cm by 4 cm blister. Staff H stated Resident #8 liked to remain on the bedpan for up to an hour. If the CNAs tried to remove the bedpan before the resident was done going to the bathroom he/she would refuse to have the bed pan removed. She stated it appeared that the top of the bedpan rested right where the blister formed. She stated she had not heard of an incident when the resident was on the bedpan overnight. During an interview on 1/28/16 at 9:20 AM with Staff C, CNA, she stated she assisted resident #8 onto the bedpan and observed the resident had a quarter sized purple-red bruise on the upper right buttock. When she assisted the resident off the bedpan she noticed a small amount of bleeding and thought the area was a skin tear. She stated the area was where the upper part of the bedpan was against the resident ' s skin. She notified the nurse and the area was assessed as a blister. Staff C stated the resident could re-position him/herself in bed but required assistance to get on and off the bedpan. She cannot recall if the resident was to be turned (repositioned) every two hours before the area was identified. During an interview on 1/28/16 at 12:40 PM with Staff I, CNA, she stated she works night shift and has cared for Resident #8. She stated the resident could notify the staff when he/she needed the bed pan. Staff I stated the resident would frequently fall asleep at night while positioned on the bedpan and the night staff needed to be careful to check on the resident shortly after assisting him/her onto the bed pan for this reason. Staff I stated the resident never refused to get off the bed pan for her but occasionally would request more time on the bed pan to finish going to the bathroom. She stated she was unaware of any incident where the resident was on the bed pan all night. During an interview on 1/28/16 at 12:20 PM with Staff J, CNA, she stated she had not heard about the resident being on the bedpan all night. She stated staff are to leave residents on the bedpan no longer then the time it takes the resident to go to the bathroom. She cannot recall Resident #8 ever staying on the bedpan longer then 10-15 minutes. During an interview on 1/27/16 at 12:40 PM Staff O, LPN, stated she recalled vaguely an incident with Resident #8 and a bedpan but cannot recall any details. She stated she would check to see if an incident reported was generated. Staff O stated later she was unable to find an incident report. She stated protocol was to reposition bed fast residents every 2 hours and to remind residents capable of self-positioning to frequently change position. Review of the Nurse ' s Notes dated 12/23/15 at 10:00 a.m. indicated the resident ' s pressure wound measured 4.5 cm by 4.5 cm with a depth of 4 cm. Wound tunnels were noted at the 6:00, 9:00, and 12:00 position and the treatment was changed to clean with wound cleanser, apply med-honey to slough, pack with acetic acid, and cover with a dressing. Review of a Wound Clinic note dated 1/26/16 revealed the wound measured 1.8 cm by 3 cm by 2.7 cm and was debrided. The note indicated the wound was clean and a collagen treatment was initiated to aid in the development of granulation tissue. LEFT HEEL: The Weekly Pressure Ulcer Record identified the resident had an onset of a pressure ulcer located on the left heel on 9/24/15 (upon admission). The notes reflected the staff used an air mattress and bunny boots for pressure relieving interventions (bunny boots do not float heel) until the resident went to the hospital on [DATE]. The record dated 12/28/15 reflected the pressure sore to not be open and healed. RIGHT HEEL: The Weekly Pressure Ulcer Record identified on 12/28/15, the right heel had a blister (Stage II). The record indicated pressure relieving interventions were in place but did not identify the type for staff to use. The Weekly Pressure Ulcer Record dated 1/26/16 identified a Stage II pressure ulcer present and measured 1.8 by .8 centimeters with a small amount of red drainage present on old dressing. The pressure relieving interventions consisted of an air mattress (on bed) and bunny boots (do not float heels).

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision and assistance to the bathroom in order to prevent against hazards and potential accidents. The facility reported a census of 76 residents and the sample of 8 residents. Findings included: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 10/20/15. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 10. A score of 10 identified the resident as moderately cognitively impaired for daily decision making. The MDS reflected Resident #1 required extensive physical assistance of one staff member for transfers, toileting, personal hygiene and bathing needs. The MDS indicated the resident had balance deficits and could only stabilize self with staff assistance. The MDS indicated the resident always continent of bowel and bladder. The MDS noted the resident to have [DIAGNOSES REDACTED]. The MDS indicated the resident exhibited dyspnea (shortness of breath) with exertion and when lying flat. The Care Plan identified the resident to be at risk for falls and instructed staff the resident required extensive assistance for activities of daily living and transfers related to periods of confusion. The Care Plan instructed staff to assist with toileting before and after meals, provide pericare as needed, provide assist of one for all transfers, and provide a shower/bath/whirlpool twice a week. The Care Plan indicated the resident used oxygen per nasal cannula due to shortness of breath with exertion and shallow diminished respirations. The Nurse ' s Notes dated 1/13/15 at 5:10 p.m. identified the resident ' s family member found the resident in the bathroom in a wheelchair. The resident ' s pants were down. The bathroom door had been closed when the resident was found. The resident's oxygen saturation registered at 79%. The resident ' s vital signs were blood pressure at 143/72, pulse rate at 102 (normal 60-100) and respiratory rate at 20 (normal 16-20). Staff documented the resident sleepy but answering questions. The resident had oxygen on per nasal cannula from the potable tank, located on the wheelchair. The portable tank had been empty. The staff documented they switched the oxygen to the concentrator that had been located in the bathroom; the staff documented the oxygen saturation raised to 95% on 2-3/NC. The resident had been incontinent of urine in the wheelchair. The staff documented the CNA was sent to the room to replace the oxygen tank and the resident ' s family member cleaned and changed the resident. On 1/27/16 at 11:50 a.m. Staff A, CNA (certified nursing assistant) was interviewed and stated she had been working as a float nurse on Hall 6 when another CNA Staff C, had asked her to take Resident #1 to the bathroom before placing the resident in a recliner after lunch. Staff A stated she then took the resident into the bathroom in the wheelchair. Staff A stated the resident had not been incontinent so she just pulled down the resident's clothing and placed him/her on the toilet. Staff A stated the resident had oxygen on from the wheelchair portable tank, and she did not change it to the oxygen concentrator. Staff A stated she left the wheelchair in the bathroom with the resident. Staff A stated she believed the bathroom door was about 1/2 the way open. Staff A stated she left Resident #1 in the bathroom, telling the resident to pull the call light cord when finished. Staff A stated as she came out into the hall, the charge nurse told her she needed to go to the Royal side because one of the aides for there had to go home. Staff A stated she simply forgot to tell anyone that Resident #1 remained in the bathroom and she did not realize the resident had been left in there for several hours. Staff A stated she did not know exactly the time she took the resident into the bathroom but just after lunch when taking residents back to their rooms, usually between 1:00 p.m. and 1:30 p.m. (approximately 3 1/2 hours the resident remained in the bathroom). Staff A stated she left the facility at 2:30 p.m. During an interview with Resident#1's family member on 01/27/16 at 7:00 p.m. she stated she had come to the facility at approximately 5:30 p.m. on 01/13/16, stating that she had actually come in a little later than normally. She stated the resident had not been in the dining room which she usually was. She stated she went into the resident's room but the resident had not been sitting in the recliner. She stated the bathroom door was shut so thought the staff had the resident in the bathroom. The family member stated she had sat on the bed waiting for a few minutes but did not hear any voices from the bathroom. She stated she walked over, opened the door and found the resident sitting in a wheelchair with a nasal cannula in his/her nose but when she looked at the oxygen tank on the wheelchair noted it to be empty. She stated the resident had been sleeping pretty soundly in the wheelchair. She stated she went out of the bathroom to find a nurse to show her hoe she found her family member. She stated the resident brief had been saturated with urine as well wheelchair cushion. She stated that the nurse the nurse started to do an assessment as she replaced the oxygen from the empty tank to the concentrator that had been setting in the bathroom. She sated the resident's oxygen saturation had been pretty low but doesn't recall the exact number but had been in the low 70's. She stated after the assessment, the nurse left and it was 15 minutes before anyone came back in the room. The family member stated she is the one that cleaned the resident up, put the resident in dry clothes and got the resident ready for bed. On 01/27/16 at 11:15 a.m. Staff K, registered nurse, was interviewed and stated on 01/13/16 around 5:15, she had been standing at the medication cart when a family member came to her and asked her to go to Resident #1's room. Staff K stated the family member told her they had found Resident #1 sitting in a wheelchair in the bathroom with the door closed. The resident had been sitting with his/her back to the door, in a brief with the pants down around the ankles. The resident had oxygen on per nasal cannula from a portable oxygen tank on the back of the wheelchair. The oxygen tank had been empty. Staff K stated the oxygen concentrator which had been stored in the bathroom had not been utilized. Staff K stated with an assessment, she noted the resident ' s oxygen saturation as low, about 79%. Staff K stated the resident seemed sleepy but coherent. Staff K stated when she switched the resident to oxygen on the concentrator, the oxygen saturation level elevated. Staff K stated the resident did not know how long he/she had been in the bathroom. Staff K stated she had last seen the resident when Staff A propelled the resident to his/her bedroom at 1:30-1:45 p.m. Staff K stated at around 4:00 or 4:30 she passed medication and looked in the resident ' s room. Staff K stated she did not see the resident in the room and the bathroom door was closed. Staff K stated she did not see the oxygen tubing draped across the floor as usual (with concentrator use). Staff K stated the nursing assistants usually change the oxygen from the wheelchair tank to the concentrator when they bring the resident back to the room. On 01/27/16 at 12:15 p.m. Staff C, CNA stated she had been assigned to Hall 6 on 01/13/16. She stated she had asked Staff A to take Resident #1 to the bathroom before placing the resident into the recliner. She stated that normally they would change the resident's oxygen to the concentrator, and walk the resident into the bathroom. Staff C stated she did not see the resident in the recliner when she came out of the next room so she thought Staff A still had the resident in the bathroom. Staff C stated she did not see the resident the rest of the shift as she finished her task and then attended a staff meeting. On 01/27/15 at 1:50 p.m. Staff E, CNA stated she had been assigned to Hall 6 for the afternoon shift on 01/13/16. She stated she went to the staff meeting right after coming in for the shift. She stated after the meeting she and Staff C did rounds. She stated during rounds the 2 CNAs would walk down the hall, glance in the door and the staff going off would tell the staff coming in anything pertinent about the resident. Staff E stated when they did not see Resident #1 in the room; Staff C told her the resident was probably in therapy or the beauty shop because the wheelchair had not been in the room. She stated after rounds would just go to the nursing station and see who needed baths. She stated that around 3:30 to 4:00 p.m. would start toileting residents. Staff E stated that she had been a little concerned that the resident was not in the room but though the resident had gone to therapy or out with family. She stated she did check the sign out book, but sometimes people don't sign it. She stated she did not go in to check the bathroom and doesn't remember if the bathroom door had been closed.

Based on observation, record review, interviews with resident, staff and physician and review of the facility policy/procedures, the facility failed to assess and provide CPR (Cardiopulmonary Resuscitation) to an unresponsive resident with no heart beat or breathing (Resident #5). The facility identified 27 residents with advanced directives to receive CPR. The sample consisted of 4 residents and the facility reported a census of 81 residents. Findings include: 1. Resident #5 had a MDS (Minimum Data Set) assessment with a reference date of [DATE]. The MDS indicated the resident had [DIAGNOSES REDACTED]. The MDS identified the resident had the ability to make self-understood and could understand others. The resident had short and long term memory deficits and dependent upon staff for activities of daily living skills. An Interim Plan of Care dated [DATE], indicated the resident required staff assistance with activities of daily living (ADL'S), as confused at times and requested a Full Code status.(CPR) An Internal Medicine History and Physical form dated [DATE] at 12:57 a.m., identified the resident's request for a Full Code status. An admission orders [REDACTED]. A Regency Care Center and Assisted Living Resuscitate form, signed by the resident's family member on [DATE] and witnessed by two (2) facility staff members identified the resident requested to receive CPR. During an interview on [DATE] at 8:44 a.m., Staff I, Licensed Practical Nurse (LPN) confirmed he/she witnessed the family member sign the CPR request form. During an interview on [DATE] at 3:20 p.m., a family member confirmed it had been his/her mother/father's wish to have received CPR in the event he/she went into [MEDICAL CONDITION]. The same family member confirmed he/she had been aware the facility failed to perform the procedure when his/her family member had been found non-responsive and without a pulse or respirations. During an interview on [DATE] at 3:16 p.m., the resident ' s physician confirmed he/she expected staff to have performed CPR if the resident had been a Full Code status. Review of the facilities Nurse's Notes identified the following documentation: On [DATE] at 6:20 p.m. the Skilled Nursing Facility (SNF) level of care (LOC) related to (r/t)[MEDICAL CONDITION]. Alert and oriented times (x) ,[DATE] with very appropriate responses today. Fair diet and fluid intake, continued to need encouragement with intake. Heart rate regular (HRR). Lung sounds (LS) remained mildly coarse with moist cough. No acute respiratory distress. Abdomen soft and non-tender with bowel sounds (BS) active x 4. 1 plus (+) non-[MEDICAL CONDITION] on bilateral lower extremities (BLE). Maximum assistance of 1 with ADL'S. Two person pivot transfers. Denied pain. Treatment completed to buttocks. Refused to have been in bed on either side. Educated on skin integrity. On [DATE] (no time) - Temperature (T) 97.8 (normal 98.6) pulse (P) 72 (normal ,[DATE]), respirations (R) 18 (normal ,[DATE]), blood pressure (B/P) ,[DATE] and pulse oximetry (PO 2) 96% (,[DATE]) at room air (RA). On [DATE] at 10 p.m. - T 98.2, P 84, R 20, B/P ,[DATE], PO2 at 97% RA. Continued on SNF LOC for physical therapy (PT), occupational therapy (OT), speech therapy (ST) and restorative therapy (RT). Alert and oriented x ,[DATE]. Breath sounds coarse with occasional moist cough noted. Respirations easy and non- labored. No respiratory distress noted. No signs and symptoms (S/S) of abdominal pain or nausea or vomiting (N/V). Abdomen soft, non-tender with active bowel sounds and 1 plus [MEDICAL CONDITION] (non-pitting) of both lower extremities. The resident required extensive assistance by 2 people for pivot transfers. The resident required maximum assistance of 1 staff person for activities of daily living. The resident had no acute distress noted. On [DATE] at 1:10 a.m. the staff found the resident lying in bed without a palpable blood pressure, no apical pulse and no respirations. The resident ' s eyes were open and chin black. The staff closed the resident ' s eyes. On [DATE] at 1:25 a.m. the facility received a new order from a physician to release the body to a funeral home of the family ' s choice. The nurse placed a call to a family member with no answer. The nurse placed a call to another family member and notified of the passing of the resident. On [DATE] at 1:30 a.m. per the family member, he/she planned to contact another family member related to the funeral home and let the facility know. The body had been cleaned and positioned at that time. On [DATE] at 1:45 a.m. a message left on another family member's cell phone as on call phone had no voice mail set up. On [DATE] at 2 a.m. a, family member returned call. Plan to send resident to a named funeral home. On [DATE] at 2:45 a.m. a, funeral home personnel was at the facility and body released. On [DATE] at 2:45 a.m. the resident ' s medications removed from the medication container to go back to the pharmacy. On [DATE] at 2:45 a.m., personal belongings remained in room. Zip locked bag pendant, hair bow and ring placed in medication room. Unable to remove a silver bracelet from the resident's right wrist. On [DATE] (no time), family called to follow up and asked if there had been any questions and if their personal items had been picked up or if any help had been needed. Family stated items had already been picked up. No questions and/or concerns. Review of a Verification of Investigation form (not dated), documented the following: The resident, an [AGE] year old male/female had been admitted for SNF LOC on [DATE]. [DIAGNOSES REDACTED]. Resident provided nursing and therapy services as ordered upon admit. A doctor visit on [DATE] with new orders followed. On [DATE] at approximately 1:10 a.m., a staff CNA (certified nursing assistant) found the resident during routine rounds in bed absent of vital signs and reported that to an RN on duty immediately. Resident had been confirmed to have no vital signs by a nurse and the doctor had been notified as well as family that the resident had expired. The doctor ordered a release of the body to a funeral home of the family ' s choice. On admission, the resident's family member (responsible party but no Power of Attorney documented) had signed a resuscitate consent indicating CPR should have been performed if the resident were to have expired. That had also been included on the resident's admission orders [REDACTED]. No CPR had been initiated by either nurse on duty. During an interview on [DATE] at 3:45 p.m., Staff J, CNA stated around 11:,[DATE]:30 p.m. (during 1st rounds) the resident had been sleeping peacefully, almost smiling in his/her sleep. The staff member checked the resident's brief for incontinence, found it dry, brought in fresh water and left the resident to sleep. The staff member returned at 1 p.m. and found the resident positioned on his/her back with his/her eyes and mouth open. The staff member stepped just outside the resident's door and motioned Staff K, CNA for assistance. Staff K responded and checked the resident for breathing and a pulse while Staff J felt the resident's legs which had been described as warm between the legs however the resident's entire body had been pale. Staff J could not recall the resident having been blue in color. Staff J then touched the resident's arms and face which had been cool to the touch but not cold. The staff member stated she assumed because of the cool temperature in that part of the building. Staff J used her cell phone and called the nursing facility telephone number. Staff L, Registered Nurse (RN) responded. At that time Staff J informed the nurse she felt the resident had passed away. Staff L responded right away, stood by the foot of the resident's bed and said yes he/she is gone. Staff K asked the nurse if he/she wanted to check the resident and the nurse said she would take her word for it. Staff L then left the resident's room to find Staff M, RN (who had been the resident's charge nurse). Staff M entered the resident's room, listened to the resident with a stethoscope, and instructed Staff J and K to provide post mortem care. Staff M then left the room. During an interview on [DATE] at 11:30 a.m., Staff K (CNA) stated she/he came around the nurse's station and Staff J had been in the hallway. Staff J told him/her to hurry and run. As he/she arrived, Staff J stated he/she thought the resident had passed away. Staff K requested Staff J call the resident's charge nurse, however, Staff J told him/her the nurse had been in the assisted living area so Staff J called the facility telephone and reported the incident to Staff L. As the staff members entered the resident's room, the resident had been positioned on his/her back, head turned to the right with his/her eyes and mouth open. Staff K approached the resident and called the resident by name with no response as the staff member touched one arm that had been out of the covers and cold to the touch. However, the room window had been open so it was cold in the room. Staff K palpated but could not feel a pulse. Staff K stated he/she then pulled back the resident's blankets and the resident's skin had been warm and clammy. Staff L entered the resident's room and stood at the foot of the bed while Staff K had been touching the resident's body and said yes he/she looked deceased . Staff K asked Staff L if she wanted to assess the resident and she said no, she would take his/her word for it, looked at her watch and called the time of death as 1:10 a.m. Staff K asked the nurse if the resident had been a full Code or DNR and the nurse said she did not know. Staff L then directed the staff to provide post-mortem care and left the resident's room. Staff K left the room to retrieve cleansing supplies and when he/she returned, Staff M had been standing by the resident's dresser just inside the doorway. Staff M said she had checked the resident earlier and the resident had been fine. Staff K asked Staff M if the resident had been a Full Code or DNR and Staff M said the f- (expletive) if I know. The staff member never observed Staff M assess the resident however he/she went into the resident's bathroom to gather more supplies then Staff M left the room to call the resident's family. Staff K and J then provided post-mortem care and when they positioned the resident on his/her right side, the resident took 2 breaths and his/her eyes rolled back but the fingers and top lip had been purple. Staff K left to get Staff M who had just spoken with the resident's family member and told him/her the resident took 2 breaths and again asked about the code status. Staff M said f (expletive) I don't know and went through the resident's chart while randomly cussing. When she observed the CPR page, the staff member said Oh f (expletive) and picked up the telephone and called Staff L. When they hung up, Staff K asked if they planned on providing CPR and Staff M said f (expletive), I am not going to do CPR on anyone tonight and turned her chair around. Staff K again asked if they planned on providing CPR and what they planned on doing when Staff M directed him/her to go back to the resident's room and finish post-mortem cares which he/she did with no signs of life at that time. When cares had been completed the staff member left the resident's room to do rounds and having felt upset but did not know what to do. When the staff member went outside for a break, Staff M came outside and asked the staff member if he/she had been OK. Staff K said not really as the resident had still been warm and took a couple breaths. Staff M said no he/she was not and this is what happened. Rigor Mortis had already set in and that is why we had not performed CPR and that had been our story and we are sticking to it. Staff K looked at Staff M and went back inside the building. Staff K knew the funeral home came quickly and even at that time rigor mortis had not set in. Because the staff member had not known what to do she generally spoke with a family member who directed him/her to tell someone or call the Department of Inspections and Appeals. When the staff member returned to work at 10 p.m. that night, he/she reported the incident to Staff I who advised him/her to call the Administrator the following day. The staff member did not call the Administrator in the morning because he/she felt threatened and scared as Staff M had been described as big and rough around the edges and unsure if he/she would lose his/her job if he/she had not stuck to the story. The staff member spoke with the Administrator the following morning. During an interview on [DATE] at 4:21 p.m., Staff L, Registered Nurse, confirmed she received a telephone call from Staff J that someone had passed away and her charge nurse went to the Assisted Living area. Staff L went to the resident's room without a stethoscope and found the resident not breathing and pale. The staff member stated she touched the resident's arm which had been cold and stiff but did not uncover the resident any further. The staff member described the resident's lips as pale but not cyanotic and she failed to check for any further cyanosis. The staff member then went to get Staff M in the Assisted Living who returned with her. The staff member thought Staff M had been getting the resident's chart to check the code status and returned to her assigned area of the building to care for her residents. Approximately ,[DATE] hour later Staff M called on the telephone and said the resident had been a Full Code. Staff L stated she told Staff M they needed to perform CPR or they would get into trouble. Staff M said whatever and that had been it. Staff L stated if a resident requests CPR, then the nurses are required to perform the CPR. During an interview [DATE] at 10:03 a.m., Staff M confirmed he/she had been the charge nurse the night of the resident's death however she had been in the Assisted Living when the event occurred. The staff member stated she last observed the resident around 9 p.m. and described the resident as normal and alert and oriented x (times) 3 (person, place and time). The staff member stated she had been at the Assisted Living for approximately 10 minutes when Staff L approached and said she had been a barer of bad news, you have a dead patient. By the time Staff M arrived at the resident's room with a blood pressure cuff, stethoscope and a pulse oximetry device, Staff J and K had already provided post mortem cares. Staff M then checked the resident ' s vital signs with no signs of life. The staff member went to the nurse's station and called the physician. The staff member confirmed she had not checked the residents CPR status and she assumed Staff L had done this as she had been the first nurse to respond to the situation. Staff M stated she was wrong in not checking the status for herself. During an interview [DATE] at 10:39 a.m., Staff M indicated when he/she assessed the resident his/her face had been cold, chin hard to close, body had been cool, not warm and not cold and with no mottling (purple/blue blotchy skin). The staff member also confirmed the window to the resident's room had been open. During an interview on [DATE] at 2:19 p.m., Staff I stated when she arrived at the facility on [DATE] for the 6 a.m. to 6 p.m. shift, she overheard Staff M telling another staff member the resident had passed away that night. The staff member asked Staff M how she had been doing and she cried and said what she was supposed to do as the resident had been in rigor mortis. The staff member could not recall the entire situation just that she had been in the Assisted Living when the event occurred and when she arrived in the resident's room, she observed the resident ' s with a stiff jaw. Staff I stated between 10:30 p.m. and 12:00 a.m. a conversation had been brought up by Staff K related to the resident's death. Staff I told Staff K she had been informed the resident had been in rigor mortis. Staff K told her the resident had not been in rigor mortis rather the resident had been warm to the touch when found and felt there had been ethical issues because he/she had asked the nurse about the resident's code status and he/she reacted nonchalantly about the event as Staff K began to cry. Staff I directed Staff K to inform the Administrator in the morning. A timeline of events provided by the Administrator dated [DATE], documented the following: On [DATE] - Staff M called at approximately 2 a.m. and informed him/her the resident had expired. On [DATE] at approximately 9 a.m. to 10 a.m. two staff members informed him/her CPR had not been performed. Around 11 a.m. to 12 p.m. he/she reviewed the resident's chart and the charting appeared reasonable. On [DATE] at approximately 2 p.m. - 3 p.m. Staff I asked Staff K if he/she had spoken with the Administrator. On [DATE] at approximately 7 a.m. to 8 a.m. Staff K shared concerns about the resident's death. At that point he/she investigated the event further. On [DATE] at approximately 11 a.m. to 1 p.m. Staff M had been suspended. On [DATE] at approximately 4 p.m. to 6 p.m., Staff L had been suspended. Review of the facility Policy and Procedure Emergency Response form dated [DATE], the following medical emergencies may have been considered a code event: a. [MEDICAL CONDITION]: absence of a heart rate. b. Unresponsiveness: Unable to arouse with verbal (shouting) and/or tactile (sternal rub) stimuli. The procedure included the following: a. Upon discovery of a resident with a medical emergency, the employee responding would initiate the emergency response protocol by assisting the resident into a supine position to determine: 1. Responsiveness would have been determined by attempting to arouse using verbal (shouting) and/or tactile (sternal rub, shaking) stimuli. 2. Code status would have been verified. b. The first licensed nurse to respond to the scene had been responsible for evaluation of the medical emergency and would direct the activities of the emergency response protocol. This licensed nurse would remain with the resident until stable or care had been transferred to the EMS (Emergency Medical System). c. Code status would have been identified; if a Full Code status identified, CPR would have immediately been initiated by an individual with current CPR training if the resident had been identified in cardiopulmonary arrest. d. The responding staff member would have summoned help by announcing CODE and the location until qualified staff arrived to the location of the resident. Staff with CPR training had been expected to respond. 1. The staff member would have determined the status of the airway and the presence of spontaneous respirations by opening airway and listening/feeling for the presence of breathing. 2. The staff member would have determined the presence of a heartbeat by palpating the carotid artery pulse or auscultating for presence of a apical pulse using a stethoscope. e. Staff responding to the Code event location would have brought the emergency supply cart. f. If a resident had not been spontaneously breathing or ineffectively breathing, staff were to administer rescue breaths using an ambu-bag or a mouth shield. g. If no pulse had been auscultated or palpated or insufficient to peruse critical organs, staff were to begin chest compressions. h. Continue chest compressions until: 1. The resident showed signs of life (spontaneous heartbeat/respirations: 2. Another qualified person took over or 3. A physician gave the order to cease CPR. i. The licensed nurse directing the Code event would delegate a staff member to activate EMS/911. Note: At the time of the complaint investigation, the complaint was coded at a K, immediate and serious jeopardy. By [DATE], the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to G. The Administrator presented in-service training for CPR/DNR emergency response, following physician orders, abuse/neglect prevention & reporting and death of a resident. The facility audited resident charts to determine code status and ensure the status is on the face sheet located in the resident's chart and on the Medication Administration Record [REDACTED]. The nurses are to update the MAR, PCC and the POS (Physician Order Sheet) by notification per fax to the pharmacy. As of the [DATE] exit conference the facility continued to need to: · Continue to provide inservices to nursing staff regarding CPR/DNR emergency response, death of a resident, following physician orders, abuse/neglect prevention and reporting. · Continue to monitor the code status of each resident is kept on the chart face sheet and the MAR indicated [REDACTED] · Continue to audit that all nurses have current CPR training and monitor to confirm at least one nurse is available each shift who is CPR qualified. · Continue to audit and monitor all charts of residents who expire to ensure proper procedure was initated.

Based on record review, the facility's Bill of Rights, and interviews with the resident, family, and staff, the facility failed to ensure one (1) of ten (10) residents were free from verbal abuse, disparaging remarks, mental/emotional distress made by the Administrator; and failed to maintain the resident's dignity or treat the resident with consideration and respect. On 3/4/14, the Administrator and multiple staff entered Resident #2's room and packed away the resident's personal belonging without allowing the resident to make any decisions or be allowed in his/her room as staff removed his/her personal possession. Multiple staff reported the resident got extremely upset, crying, screaming, anxious, and staff reported being concerned for the resident's health and wellbeing due to the Administrator's harassing tactics. Staff reported the Administrator directed staff to keep Resident #2 out of his/her room against his/her free will and yelled at the employee when the resident returned to his/her room. Resident #2's family member reported it's as if the Administrator bullied his/her loved one. The Administrator reported the resident participated in making choices and denied any wrongdoing in her treatment of [REDACTED]. The facility staff acknowledged Resident #2 should have been treated with consideration and respect by the Administrator. Staff interview identified Resident #2 had been upset for a couple days after the incident. The facility identified a census of 80 residents. Findings include: According to a Minimum Data Set (MDS) assessment form dated 1/23/14, Resident #2 had the following Diagnoses: [REDACTED]. The MDS assessment determined Resident #2 required one staff to assist with transfers, bed mobility, personal hygiene, and he/she did not walk in his/her room or on the unit during the 7 assessment period. The test for balance identified Resident #2 was not steady and only able to stabilize his/her balance with staff assistance when moving from seated to standing position. The assessment indicated the resident with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which reveals no cognitive impairments. The assessment identified the resident with no mood or behavior problems. According to a Care Plan with a care conference dated 1/29/14, the resident could have been verbally aggressive and resistive to assistance (dated 11/20/13). The approaches included the following: a. 1:1 intervention as needed (PRN). b. Assess for safety awareness PRN. c. Monitor for significant mood/behavior/cognitive changes. d. Maintain a consistent daily routine as much as possible. e. The resident hoarded items in his/her room (example food, papers and plants: Staff would assure no out-dated or rotted items were left in the room. (dated 3/5/14). According to an Admission Agreement dated and signed 11/22/11, the facility and the resident's agreement included the following: a. The facility reserved the right to limit the personal effects the residents brought into the facility. b. The facility had been unable to exercise complete control over the resident's personal effects, and therefore the facility should not be responsible for loss or damage to said personal effects not occasioned by the negligence of the facility. During an interview on 3/27/14 at 3:45 p.m., Resident #2 stated he/she could not recall the date, but the Social Services worker, Administrator, Director of Nursing (DON), Environmental Supervisor and Maintenance Supervisor entered his/her room and started to pack up his/her belongings while throwing his/her items into boxes. Resident #2 reported he/she did not get to choose the items to retain in his/her room and staff did not allow him/her to be present during the downsizing process. According to the resident, the staff told him/her to go away and that he/she had only been in the way. The resident indicated his/her belongings were now stored downstairs in the facility. During the conversation the resident indicated the previous Saturday he/she had been invited to a baby shower and wanted to get dressed up however his/her dress clothing had been stored downstairs locked up in the office of the Maintenance Supervisor and no other staff member had the key so the resident could not access his/her clothing. At that point the resident became teary and cried stating his/her belongings may not mean anything to them (the facility) but the items had been his/her stuff and meant a lot to him/her as he/she continued to cry. During further interview on 4/1/14 at approximately 3:30 p.m., the resident indicated he/she had not given the Administrator permission to remove any of his/her personal items at her discretion and without the resident's prior approval. During an interview 4/1/14 at 1:30 p.m., the Social Services Worker (SSW) indicated she participated in conversations with the resident prior to the downsizing event to inform the resident he/she would eventually get a roommate and also offered to assist him/her to pack up some of the belongings. However, every time she offered her assistance, the downsizing was not a priority for the resident (the record contained no documentation present to validate these interactions/conversations). The SSW stated the Administrator brought it to her attention that she spoke with Resident #2 before the event and received permission by the resident to downsize his/her belongings at her own discretion. The day the downsizing occurred, the Administrator asked Staff L, Activities to take the resident to an activity but the SSW could not say if the resident wanted to go or not. At that point, the DON, Administrator, Environmental Services Supervisor, Maintenance Supervisor and herself entered the resident's room as the Administrator explained the plan to the resident. When the staff were packing the resident's items the resident kept asking where his/her things were going and seemed upset and anxious based on the resident's facial expressions. At that point, the Administrator told the resident it would have been best if the resident was not present during the downsizing process and SSW felt the resident had not been happy based on his/her body language. Staff L then removed the resident from the room as the resident periodically returned and at one point took a picture of his/her spouse and other odds and ends off of the cart. When he/she removed the items he/she raised his/her voice and got upset but the staff continued to pack the resident's personal belongings anyway. The removed items were taken downstairs in boxes on a cart and locked up in an office. The SSW indicated she felt the downsizing could have been handled differently based on the resident's reaction to the event. During an interview 4/1/14 (time unknown), the DON indicated the Administrator informed her she had spoken with the resident and the resident's family member and the resident agreed to the Administrator removing his/her personal belongings of the Administrator ' s choice. The day of the incident the Social Services worker, Administrator, Maintenance Supervisor and the Environmental Services Supervisor were already in the resident's room packing his/her belongings when she entered the room at which point the resident had been present and verbally screaming, " this is my stuff and very upset " . The Administrator requested Staff L come to the resident's room and remove him/her. The resident came back into the room a couple times and continued very upset as the staff continued to pack the belongings. At one point the Administrator yelled at Staff L saying I thought I told you to take him/her out of here. The resident then went outside the facility utilizing the door by the reception desk with Staff L accompanying him/her and stayed out there approximately 20-30 minutes as the staff continued packing. The staff member indicated when the resident kept returning to the room the Administrator became more agitated with the resident and raised her voice when speaking with him/her which caused the situation to escalate however she never had a fear for the resident's physical condition. During an interview 3/28/14 at 8:15 a.m., the Assistant Director of Nursing (ADON) indicated when she first became aware of the situation she had been at the Ambassador nurse's station when she observed the resident in the area totally upset, yelling, screaming and balling his/her eyes out. The staff member could not remember the exact words utilized by the resident however he/she verbalized they were taking all of his/her stuff. The staff member walked down to the business office and as she walked past the resident's room she observed the Administrator, Environmental Services Supervisor and the DON in the resident's room packing his/her belongings. The staff member then heard the Administrator say " I need you out of here because all you will do is cause problems. " Since the event staff have been back and forth to the basement retrieving various items removed from the resident's room. Additionally the staff member felt the Resident remained upset because he/she had no choice related to the items removed and was not allowed in the room during the process. The staff member agreed the resident's rights were violated during the process. During an observation 3/27/14 at 4 p.m., the Maintenance Supervisor showed the surveyor the resident's belongs that had been stored in his locked office downstairs. The items were stored in various boxes and etc in no particular order with the clothing items hung on a laundry cart. During an interview 3/28/14 at 10:37 a.m., the Maintenance Supervisor indicated he assisted with the downsizing process by carrying the resident's personal items downstairs however the process of downsizing had already begun when he entered the room. The staff member indicated the resident had been back and forth in the room during the process, the resident as given choices of what he/she wanted removed from the room, the resident could have retrieved any items as he/she needed and/or wanted and as the resident having never been happy. During an interview 4/1/14 at 2:26 p.m., the Environmental Services Supervisor indicated she could not remember the exact day but around breakfast she had been told today was the day and as a group the Administrator, Social Services worker, DON and herself walked into the resident's room to remove some of the resident's personal belongings. Originally the staff member indicated the resident as not present but then she changed her mind and confirmed the resident as present when the staff began to pack his/he personal belongings but not participating in the event because the packing of the items became too emotional for him/her so a CNA removed the resident for breakfast. At that point, the staff member left the room to continue with her housekeeping duties until she had been called back and removed the laundry cart full of the resident's clothing and trinkets and proceeded to wheel the cart downstairs. The staff member indicated she later returned to the resident's room and assisted him/her to rearrange the room and look for specific items like remotes. The staff member denied the resident verbalizing discontent over the removal of the belongings and felt the situation had been handled correctly. During an interview 3/28/14 at 9:30 a.m., Staff L (activities ) indicated on Tuesday afternoon just before bingo she had been called to the Administrator's office with the Administrator and the Social Services worker present and told she needed to distract the resident during the removal of his/her personal items due to the stress the process may cause the resident and they wanted the resident kept busy until they called. As the staff member assisted the resident to leave the room the resident had not liked it and started crying when she observed staff going through his/her stuff just throwing items into boxes with no organization. At first the Administrator allowed the resident to stay with the clothing but as he/she started yelling and became more upset the Administrator wanted the resident removed. The resident then utilized his/her motorized wheelchair, left the room and went outside the facility door by the receptionist's desk into the cold weather without a coat. The staff member indicated she had been scared for the resident and wanted to help him/her so she followed the resident outside where the resident remained for about 15 minutes. When they returned into the facility the process had been completed. The staff member verbalized discontent with having been put in that position but she was forced to remove the resident. She also felt the entire situation could have been avoided if the resident had been allowed to have been involved in the removal of his/her personal items. During an interview 3/28/14 at 1 p.m., Staff N, Business Office indicated on Tuesday March 4th, 2014 between 10:30 and 10:45 a.m. she heard commotion and the resident crying and yelling. The staff member knew the Administrator had not allowed the resident into his/her room as he/she sat in the hallway saying " they are taking my stuff away " . The staff member felt the circumstance had been very traumatic for the resident and feared he/she might of had a [MEDICAL CONDITION]. The staff member then stood in the hall by the door and observed staff just throwing items into boxes, placing the boxes on a cart and the Maintenance Supervisor take the cart downstairs. The staff member knew the resident had been informed on Monday he/she had until Friday to pack up some of her personal items but rather went into his/her room on Tuesday and packed and removed his/her personal items. The staff member confirmed she felt the resident had not been treated with dignity and respect and that no one should have been treated in that manner. During an interview 4/1/14 at 4:10 p.m., Staff O, Administrative Assistant indicated she could not recall the day but sometime in the afternoon around bingo time the Administrator asked her to call Staff L and the previous Activity Director to the office. The Administrator then told Staff L to distract the resident by taking him/her into an activity or outside. As Staff L took the resident to bingo the resident observed the Administrator, DON and the Social Services worker go into his/her room and proceeded to call the Maintenance Supervisor and Environmental Services Supervisor to the room as well. The staff member had been unaware of how long the resident remained at bingo before he/she returned to his/her room and observed the Administrator, DON and the Social Services worker going through his/her belongings. The staff member over heard the resident yelling at the staff asking them what they were doing. The resident became extremely upset as he/she propelled his/her wheelchair up and down the hallway. The staff member felt the entire incident had been draining on the resident to the point she feared the resident may have a [MEDICAL CONDITION]. Although the staff member denied hearing the conversations that occurred in the room due to the door having been shut at one point she did enter the room as the DON had a telephone call. Upon entry she observed staff throwing items in the garbage but could not recall what and also throwing other items into boxes and taking them downstairs. The staff member confirmed she felt the situation had not been handled in-appropriately as the resident had originally been given a few days to down-size his/her personal items on his/her own. The staff member knew the resident started removing envelopes, magazines and etc., because she took the items outside to the waste receptacle herself. During an interview 4/2/14 at 11:05 a.m., Staff P, Registered Nurse (RN) indicated the day the resident's room had been downsized she observed the Administrator in the doorway of the resident's room telling the resident things were going to be done as the resident screamed back at the Administrator. Staff P observed the resident propelling his/her wheelchair up and down the hallway very upset at which time she had been worried about the resident's health condition. The staff member expressed disagreement with the situation as the facility had not been filled to capacity and no waiting list had been present for residents who may have requested to move into the resident's room. Staff P confirmed the resident acted upset for days following the event. During a family interview 4/3/14 at 9:20 a.m., a family member indicated he/she knew his/her mother/father would eventually receive a roommate which obviously meant the resident would have to down-size. However, the family member had not been informed when that occurred. Additionally, the family member denied giving the Administrator permission to remove items from Resident #2's room without him/her present and making decisions and at the facility's own discretion. The family member felt the Administrator had bullied his/her family member. Review of the March 2014 Activity Schedule, on March 4th at 2 p.m. bingo had been scheduled. During an interview 4/3/14 at 8:45 a.m., the State Climatologist confirmed the climate conditions on 3/4/14 at 2 p.m. in the Des Moines/Norwalk area as follows: a. 30 degrees. b. Wind Southeast at 10 miles per hour. c. A wind chill of 21 degrees. d. Mostly cloudy conditions. e. 3 inches of snow on the ground from 4/1/14. During an interview 4/3/14 at approximately 12 p.m., a Corporate Nurse and Staff N indicated the facility's census on 3/4/14 as 70 with the facility licensed for a total of 101 residents. A written statement provided by the Administrator on 4/25/14 documented the following: Myself, Staff A the Social Services person, Activities Assistant, DON, Staff E the maintenance and Staff D were present during the process. Prior to my leadership, the staff, including Staff D and the previous Maintenance Director had already been taking the resident's items to a Norwalk storage unit to make accommodations for a new roommate and stop the hoarding. Staff A and my-self went through the move with him/her, item by item and where the furniture was going to be placed with the resident's permission prior to the process. The resident is in an electric wheelchair (scooter) and controls the device on his/her own and can come and go as he/she pleases. The resident participated in the move and directed what he/she wanted left in his/her room and knew what was being stored in the unit for him/her. Staff A went through Resident #2's jewelry with him/her. The Administrator went through his/her clothes with Resident #2 and he/she decided what to keep in there for spring/summer and took down his/her fall/winter clothes. Resident #2 came and left several times during the process and assisted us in putting items away along with telling us which book belonged to the library and etc. The resident was pleased verbally with the outcome of the room and was again shown where everything was as a reminder. After the resident found out that the roommate he/she thought he/she was getting did not want to move into his/her room he/she was upset. The items in his/her room could not be taken to the Norwalk storage anymore as the family member stopped paying the storage payment. We allow his/her items to be stored in the secured unit in the community. The resident's family member was worried about how many items the resident was purchasing and writing bad checks on a checking account. The resident's family member wanted to close the account and did after the family member and the resident requested the Administrator become representative payee and signed the paperwork. The resident was behind approximately $27,000. in rent and was going to be involuntarily discharged (potentially) and was trying to keep the costs down. The (facility) was simply assisting the resident and family with making the necessary changes for his/her room safety/roommate situations/and removing hazardous unsafe items found such as out dated food and etc. The resident participated in the move and was part of the move and decisions. During an interview with the Administrator on 4/25/14 from 9:50 a.m. to 10:40 a.m. she reported the following: the downsizing began in her office as part of the planning and reorganizing of the room as the resident had a history of [REDACTED]. The Administrator reported the ADON and Maintenance had started the process in the room we have been talking about because they knew it was going to be a big deal for Resident #2. The Administrator said Resident #2 came to her office and gave permission to begin downsizing. The Administrator thought the items were going to go to the storage garage but the family member told the Administrator they no longer had the storage unit and the items would go to the basement. She said when she spoke to Resident #2, Staff A, the Social Worker was taking notes as they spoke with Resident #2 out positioning furniture in her room and that Resident #2 made the decision of where his/her bed would be located. The Administrator said she was on vacation the day the resident moved into Resident #2 ' s room and they felt Resident #2 and the roommate would get along well as both liked the same things. Additionally, the Social Worker had spoken with Resident #2 before the new roommate was moved. The Administrator indicated the day of the downsizing, she was in her office with Resident #2 and described him/her as nervous and anxious. The Administrator said that Staff A and herself headed to Resident #2's room and talked to Resident #2 and he/she agreed with the downsizing. They got the maintenance staff to assist while Resident #2 was still in the room. Resident #2 was normal (not crying and was just him/her(self). The maintenance, housekeeping, and Staff L with activities were present as the Administrator went through Resident #2's closet with him/her present. Resident #2 asked the Administrator if the clothing could be kept in the Administrators office because the Administrator had a closet. The Administrator told Resident #2 it would be better to put the clothing on a rack and keep them in the basement. Staff A and Resident #2 went through his/her jewelry and then went through the TV cart while Resident #2 was asked what items she would like to keep. The Administrator stated Resident #2 got teary eyed so she knelt down by Resident #2 and said, do you trust us and Resident #2 said "yes". She then asked Resident #2 if it would be better to go to bingo while the process was going on so Staff L escorted Resident #2 to bingo but Resident #2, kept coming back and forth from activities to the room. The Administrator stated Resident #2 had been behind in payments at the facility in the amount of $27,000. Resident #2 still had land so he/she would not qualify for assistance and went onto describe the financial and family dynamics. The Administrator again described that Resident #2 showed anxiety because the resident's room was smaller but he/she never asked the staff to stop the downsizing process. The Administrator said the DON, Staff A and herself were always together when talking to Resident #2. The Administrator said that Resident #2 would change his/her mind about items stored in the basement and the facility had put it on his/her care plan that if he/she wanted something brought up, then at another time the item would have to go back downstairs. After the downsizing occurred the room was cleaned and dusted and when Resident #2 returned to his/her room he/she told the Administrator the process had turned out better than expected. The Administrator indicated Resident #2 wanted a picture changed to another wall in his/her room and that was done. The Administrator confirmed at one point in the process, Resident #2 did go outside for air. The Administrator stated the downsizing began the day Resident #2 gave permission. The facilities Resident Rights form included the following: a. Each resident maintained the right to have been informed of and participate in the planning of their care and treatment and any changes in their care and treatment. b. The residents had the right to have been free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. c. The facility must care for you in a manner and environment that enhanced or promoted your quality of life. d. The facility staff would treat you with dignity and respect in full recognition of your individuality. e. You may choose your own activities, schedules, health care and any other aspect significant to and affecting your life within the facility. f. You have the right to have received services with reasonable accommodations to individual needs and preferences. g. You have the right to make choices about aspects of your life in the facility that would have been important to you.

Based on record review the facility failed to assess and monitor bowel regimen and provide timely interventions by administering laxative and suppositories according to facility bowel policy (Resident #15,#18, #20) and failed to assess a resident (Resident #16) when it was discovered the resident had a change in condition. The sample consisted of 5 residents and the facility reported a census of 80 residents. Findings include: 1. Resident #15 had an admission Minimum Data Set (MDS) assessment with a reference date of 8/24/12 which identified [DIAGNOSES REDACTED]. The Certified Nurse's Aide (CNA) Documentation sheet dated August 2012, documented the resident did not have a bowel movement on August 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31, 2012. Across the top of the CNA Documentation sheet and above August 20, and 22, written indicated Milk Of Magnesia (MOM) given. Across August 28, hand written is -yes per resident statement. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR indicated [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Nurse's Notes dated 8/31/12, at 6 AM documented upon reviewing the Bowel Movement (BM) log the resident has had no BM charted for several days. The resident's abdomen is distended, hard and the resident complained of abdominal pain, rated a 10 on a scale of 10 and bowel sounds are hypoactive. A phone call to the physician and received new orders for enema now and Milk Of Magnesia 30 milligrams by mouth every day. Enema given at 5:40 AM, awaiting results, no nausea or vomiting, resident's temperature is 98.5. The Nurse's Notes dated 8/31/12, at 9:15 AM documented orders received per physician to send to the emergency room to evaluate and treat abdominal pain. The Resident Transfer Form dated 8/31/12, documented the resident had as small BM after an enema at 5:30 AM. The resident is yelling out in pain holding his/her abdomen. The resident's last BM 8/28/12. The Hospital History & Physical report dated 8/31/12, documented the resident was admitted from the care center for abdominal pain, constipation, no BM since 8/28/12. The elderly resident is mildly confuse and complains of left sided rib cage pain from a recent fall. The abdominal CT scan showed a moderately large amount of stool in the right colon. Constipation is worsened by pain medications. The left rib x-ray showed no fracture but question a contusion. Anticipate a stay of 1-2 days. 2. According to the MDS dated [DATE], Resident #20 had [DIAGNOSES REDACTED]. The MDS documented the resident's BIMS score 0 of 15 and with long and short term memory problems. The MDS documented the resident as non ambulatory and depended on staff for all care. a. CNA Documentation sheet dated July 2012, documented Resident #20 with no BM on 7/4, 7/5. 7/6, 7/7 and 7/8. No BM on 7/15, 7/16, 7/17. 7/18. 7/19 and 7/20. No BM 7/24, 7/25, 7/26, 7/27, 7/28, 7/29, and 7/30. The July 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Milk Of Magnesia Suspension 30 cubic centimeters given on 7/26. The July 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. b. The CNA Documentation sheet dated August 2012, documented Resident #20 with no BM on 8/3, 8/4, 8/5, 8/6, and 8/7. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The August 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The CNA Documentation sheet documented no BM on 8/27/12. 3. According to the MDS assessment dated [DATE], Resident #18, had [DIAGNOSES REDACTED]. The MDS assessment documented the resident non ambulatory and dependent on staff for all activities of daily living. Review of the August 2012, CNA Documentation sheet documented Resident #18, with no bowel movement on August 13,14,15,16. Review of the August 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility Bowel Movement Management policy directed staff to perform the following: a.The CNA documentation form shall include the documentation of Resident's bowel movement every shift. b. The night nurse at the end of the shift shall evaluate the BM documentation records and assess for Resident's BM irregularity. c. Residents who have not had a BM in the last two days shall be given prune juice. d. Residents who have not had a BM in the last (3) days, shall be placed on a list and provided MOM on the (6-2) shift. e. Residents who have not had a BM in four days shall be given a suppository. f. If the Resident doesn't have results from the suppository the day shift nurse shall assess the Resident. The assessment may include the Resident's cognitive status, behavior, abdomen status, pain, bowel sounds, temperature, and appetite and shall include a rectal exam. This shall be documented in the Nurse's Notes. g. If appropriate the Resident shall be given fleets to promote bowel evacuation. h. If a Resident does not have results from the fleets enema the Physician shall be notified for further orders. 4. According to the MDS assessment dated [DATE], Resident #16 had [DIAGNOSES REDACTED]. The MDS documented the resident as non ambulatory with severe cognitive impairment, long/short term memory problems and dependence on staff for all activities of daily living. The Admission Nursing assessment dated [DATE], documented Resident #16 had a [DIAGNOSES REDACTED]. The Nurse's Notes dated 8/21/12 at 3 AM documented the resident rested quietly in bed until approximately 1 AM., then CNA found the resident had pulled his/her [MEDICAL TREATMENT] catheter from his/her neck. Pressure applied with minimal bleeding noted. No bruising, hematoma noted at this time, pressure applied. The resident is combative during cares and pulled at his/her urethral catheter. A call placed to the physician with no new orders. Scheduled [MEDICATION NAME], and as needed [MEDICATION NAME] given with minimal decrease in restlessness. One on one supervision provided, will continue to monitor. The Nurse's Notes dated 8/21/12, (no time documented) documented physician orders [REDACTED]. The Nurse's Notes dated 8/21/12, at 6:30 AM documented blood pressure 149/75, pulse 76, respirations 46, temperature 97.9 and pulse oximetry at 93 % on room air. The Nurse's Notes dated 8/21/12, at 12 AM documented blood pressure 128/73, pulse 86, temperature 98.9, respirations 16 and pulse oximetry 935 on room air. The resident continues with increased restlessness, taking off his/her clothes, pulling out Foley catheter. A small amount of tea colored urine noted in the drainage bag. Band-Aid to right chest changed with minimal bleeding noted. Routine [MEDICATION NAME] and [MEDICATION NAME] given with minimal relief. The resident is sleeping intermittently for short periods of time. The Nurse's Notes dated 8/22/12 at 9:30 AM documented blood pressure 104/55, pulse 80, respirations 18, temperature 97.1 and pulse oximetry 94% on room air. The resident is oriented to self, with no restlessness or increased anxiety. The resident is resting calmly in the reclining wheel chair in the TV lounge area at this time. No behaviors noted so far this shift. Band-Aid to [MEDICAL TREATMENT] catheter site changed and intact. The resident displays no signs of pain or discomfort. The Nurse's Notes dated 8/22/12, at 7:53 PM documented the resident is noted without respirations, heart rate, blood pressure. Son, hospice , ARNP notified orders received to release the body to the funeral home. Medications returned to pharmacy. The clinical record lacked any further assessments completed from (9:30 AM until 7:53 PM (10 hours later). On 9/18/12, at 3:50 PM Staff H LPN reported she arrived at work on 8/22/12, at approximately 7 PM. She reported Resident #16 was up in his/her wheel chair in the common area. She reported she came in to pass medications and do blood sugars because Staff C had left. Staff H stated she got report from a sheet of paper left at the Nurse's Station. by Staff C who had to leave early. The report documented Resident #16's pulse oxcimetry was above 90 % and he/she was declining. Staff H reported as she walked by Resident #16 sitting in front of the TV she noticed he/she did not look well, the resident looked pale and had labored breathing. Staff H reported she did not stop because she was helping a CNA get a Resident of the floor after a fall. Staff H stated when she finished assisting the CNA she walked by Resident #16, and placed her hand under his/her shirt to see if their skin was clammy, the skin was dry, respirations were labored and the resident looked pale. Staff H reported the CNA stated he's been like that.

Based on observation, record review and staff interviews, the facility failed to ensure a resident was free of any significant medication errors. The facility failed to give medications and check blood sugar tests as directed by the physician (Resident #23). Concerns were identified for 1 of 28 residents reviewed. The facility reported a census of 80 residents. Findings include: 1. The Admission Record for Resident #23 identified a date of admission to be 9/17/2012. A hospital Discharge Summary dated 9/13/12 noted Resident #23 as admitted to the hospital on [DATE] due to neuroendocrine malignancy with a medical complication of respiratory insufficiency and other pertinent [DIAGNOSES REDACTED]. The physician assessed this resident as in a very debilitated state. Operations/Procedures Performed dated 8/31/12 included distal pancreatectomy, splenectomy, bilateral adrenalectomy, enucleation of four nodules from the liver, and radio frequency ablation of nine liver masses. The 24 page SNF (skilled nursing facility) referral found in the resident's record noted the resident was five foot tall and weighed 197 pounds. The referral noted the resident ' s current pneumonia needed to be cleared prior to surgery that would allow a reduction in [MEDICATION NAME] levels and to regain function. The current medications on the pre-admission referral dated 9/7/12 included: [MEDICATION NAME] (prevents [MEDICATION NAME] spasms for asthma and [MEDICAL CONDITION]) inhaler twice daily, Vitamin D3 daily, [MEDICATION NAME] injection ([MEDICAL CONDITION] every 12 hours, [MEDICATION NAME] (diuretic) daily, [MEDICATION NAME] (pain) as needed, Insulin twice daily, Insulin three times daily ([DIAGNOSES REDACTED]), [MEDICATION NAME] twice daily ([DIAGNOSES REDACTED]), [MEDICATION NAME] (for hypertension) daily, [MEDICATION NAME] (anti-anxiety) as needed, [MEDICATION NAME] (Diabetes) twice daily with meals, Nicotine patch, Sandostatin injection (for tumors) every four weeks, [MEDICATION NAME] injection three times daily, [MEDICATION NAME] (antipsychotic) every bedtime, [MEDICATION NAME] ([MEDICATION NAME]) every 12 hours, [MEDICATION NAME] three times a day with meals, Potassium, [MEDICATION NAME] (Adrenal Cortical Insufficiency) twice daily, [MEDICATION NAME] (diuretic daily), and [MEDICATION NAME] (anticoagulant) daily. This referral also noted this resident received a blood transfusion on 9/6/12. The resident ' s temperature registered 97.9 degrees Fahrenheit. The resident's abdomen was soft, with large striae throughout, subcostal incision was well approximated, drain with serous fluid, mildly distended, slightly more tender to palpation in the right side of the abdomen. The wound was clean, staples and retention sutures were in place. The resident ' s blood sugar on 9/7/12 at 6:15 a.m. tested 197. The resident received sliding scale insulin. The resident ' s current condition included metastatic neuroendocrine tumor. The admission orders [REDACTED]. The physician's orders [REDACTED]. twice daily. The physician orders [REDACTED]. A Nurse's Note dated 9/17/12 at 1:45 p.m. indicated the resident was transported by the county fire department and admitted to the facility. The resident exhibited shortness of breath, had coarse lung sounds and used oxygen at 2 liters per minute by nasal cannula. The nurse ' s note indicated the resident had an appointment on 9/19/12 in Iowa City. The Warren County Health Services would fax the physician the results of the resident ' s blood/laboratory tests taken that day. The physician and pharmacy was notified of the admission. The next Nurse's Notes dated 9/17/12 at 6:00 p.m. noted new orders received for an antibiotic medication due to pneumonia. The physician, resident and pharmacy notified. The next Nurse's Notes dated 9/18/12 at 7:00 a.m. noted resident resting quietly at this time. The next Nurse's Notes dated 9/18/12 at 8:00 a.m. noted the nurse received a call, informing her of this resident's abnormal laboratory values. The resident's temperature registered 101.7 degrees Fahrenheit, heart rate of 126, respirations 24 (normal 16-20), staples intact, bowel sounds times four, serousanguanious drainage noted right abdomen, and bilateral [MEDICAL CONDITION]. The resident had hemoglobin of 7.0 (low). The next Nurse's Notes dated 9/18/12 at 8:10 a.m. indicated staff placed a call to the resident's primary physician, noting increased temperature and blood value. The physician provided a new order to send the resident to the emergency room for an evaluation. A Nurse's Notes dated 9/18/12 at 10:00 a.m. had documentation of: " Late entry Dr. Miller notified that patient didn't get HS (bedtime) and am (morning) medications at 8:10 a.m. A Nurse's Notes dated 9/18/12 at 2:30 p.m. noted the resident's primary physician's office telephoned and reported the resident as admitted to Mercy Intensive Care Unit. Review of the resident ' s record including nursing notes and medication and treatment records lacked any documentation to show the nurses checked the resident's blood sugar prior to meals as ordered and the nurse failed to give the resident insulin, oral medications and other injections, and TB test as ordered, with the exception of the one new antibiotic. The Resident Transfer Form dated 9/18/12 noted the resident did not receive any morning medications. This form failed to include the failure to give this resident any afternoon and evening medications the day prior and including the prescribed steroids and insulin. A Medication Error Report dated 9/20/12 noted on 9/17/12 at bedtime this resident failed to receive any bedtime medications including [MEDICATION NAME], [MEDICATION NAME], Senna, [MEDICATION NAME], and [MEDICATION NAME]. Outcome to resident: no increased pain, alert and oriented times three and no shortness of breath. A hand written note dated 9/21/12 by Licensed Practical Nurse, Staff F noted on 9/17/12 Staff F admitted Resident #23 to the facility. The nurse completed the resident ' s assessment and notified pharmacy by a fax report. Staff F reported off to the oncoming nurse and asked the oncoming nurse (Staff J) to complete the skin assessment and TB test. Staff F denied receiving any fax or phone call from the pharmacy stating they did not receive the orders she had sent. An undated hand written statement by Staff J (Registered Nurse) indicated on 9/17/12 he received report on the beginning of his shift that the medication orders had been faxed to the pharmacy. At approximately 6:30 p.m. he gave this resident an antibiotic due to a telephone call from the physician noting pneumonia. Shortly afterwards, he received as needed medications from the pharmacy. He was expecting the pharmacy to deliver the rest of the resident ' s medications. At approximately 1:30 a.m. he called the pharmacy to see where the medications were. Staff J was informed the pharmacy only received the third page of the orders. Staff J faxed the orders to the pharmacy. Staff J never received the medications from the pharmacy by the time he left at 6:15 a.m. On 9/24/12 at 3:20 p.m. the Administrator and the Director of Nursing was interviewed and stated they had received all the information regarding this resident from the hospital. On 9/17/12 the facility received a phone call from a home care agency stating the resident had discharged from the hospital, had gone home, was not doing well and needed to be admitted to the facility that day. The facility still had all the information from the hospital so they agreed to admit the resident that day. The resident came to the facility about 2:00 p.m. and was admitted by a Licensed Practical Nurse (Staff F). Staff F worked that day from 6:00 a.m. to 6:00 p.m. At 6:00 p.m. a Registered Nurse (Staff J) came on duty. The facility used a pharmacy service that normally delivered medications around 10:00 p.m. to 10:30 p.m. That evening the pharmacy only delivered this resident ' s as needed medications. Around 1:00 a.m. the next morning, Staff J telephoned the pharmacy and learned the pharmacy only received orders for the as needed medications, not for the routine medications. The pharmacy only received one of the three pages of physician orders. The facility could not find their confirmation of the fax. On 9/17/12 at 4:38 p.m. the pharmacy had sent the facility a fax asking about the resident ' s orders; however both Staff F and Staff J deny seeing this fax. The facility policy directed the nurses to check the fax machine for new faxes. At 2:00 a.m. on 9/18/12, Staff J then sent the pharmacy all three pages of the resident ' s admission orders [REDACTED]. The Director of Nursing found out about the error on 9/18/12 and began an investigation to see why this resident did not receive the medications as ordered. The Director of Nursing verified the resident did not receive the prescribed [MEDICATION NAME] as ordered and stated they did keep [MEDICATION NAME] in the facility emergency kit. On 9/18/12 the resident had an elevated fever and had abnormal blood values and was sent to the emergency room . The resident did not return to the facility. The Director of Nursing stated no disciplinary actions were given regarding the nurses ' failure to check this resident ' s blood sugar as ordered and failed to give this resident his/her medications including insulin and steroids as ordered. The Director of Nursing stated the facility received the returned, signed physician orders [REDACTED].) The Director of Nursing stated she talked with the resident ' s physician who told her not to feel bad, due to errors happen. A Nurse's Notes labeled DON Investigation dated 9/18/12 noted the Director of Nursing (DON) talked with a surgical oncologist at the University Of Iowa hospital on [DATE] at 11:30 a.m. who stated this resident's [MEDICATION NAME] level was critical. The physician noted various factors that could contribute to a critical [MEDICATION NAME] level. The physician noted this resident was very obviously progressively becoming ill as indicated by Mercy Hospital records. When interviewed on 9/25/12 at 2:26 p.m. a pharmacy supervisor stated she has researched this situation with Resident #23. The pharmacy has an online system in place that shows on 9/17/12 they only received two pages from the facility regarding this resident. The first page was their standing orders and the second page was only the as needed medications. The pharmacist questioned these orders so they attempted to call the facility to ask why they only received two pages and did the resident have orders for routine medications. Their phone calls went unanswered so they then sent the facility a fax asking them to clarify the orders. They did not get a response to their fax. The after-hour pharmacy then received a phone call around 8:00 p.m. regarding the new antibiotic order. The facility was instructed to use the antibiotic from the emergency kit. The facility then called the pharmacy on call about 2:00 a.m. at which time the facility staff was asked to fax all pages of the resident's orders. The on call pharmacy then called this pharmacist who had to call an on call physician to verify the new orders, due to two of the orders were for controlled substances. Then they gave these new orders to Walgreens to fill and deliver to the facility. The medications were delivered and signed for on 9/18/12 at 8:50 a.m. This pharmacist stated their pharmacy does stock the facility's emergency medication kit and they do keep [MEDICATION NAME] in the emergency kit, so the nurse could have given this resident [MEDICATION NAME] at bedtime as ordered. When interviewed on 9/25/12 at 2:10 p.m. the Licensed Practical Nurse, Staff F stated she admitted this resident to the facility on [DATE]. She stated she hand wrote out the orders for this resident to send to the pharmacy and to this resident's physician. She verified the hand written orders included to check this resident's blood sugar between 4:00 p.m. and 5:00 p.m. Staff F denied knowing any reason why she failed to check this resident's blood sugar. Staff F stated this resident was anxious on admission and Staff F reassured the resident the staff would care for him/her as best they could. Staff F verified they did not check this resident's blood sugar that night as ordered and the resident did eat supper that night. Staff F stated she did not give this resident any medications that night prior to supper due to the medications had not come in from pharmacy. Staff F stated she was busy that night due to the new admission. She stated the normal routine for a new admission is they do not receive any of their medications until after the pharmacy delivers the medications and it is usually later at night when they come. Staff F stated when she sends a fax she does get a verification however she did not keep the verification of the fax that day. When interviewed on 9/25/12 at 2:20 p.m. a Registered Nurse, Staff J stated on 9/17/12 he was informed in report at 6:00 p.m. of this resident's new admission and the day nurse had asked him to finish the skin assessment and to do the TB test. Staff J stated he knew the physician orders [REDACTED]. He denied knowing this resident had an order for [REDACTED]. Although he faxed the orders, he did not read this resident's physician orders [REDACTED]. Staff J stated they did not administer the TB test as requested due to the resident had an infection and just started on an antibiotic. Observation on 9/25/12 at 5:20 p.m. revealed the emergency medication lock boxes both in the front nurse ' s station and also in the back nurse ' s stations both contained the insulin [MEDICATION NAME]. A Hospital Iowa EMS Report dated 9/18/12 read, "Patient was brought to ER (emergency room ) today with fever of 101.7 degrees Fahrenheit and was hypotensive with blood pressures initially in the 70-80 systolic range. [MEDICAL CONDITION] of pancreas that has spread to liver and had surgery at the U of I Hospital. Patient was discharged from there on the 13th of this month and returned to nursing home for continued care. Patient has developed pneumonia of right lower lobe and wasn't taking all the meds needed. Patient was brought to ER by ambulance due to fever. Upon arrival at hospital, it was noted that patient was also hypotensive. Patient [DIAGNOSES REDACTED]. Patient is being transferred to U of I Hospital for further care and is being transported by ambulance due to need for continual monitoring with patient having low blood pressure." Patient asked for pain medicine due to back, lower abdominal pain from lying position. [MEDICATION NAME] (narcotic) given as noted. A physician's Consultation report dated 9/18/12 noted resident with metastatic [MEDICAL CONDITION] status [REDACTED]. At the skilled nursing facility, the patient had an episode of [MEDICAL CONDITION] and lightheadedness and fell . (He/she) is currently complaining of abdominal pain and has been having weakness and fevers over the last couple of days. Assessment included blood pressure measured 87/56, heart rate: 95, resident obese, lethargic and confused. There were diffuse inspiratory and expiratory wheezes with decreased breath sounds noted. CT revealed a near complete collapse of the right middle lobe (lung) and fluid and gas collection in the left upper quadrant suspicious for abscess. Impression included: [MEDICAL CONDITION], adrenal crisis and probable intraperitoneal abscess. The resident will transfer to the University of Iowa to the surgical intensive care unit upon arrival.