Every finding on record at Riverside Health & Rehabilitation Center

Based on review of the clinical record, facility documentation/policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for skin impairments, the facility failed to ensure changes in the resident's skin condition were identified, reported, and evaluated in accordance with facility policy. Multiple NAs observed bruising and swelling to the resident's right groin and upper inner thigh beginning on the day of admission and on multiple subsequent dates but failed to report the findings to licensed nursing staff. Additionally, the licensed nurse responsible for the weekly Skin Check on 7/9/26 signed the assessment as complete despite not visualizing the right inner thigh and groin area. The findings include:Resident #1's diagnoses included cerebral palsy (lifelong conditions that affect movement, balance and posture due to damage to a developing brain), intellectual disabilities, difficulty in walking and age-related osteoporosis without current pathological fracture.The admission Evaluation by RN #1 dated 6/30/26 identified Resident #1 was alert and oriented to person, place, time and situation, required partial assistance with bed mobility and substantial assistance for transfers and ambulation and identified there were no skin issues present on admission.The Resident Care Plan (RCP) dated 7/1/26 identified Resident #1 had the potential for skin breakdown due to refusals to ambulate, impaired mobility, diagnoses of cerebral palsy and seizures, reported incontinence, right knee pain and a Braden score identifying Resident #1 was at risk for pressure ulcers. Interventions included completing skin checks with care and reporting any changes to the licensed nurse, turning and repositioning every two (2) to three (3) hours and/or as tolerated, completing weekly skin evaluations and updating the provider with any changes.The Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 7/1/26 identified Resident #1 was at risk for developing pressure ulcers.A provider note by APRN #1 dated 7/1/26 at 8:15 AM identified Resident #1 was sent to the Emergency Department (ED) on 6/28/26 following a fall at home with right knee pain and gait instability. Resident #1 refused to bear weight despite an unremarkable workup, including a negative right knee x-ray and CT of the head (imaging that uses x-rays and computer to make detailed imaging of the brain, skull and sinuses), the gait instability was thought to be behavioral in nature and Resident #1 was admitted to the facility on [DATE]. On assessment, there was no joint pain or stiffness, no muscle pain, no limited range of motion, no weakness, the skin was warm and dry with no skin discoloration and no bruising or lesions. The note directed monitoring for changes in condition and to notify the provider of acute changes.Review of nurse's notes dated 7/1/26 though 7/7/26 failed to identify any skin abnormalities or changes to Resident #1.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 7), was dependent on staff for bed mobility and transfers, and ambulation had not been attempted due to safety concerns. No skin impairments were identified, Resident #1 reported occasional moderate pain.Review of nurse's notes dated 7/8/26 through 7/9/26 failed to identify skin abnormalities.A Skin Check by RN #2 dated 7/9/26 identified skin was warm and dry, skin color was within normal limits with normal skin turgor, and no skin issues were identified.A provider note by APRN #1 dated 7/10/26 at 10:00 AM identified Resident #1 was seen emergently for evaluation due to continued right hip pain with new associated large bruising and swelling to the abdomen and groin area. Resident #1 had visitors when Resident #1 complained of increased pain to the right hip and right lower extremity and large bruising with swelling was noted. History was limited due to intellectual disabilities. On examination, a large area of ecchymosis (skin bruising) was noted to the lower abdomen, most being right sided and a large area of ecchymosis was noted to the right groin/right upper thigh. The areas were not tender to touch and some edema was noted to the right upper thigh in the area of the ecchymosis. APRN #1 identified it was the first time she observed the ecchymosis areas, identifying it as spontaneous. Right knee and hip pain were the same and there were no concerns that prescribed aspirin was the cause. There was concern for a pelvic fracture. Review of the admission paperwork identified no diagnostic studies had been completed for the hips or pelvis.A Situation Background Assessment Recommendation (SBAR) summary by LPN #1 dated 7/10/26 at 10:15 AM identified Resident #1 reported nine (9) out of ten (10) pain to the right upper inner thigh. On observation, discoloration was noted to the right groin, inner thigh and buttocks, swelling was noted and the area was firm and tender to touch. The APRN was notified and new orders were obtained to transfer Resident #1 to the ED.A Skin Issue Evaluation by the ADNS dated 7/10/26 at 10:49 AM identified new bruising was noted to the right lateral (outer) thigh and it was unknown how long the bruising had been present. The area measured 7.29 centimeters in length by 7.03 cm in width.The Prehospital Care Report (ambulance run sheet) dated 7/10/26 identified dispatch was called at 11:15 AM and arrived at 11:22 AM. Staff reported Resident #1 complained of continuous pain. Upon visual assessment by Emergency Medical Services (EMS) Resident #1 had obvious bruising that went from the outer edges of the genital region down to the back of the knee. The bruising had mostly yellowed, with some purple discoloration closer to the genital region. Resident #1 reported pain worsened on palpation and was as high as a ten (10 out of 10).Review of hospital documentation dated 7/10/26 identified x-rays of the right femur (thigh bone), right hip and right pelvis were obtained due to bruising to the right inner thigh. The x-rays resulted with a displaced comminuted intertrochanteric fracture of the right femur (a break in the upper femur between the greater and lesser trochanters, where the bone is fragmented and the pieces are misaligned).Interview with NA #1 on 8/6/26 at 11:46 AM and review of facility statement identified she worked the 11:00 PM to 7:00 AM shift and was assigned to Resident #1 on 6/30/26, 7/1/26, 7/6/26, and 7/8/26. On 6/30/26, she observed bruising to the right groin and genital area and Resident #1 complained of right hip and leg pain during incontinence care. Resident #1 stated the bruising was from a fall at home. She reported asking a licensed nurse whether Resident #1 had a hip injury due to the bruising and pain but could not recall the date or which nurse she spoke with. She recalled the bruising being yellow in appearance throughout all of her observations of Resident #1.Interview with NA #5 on 8/6/26 at 12:11 PM identified she worked both the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts and was assigned to Resident #1 on 7/2/26, 7/4/26, and 7/8/26. She reported observing large bruising from the right groin to the right upper leg on each of those dates and Resident #1 reported it was from a fall, so she assumed it was present on admission and did not report it.Interview with LPN #2 on 8/6/26 at 12:37 PM identified she worked the 11:00 PM to 7:00 AM shift and was assigned to Resident #1 on 7/1/26, 7/2/26, 7/3/26, 7/6/26, 7/7/26 and 7/8/26. She identified no bruising, discoloration, or swelling of Resident #1's right side was reported or observed by her on those dates. She identified medicating Resident #1 with acetaminophen for pain several times throughout her shifts for generalized pain.Interview with LPN #4 on 8/6/26 at 1:08 PM identified she worked both the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts and was assigned to Resident #1 on 7/3/26, 7/6/26 and 7/7/26. She identified no bruising, discoloration, or swelling of Resident #1's right side was reported or observed by her, and identified she administered multiple doses of acetaminophen for generalized pain.Interview with LPN #3 on 8/6/26 at 1:15 PM identified she worked the 11:00 PM to 7:00 AM shift and was assigned to Resident #1 on 7/9/26 into 7/10/26. She stated no bruising, discoloration, or swelling of Resident #1's right side was reported or observed by her.Interview with LPN #1 on 8/6/26 at 1:27 PM identified he worked the 7:00 AM to 3:00 PM shift and was assigned to Resident #1 on 7/5/26, 7/8/26, 7/9/26, and 7/10/26. He stated no bruising, discoloration, or swelling of Resident #1's right side was reported or observed by him until 7/10/26. When bruising was reported on 7/10/26, he observed mostly yellowed bruising that did not appear new. At that time, Resident #1 complained of seven (7) to eight (8) out of ten (10) pain.Interview with NA #6 on 8/6/26 at 1:30 PM and review of facility statement identified she worked the 7:00 AM to 3:00 PM shift and had been assigned to Resident #1 on 7/3/26, 7/6/26, 7/9/26 and 7/10/26. On those dates, she observed discoloration on Resident #1's right inner thigh and groin but due to a fading appearance, did not report it to nursing staff. She also identified Resident #1 had occasional pain when turned onto the right-side during bed mobility but could not recall which nurse she informed.Interview with APRN #1 on 8/6/26 at 1:56 PM identified she assessed Resident #1 on 7/1/26, including a skin assessment, and did not observe bruising, discoloration, or swelling to the right groin, abdomen, right upper inner thigh, or right hip. Range of motion was not completed to the right lower extremity because Resident #1 did not want to move, but Resident #1 did not complain of pain and did not exhibit signs or symptoms of pain during the assessment. APRN #1 reported she was not aware of any skin changes prior to 7/10/26. She identified that if bruising, discoloration, or swelling had developed after her initial assessment on 7/1/26, a provider should have been notified immediately to prevent a delay in treatment. During her assessment on 7/10/26, APRN #1 observed extensive dark purple bruising to the lower abdomen, groin, right inner thigh, and right hip, with yellow discoloration around the edges. She identified that the bruising was likely related to the fall at home prior to admission and that any bruising, discoloration, or swelling should have been documented upon initial observation.Interview with RN #2 on 8/6/26 at 2:18 PM identified that he worked both the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts and was assigned to care for Resident #1 on 7/1/26, 7/2/26, 7/8/26, 7/9/26, and 7/10/26. He identified that he did not observe or receive reports of bruising, discoloration, or swelling to Resident #1's right side until 7/10/26. RN #2 reported that during the weekly Skin Check on 7/9/26, he was unable to visualize Resident #1's right inner thigh and groin area because Resident #1 kept his/her legs tightly closed. He identified that he did not feel comfortable attempting to move Resident #1's legs to visualize the areas and did not request assistance from another staff member. RN #2 acknowledged that he should have requested assistance to complete the assessment. He further identified that he signed off on the 7/9/26 weekly Skin Check as completed despite not visualizing the right inner thigh and groin areas. RN #2 acknowledged that he should not have signed off on the weekly Skin Check without completing a thorough assessment.Interview with NA #2 on 8/6/26 at 3:00 PM and review of facility statement identified she worked the 11:00 PM to 7:00 AM shift and was assigned to Resident #1 on 7/2/26, 7/3/26, 7/4/26, and 7/9/26. She observed yellowish bruising and slight swelling from Resident #1's right inner thigh to the groin on each of those dates but did not report it to the licensed nurse, believing it was present since admission. NA #2 identified Resident #1 complained of right hip and leg pain during bed mobility.Interview with the DON on 8/6/26 at 3:15 PM identified that before her investigation of the 7/10/26 incident, she was unaware NAs observed bruising to Resident #1's groin and right inner thigh. She identified that if NAs saw bruising or discoloration, they should have notified a licensed nurse rather than assume it was present on admission. Reporting the bruising when first observed would have allowed earlier notification to the provider and prevented a delay in care. She emphasized that Skin Checks must be fully completed, with all skin areas examined. She identified that if RN #2 could not visualize all areas or was uncomfortable moving Resident #1's legs, he should have requested assistance rather than document the Skin Check as complete.Although attempted, interviews with RN #1, RN #3 (Unit Manager), NA #3 and NA #4 were not obtained.Review of the Pressure Injury Prevention Management Program policy dated 3/2023 directed, in part, the licensed nurse is responsible for the completion of the skin assessment on admission using the Nursing Admission/readmission Evaluation. The licensed nurse will document a skin evaluation weekly on the Weekly Skin Check Evaluation and/or Total Body Skin Evaluation. In addition, the NAs are responsible for reporting daily any changes noted regarding assigned resident's skin integrity.Although requested, facility policies for skin impairments and ecchymosis/bruising were not available.

Based on review of the clinical record, facility documentation/ policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for notification of changes, the facility failed to ensure significant changes in the resident's condition were promptly reported to licensed nursing staff and the provider. Multiple staff observed bruising, discoloration, swelling, and/or pain involving the resident's right groin and upper inner thigh on multiple dates beginning on 6/30/26; however, these findings were not consistently communicated to licensed nursing staff or the provider as required. The provider was not notified of these changes until 7/10/26, when extensive bruising, swelling, and severe pain were identified and the resident was transferred to the Emergency Department, where a displaced comminuted intertrochanteric fracture of the right femur was diagnosed. The findings include: Resident #1's diagnoses included cerebral palsy, intellectual disabilities, difficulty in walking, and age-related osteoporosis without current pathological fracture. The admission Evaluation by RN #1 dated 6/30/26 identified no skin issues were present on admission. The Resident Care Plan (RCP) dated 7/1/26 identified Resident #1 was at risk for skin breakdown due to impaired mobility, diagnoses of cerebral palsy and seizures, reported incontinence, right knee pain, and a Braden score identifying the resident as at risk for pressure ulcers. Interventions included completing skin checks with care and reporting changes to the licensed nurse, completing weekly skin evaluations, and updating the provider with changes as needed. A provider note by APRN #1 dated 7/1/26 at 8:15 AM identified Resident #1 had been evaluated in the Emergency Department following a fall at home with right knee pain and gait instability. The note identified no skin discoloration, bruising, or lesions and directed staff to monitor for changes in condition and notify the provider of acute changes. Review of nurse's notes dated 7/1/26 through 7/9/26 failed to identify skin abnormalities or changes to Resident #1. A Skin Check completed by RN #2 on 7/9/26 identified no skin issues. A provider note by APRN #1 dated 7/10/26 at 10:00 AM identified Resident #1 was seen emergently after complaining of increased right hip and right lower extremity pain, at which time extensive bruising and swelling were observed to the lower abdomen, right groin, right upper thigh, and right hip. APRN #1 identified this was the first time she became aware of the bruising and swelling and expressed concern for a possible pelvic fracture. Review of the admission documentation identified no diagnostic studies had been completed on the resident's hips or pelvis. Resident #1 was transferred to the Emergency Department for further evaluation. An SBAR Summary for Providers by LPN #1 dated 7/10/26 at 10:15 AM identified Resident #1 reported 9/10 pain to the right upper inner thigh. Discoloration, swelling, firmness, and tenderness were observed to the right groin, inner thigh, and buttocks. The APRN was notified and orders were obtained to transfer Resident #1 to the Emergency Department. The Prehospital Care Report dated 7/10/26 identified EMS observed extensive bruising extending from the genital region to the back of the knee. Resident #1 reported pain as high as 10/10, which worsened with palpation. Review of hospital documentation dated 7/10/26 identified x-rays of the right femur, right hip, and right pelvis were obtained due to bruising to the right inner thigh. The x-rays identified a displaced comminuted intertrochanteric fracture of the right femur. Interview with NA #1 on 8/6/26 at 11:46 AM identified that on 6/30/26, she observed bruising to Resident #1's right groin and genital area and the resident complained of right hip and leg pain during incontinence care. NA #1 reported asking a licensed nurse whether Resident #1 had a hip injury due to the bruising and pain but could not recall the date or which nurse she spoke with. She recalled the bruising appeared yellow during subsequent observations. Interview with NA #5 on 8/6/26 at 12:11 PM identified she observed large bruising extending from Resident #1's right groin to the right upper leg on 7/2/26, 7/4/26, and 7/8/26. She reported she did not report the bruising because Resident #1 identified it was from a fall and she assumed it was present on admission. Interview with NA #6 on 8/6/26 at 1:30 PM identified she observed discoloration to Resident #1's right inner thigh and groin on 7/3/26, 7/6/26, 7/9/26, and 7/10/26 but did not report it because she believed it was fading. She also observed occasional pain when Resident #1 was turned onto the right side during bed mobility. Interview with NA #2 on 8/6/26 at 3:00 PM identified she observed yellowish bruising and slight swelling extending from Resident #1's right inner thigh to the groin on 7/2/26, 7/3/26, 7/4/26, and 7/9/26. She did not report the findings to the licensed nurse because she believed they were present on admission. She also reported Resident #1 complained of right hip and leg pain during bed mobility. Interviews with LPN #2, LPN #4, and LPN #3 on 8/6/26 identified they did not observe or receive reports of bruising, discoloration, or swelling to Resident #1's right side during their respective assignments prior to 7/10/26. Interview with LPN #1 on 8/6/26 at 1:27 PM identified he did not observe or receive reports of bruising, discoloration, or swelling to Resident #1's right side prior to 7/10/26. On 7/10/26, when the area was reported to him, he observed mostly yellowed bruising and Resident #1 reported 7/10 to 8/10 pain. Interview with APRN #1 on 8/6/26 at 1:56 PM identified she was not notified of any skin changes or pain concerns prior to 7/10/26. She identified that new bruising, discoloration, swelling, or other changes in condition should have been reported to the provider immediately. APRN #1 identified that 7/10/26 was the first time she became aware of the extensive bruising and swelling. Interview with RN #2 on 8/6/26 at 2:18 PM identified no bruising, discoloration, or swelling was reported to or observed by him prior to 7/10/26. RN #2 also acknowledged that he signed the 7/9/26 Skin Check as complete despite not visualizing the right inner thigh and groin area. Interview with the DON on 8/6/26 at 3:15 PM identified she was unaware of any bruising observed by NAs prior to 7/10/26. The DON identified NAs are required to report all skin changes when first observed and that assuming bruising was present on admission was not acceptable. The DON identified timely notification to the provider is essential to prevent delays in treatment. Although attempted, interviews with RN #1, RN #3 (Unit Manager), NA #3, and NA #4 were not obtained. Review of the facility's Pressure Injury Prevention Management Program policy dated 3/2023 directed staff to report daily any changes regarding residents' skin integrity. The policy further directed licensed nurses to notify the provider of any acute changes. Policies specific to bruising or ecchymosis were requested but not provided.

Based on review of the clinical record, facility documentation, facility policy, and staff interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for injuries of unknown origin, the facility failed to ensure staff immediately reported observations of significant bruising, swelling, and associated pain involving the resident's right groin and upper inner thigh to licensed nursing staff in accordance with the facility's Abuse Policy & Procedure. The location and unexplained nature of the bruising required timely assessment, investigation, and consideration of potential abuse or other causes of injury, as well as prompt reporting through the facility's chain of command and to the State Agency as required. The findings include:Resident #1's diagnoses included cerebral palsy, intellectual disabilities, difficulty walking, and age related osteoporosis without current pathological fracture.The Admission/readmission Evaluation completed by RN #1 dated 6/30/26 identified Resident #1 was alert and oriented to person, place, time, and situation and required partial assistance with bed mobility and substantial assistance for transfers and ambulation. No skin issues were identified on admission.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status score of 7), was dependent on staff for bed mobility and transfers, and ambulation was not attempted due to safety concerns. No skin impairments were identified.The Resident Care Plan dated 7/1/26 identified Resident #1 was at risk for skin breakdown due to impaired mobility, cerebral palsy, seizures, refusals to ambulate, incontinence, and right knee pain. Interventions included completing skin checks with care, reporting any skin changes to the licensed nurse, completing weekly skin evaluations, and updating the provider with any changes as needed.A provider note by APRN #1 dated 7/1/26 at 8:15 AM identified Resident #1 was sent to the Emergency Department (ED) on 6/28/26 following a fall at home with right knee pain and gait instability. Resident #1 refused to bear weight despite an unremarkable workup, including a negative right knee x-ray and CT of the head (imaging that uses x-rays and computer to make detailed imaging of the brain, skull and sinuses), the gait instability was thought to be behavioral in nature and Resident #1 was admitted to the facility on [DATE]. On assessment, there was no joint pain or stiffness, no muscle pain, no limited range of motion, no weakness, the skin was warm and dry with no skin discoloration and no bruising or lesions. The note directed monitoring for changes in condition and to notify the provider of acute changes.Nurse's notes dated 7/1/26 through 7/7/26 and 7/8/26 through 7/9/26 failed to identify skin abnormalities or changes to Resident #1.A provider note by APRN #1 dated 7/10/26 at 10:00 AM identified Resident #1 was seen emergently for evaluation due to continued right hip pain with new associated large bruising and swelling to the abdomen and groin area. Resident #1 had visitors when Resident #1 complained of increased pain to the right hip and right lower extremity and large bruising with swelling was noted. History was limited due to intellectual disabilities. On examination, a large area of ecchymosis (skin bruising) was noted to the lower abdomen, most being right sided and a large area of ecchymosis was noted to the right groin/right upper thigh. The areas were not tender to touch and some edema was noted to the right upper thigh in the area of the ecchymosis. APRN #1 identified it was the first time she observed the ecchymosis areas, identifying it as spontaneous. Right knee and hip pain were the same and there were no concerns that prescribed aspirin was the cause. There was concern for a pelvic fracture. Review of the admission paperwork identified no diagnostic studies had been completed for the hips or pelvis.A Situation Background Assessment Recommendation (SBAR) summary by LPN #1 dated 7/10/26 at 10:15 AM identified Resident #1 reported nine (9) out of ten (10) pain to the right upper inner thigh. On observation, discoloration was noted to the right groin, inner thigh and buttocks, swelling was noted and the area was firm and tender to touch. The APRN was notified and new orders were obtained to transfer Resident #1 to the ED.Review of hospital documentation dated 7/10/26 identified x-rays of the right femur (thigh bone), right hip and right pelvis were obtained due to bruising to the right inner thigh. The x-rays resulted with a displaced comminuted intertrochanteric fracture of the right femur (a break in the upper femur between the greater and lesser trochanters, where the bone is fragmented and the pieces are misaligned).Interview with NA #1 on 8/6/26 at 11:46 AM and review of facility statement identified she worked the 11:00 PM to 7:00 AM shift and was assigned to Resident #1 on 6/30/26, 7/1/26, 7/6/26, and 7/8/26. On 6/30/26, she observed bruising to the right groin and genital area and Resident #1 complained of right hip and leg pain during incontinence care. Resident #1 stated the bruising was from a fall at home. She reported asking a licensed nurse whether Resident #1 had a hip injury due to the bruising and pain but could not recall the date or which nurse she spoke with. She recalled the bruising being yellow in appearance throughout all of her observations of Resident #1. Interview with NA #5 on 8/6/26 at 12:11 PM identified she observed large bruising from the right groin to the right upper leg on 7/2/26, 7/4/26, and 7/8/26 but did not report it to nursing staff because Resident #1 stated it was from a fall at home.Interview with NA #6 on 8/6/26 at 1:30 PM identified she observed discoloration to the right inner thigh and groin on 7/3/26, 7/6/26, 7/9/26, and 7/10/26 but believed it was fading and did not report it. She reported Resident #1 had occasional pain when turned to the right side.Interview with NA #2 on 8/6/26 at 3:00 PM identified she observed yellow bruising and swelling to the right inner thigh and groin on 7/2/26, 7/3/26, 7/4/26, and 7/9/26 but assumed it was present on admission and did not report it. Resident #1 complained of right hip and leg pain during bed mobility.Interview with LPN #1 on 8/6/26 at 1:27 PM identified he cared for Resident #1 on 7/5/26, 7/8/26, 7/9/26, and 7/10/26 and was not aware of any bruising until 7/10/26. Licensed nursing staff had not been informed of bruising, discoloration, swelling, or pain related to the right thigh, groin, or hip prior to 7/10/26.Review of the facility Reportable Event (RE) dated 7/10/26 (reported 10-days after the identification of bruising) identified at 10:15 AM Resident #1 was transferred to the ED for reported nine (9) out of ten (10) pain to the right upper inner thigh. On observation discoloration to the groin, inner thigh and buttocks were noted and were tender to the touch with swelling and firmness.Interview with the APRN #1 on 8/6/26 at 1:56 PM identified that no bruising or discoloration was reported to her prior to 7/10/26. She stated that any bruising or swelling developing after her initial 7/1/26 assessment required immediate provider notification to prevent delay in treatment.Interview with the DON on 8/6/26 at 3:15 PM identified prior to 7/10/26, she was unaware that multiple NAs had observed bruising to Resident #1's groin and right inner thigh. She reported NAs should report any bruising or discoloration immediately to licensed nursing staff and that reporting residents' statements alone was not sufficient. She stated although the bruising was reported to the State Agency on 7/10/26 as an injury of unknown origin, earlier reporting would have allowed earlier provider notification and prevented delay in care.Review of the Abuse Policy & Procedure dated 12/2023 directed, in part, that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source must be reported immediately to the Administrator and Director of Nursing utilizing the chain of command. The policy further directed staff to notify the supervisor immediately upon any complaint, observation, or suspicion of abuse; the nursing supervisor/charge nurse must then immediately report the allegation to the Administrator and Director of Nursing. The policy required that allegations involving abuse or incidents resulting in serious bodily harm be reported to the Department of Public Health immediately, but no later than two (2) hours after the allegation is made, and within twenty four (24) hours for all other allegations not resulting in serious bodily injury. It also directed staff to protect the resident, begin the investigation immediately, notify the healthcare provider, and complete an RMS event report immediately after the incident is reported.Review of the Accident/Incident policy dated 7/2026 directed, in part, the facility requires all incidents, accidents, and injuries-including injuries of unknown origin such as unexplained skin bruising or skin tears-to be promptly reported, evaluated, and investigated. When such an injury is discovered, staff must immediately notify the licensed nurse or nursing supervisor, who conducts a thorough assessment including vital signs, pain evaluation, and detailed description of the injury. The healthcare provider and the resident's responsible party are notified, with all attempts documented. An RMS event is completed on the shift the injury is identified. For unknown-origin bruising, the nurse initiates a formal investigation, gathering written statements from all staff members with knowledge of the resident's care over the prior 24 to 72 hours or longer if necessary, until the cause is determined. Findings and conclusions are documented in RMS and reviewed by the Director of Nursing, Administrator, and Medical Director to ensure complete and accurate reporting. If credible evidence suggests abuse or neglect, appropriate regulatory notifications are made. Documentation must be factual, concise, and include the resident's condition, first aid provided, notifications made, and follow-up assessments for 72 hours post-occurrence, with care plan updates and interventions communicated to caregivers. This process ensures compliance with state and federal reporting requirements and supports timely identification of potential safety concerns related to injuries of unknown origin.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for pain, the facility failed to adequately manage and respond to the resident's severe pain by failing to administer ordered as-needed pain medication when severe pain was identified, in accordance with physician orders, the resident's care plan, and facility pain management policy.Resident #1's diagnoses included cerebral palsy (lifelong conditions that affect movement, balance and posture due to damage to a developing brain), intellectual disabilities, difficulty in walking and age-related osteoporosis without current pathological fracture.A physician's order dated 6/30/26 directed to administer acetaminophen 325 milligrams (mg), give two (2) tablets by mouth every six (6) hours as needed for pain.The admission Evaluation completed by RN #1 dated 6/30/26 identified Resident #1 was alert and oriented to person, place, time and situation and required partial assistance with bed mobility and substantial assistance for transfers and ambulation.The Resident Care Plan (RCP) dated 7/1/26 identified Resident #1 had pain related to a recent fall with right knee pain. Interventions included administering medications per orders, anticipating the need for pain relief, responding immediately to complaints of pain and monitoring/reporting any signs and symptoms of non-verbal pain to include changes in breathing, grunting, moaning, yelling out, mood/behavior changes and facial changes.A provider note by APRN #1 dated 7/1/26 at 8:15 AM identified Resident #1 was sent to the Emergency Department (ED) on 6/28/26 following a fall at home with right knee pain and gait instability. Resident #1 refused to bear weight despite an unremarkable workup, including a negative right knee x-ray and CT of the head (imaging that uses x-rays and computer to make detailed imaging of the brain, skull and sinuses), the gait instability was thought to be behavioral in nature and Resident #1 was admitted to the facility on [DATE]. On assessment, there was no joint pain or stiffness, no muscle pain, no limited range of motion, no weakness, the skin was warm and dry with no skin discoloration and no bruising or lesions. The note directed monitoring for changes in condition and to notify the provider of acute changes.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 7), was dependent on staff for bed mobility and transfers, and ambulation had not been attempted due to safety concerns. No skin impairments were identified, Resident #1 reported occasional moderate pain.A provider note by APRN #1 dated 7/10/26 at 10:00 AM identified Resident #1 was seen emergently for evaluation due to continued right hip pain with new associated large bruising and swelling to the abdomen and groin area. Resident #1 had visitors when Resident #1 complained of increased pain to the right hip and right lower extremity and large bruising with swelling was noted. History was limited due to intellectual disabilities. On examination, a large area of ecchymosis (skin bruising) was noted to the lower abdomen, most being right sided and a large area of ecchymosis was noted to the right groin/right upper thigh. The areas were not tender to touch and some edema was noted to the right upper thigh in the area of the ecchymosis. APRN #1 identified it was the first time she observed the ecchymosis areas, identifying it as spontaneous. Right knee and hip pain were the same and there were no concerns that prescribed aspirin was the cause. There was concern for a pelvic fracture. Review of the admission paperwork identified no diagnostic studies had been completed for the hips or pelvis.A Situation Background Assessment Recommendation (SBAR) summary by LPN #1 dated 7/10/26 at 10:15 AM identified Resident #1 reported nine (9) out of ten (10) pain to the right upper inner thigh. On observation, discoloration was noted to the right groin, inner thigh and buttocks, swelling was noted and the area was firm and tender to touch. The APRN was notified and new orders were obtained to transfer Resident #1 to the ED.The Prehospital Care Report (ambulance run sheet) dated 7/10/26 identified dispatch was called at 11:15 AM and arrived at 11:22 AM. Staff reported Resident #1 complained of continuous pain. Upon visual assessment by Emergency Medical Services (EMS) Resident #1 had obvious bruising that went from the outer edges of the genital region down to the back of the knee. The bruising had mostly yellowed, with some purple discoloration closer to the genital region. Resident #1 reported pain worsened on palpation and was as high as a ten (10 out of 10).Review of the July 2026 MAR identified that Resident #1 was not administered the ordered as-needed acetaminophen on 7/10/26 after reporting 9/10 pain at 10:15 AM and prior to EMS arrival at 11:22 AM (over one hour later).Review of hospital documentation dated 7/10/26 identified x-rays of the right femur (thigh bone), right hip and right pelvis were obtained due to bruising to the right inner thigh. The x-rays resulted with a displaced comminuted intertrochanteric fracture of the right femur (a break in the upper femur between the greater and lesser trochanters, where the bone is fragmented and the pieces are misaligned).Interview with LPN #1 on 8/6/26 at 1:27 PM identified he worked the 7:00 AM to 3:00 PM shift and was assigned to provide care for Resident #1 on 7/5/26, 7/8/26, 7/9/26, and 7/10/26. He stated no bruising, discoloration, or swelling of Resident #1's right side was reported or observed by him until 7/10/26. On 7/10/26, when bruising was reported to him, he observed mostly yellowed bruising that did not appear new. At that time, Resident #1 complained of seven (7) to eight (8) out of ten (10) pain. He reported Resident #1 had not previously complained of right hip, groin, or thigh pain, only right knee pain and he did not administer acetaminophen prior to EMS transfer.Interview with APRN #1 on 8/6/26 at 1:56 PM identified during her assessment on 7/10/26, she observed extensive dark purple bruising to the lower abdomen, groin, right inner thigh, and right hip, with yellow discoloration around the edges. Although Resident #1 was not in severe pain at the time, the bruising appeared consistent with a possible fracture. She identified that if staff identified severe pain, they should have administered available as needed pain medication or contacted the provider for an order prior to Resident #1 being transported to the ED.Interview with the DON on 8/6/26 at 3:15 PM identified once bruising was observed to Resident #1's abdomen and groin, and a possible fracture was identified with severe pain reported, LPN #1 should have administered acetaminophen and monitored the resident's response prior to transferring Resident #1 to the ED.Review of the Pain Management policy dated 12/2024 directed, in part, residents will be monitored for symptoms of pain, complete a detailed pain evaluation when pain is identified, and develop a care plan aimed at preventing, minimizing, and alleviating pain. The goals of pain care are to promptly evaluate and diagnose pain, use evaluation techniques appropriate for residents with varying cognitive abilities. Pain may be acute (sudden onset and lasting less than one month, often due to injury, trauma, or surgery), chronic, or subacute. Residents are evaluated for pain on admission, when new symptoms appear, and daily during each shift's medication pass. Staff assess physical changes or manifestations of pain, including pain-site evaluation and neurological, motor, sensory, or reflex examinations as needed. The interdisciplinary team implements a Pain Management Program that includes creating a comfortable environment, providing comfort measures such as repositioning and body rubs, administering and monitoring pain medications, offering therapeutic activities, and providing patient centered non pharmacological interventions. When pain is not relieved by current treatments and comfort measures, staff consult the healthcare provider for additional interventions.

Based on clinical record review, observation and staff interview, the facility failed to ensure resident smoking area was free from hazards. The findings include:On 1/22/2026 at 10:02 AM observation of the outdoor smoking area in the back of the building made with Environmental Worker#3. The observation identified the area was located to the right outside the exit door in a parking space located under a full overhang of the building. The ground had a wooden pallet and on the pallet was the bottom of an ash/butt receptacle with its long neck piece off and on its side on the pallet. Another receptacle was located to the right side of the area. Upon closer observation numerous cigarette butts were seen on the ground between the slats in various locations of the wooden pallet. Environmental Worker #3 indicated not being sure why the pallet was on the ground and indicated the receptacle was apart as it may have been emptied but did not know why the cigarette buts were on the ground within the wooden pallet. During an interview and review of pictures of smoking area with the Administrator on 1/22/2026 at 10:18 AM s/he did not know why a pallet was located on the ground of the smoking area and indicated people without homes are around the area and may have emptied the receptacle looking for cigarette butts they may be able to use. The administrator indicated that the environmental services are responsible for keeping the smoking area clean and safe and ensure they clean the area. An interview with the Director of Environmental Services/Maintenance on 1/22/2026 at 10:25 AM indicated Environmental Workers #1 and #3 were responsible for checking and keeping the smoking area clean, Environmental Worker #1 and another worker are responsible for supervising the two smokers. They were also responsible for checking the area during the smoking times for butts, cleaning the area and emptied trash. An interview and observation with the Administrator on 1/22/2026 at 10:45AM identified the smoking area was clean and staff informed her/him, the pallet had been placed in the parking spot used for the smoking area to prevent someone from parking there. The Administrator indicated the pallet should not have been placed there and it was removed. The facility policy labeled Safe Smoking (Resident) indicated that all residents who smoke and require supervision will be observed by staff who will be in the direct area of the designated smoking area during facility smoking. i

Based on clinical record reviews, observations, reviews of facility policies and interviews for 3 of 4 residents reviewed for ventilators and tracheostomies (Residents #76, 198, and 261), the facility failed to ensure that ventilator equipment and suction equipment were consistently changed as per facility policy. The findings included: 1. Resident #76 was admitted with diagnoses including chronic respiratory failure and ventilator dependence. A 5-day MDS assessment dated [DATE] identified Resident #76 had short-term and long-term memory problems and required tracheostomy and invasive mechanical ventilator care. A physician's order dated 1/13/2026 directed to change the ventilator circuit on the first Saturday of every month starting on 2/7/2026.A further review of the medical record failed to identify an order prior to 1/13/2026 for the changing of ventilator circuit tubing.An observation on 1/15/2026 at 10:00 AM with Respiratory Therapist (RT#1) identified Resident #76 was connected to the ventilator, and the ventilator circuit tubing was dated 12/7/2025. 2. Resident # 198 was admitted with diagnoses including acute and chronic respiratory failure with retention of carbon dioxide, and ventilator dependence. A quarterly MDS assessment dated [DATE] identified Resident #198 had long-term and short-term memory problems and was dependent for self-care. The MDS further indicated that Resident #198 required tracheostomy care. The physician's orders dated 12/26/2025 directed to suction via tracheostomy every shift and to change the suction canister and tubing weekly and as needed.A review of the Treatment Administration Record (TAR) for 1/1/2026 to 1/14/2026 identified the suction tubing and canister were documented as changed on 1/6/2026 and 1/13/2026. A review of respiratory therapy notes from 1/1 to 1/14/2026 did not identify any respiratory incidents on 1/6 or 1/13.2026.An observation with RT#1 on 1/15/2026 at 10:15 AM identified Resident #198's suction canister contained about 300 mL of green fluid; the canister was dated 12/30/2025. 3. Resident #261 was admitted with diagnoses including chronic respiratory failure with hypoxia and ventilator dependence. A quarterly MDS assessment dated [DATE] identified Resident #261 had short-term and long-term memory problems and required tracheostomy and invasive mechanical ventilator care.A physician's order dated 1/13/2026 directed to change the ventilator circuit on the first Thursday of every month to start on 2/5/2026. A further review of orders failed to identify an order prior to 1/13/2026 that directed the change of the ventilator circuit.An observation with RT#1 on 1/15/2026 at 10:10 AM identified Resident #261 was in bed and connected to the ventilator. Additionally, the ventilator circuit tubing was dated 12/7/2025 on an inhalation filter that was attached to the inhalation tubing and ventilator. On 1/15/2026 at 10:18 AM, an interview with RT#1 indicated suction canisters and suction tubing needed to be changed weekly. Additionally, RT#1 indicated that ventilator circuit tubing should be changed monthly and was not sure why the ventilator tubing for Residents #76 and #261 had not been changed yet.On 1/20/2026 at 1:10 PM, an interview with the Director of Respiratory identified ventilator circuit tubing, including inhalation and exhalation filters, was a single-use component and should be changed in the first week of the month. The Director of Respiratory indicated different residents are scheduled for ventilator circuit changes on different days of the week to balance the workload among the respiratory therapists. Additionally, the Director of Respiratory indicated that the suction canister and tubing should be changed weekly. The Director of Respiratory indicated he was working on a method to monitor compliance with ventilator circuit tubing changes. A review of the ventilator manufacturer's cleaning and maintenance recommendations indicated that single-use components should be replaced regularly following institutional standards. A facility policy for Clinical Services Ventilation Management identified that ventilator circuits and filters should be replaced per manufacturer guidelines. A facility policy for Clinical Services Equipment and Supply Cleanliness identified ventilator circuits were to be changed every 30 days and documented in the electronic medical record. The policy did not indicate when suction canisters and tubing should be replaced; however, it identified that the [NAME] suction device (a component of the suction set-up for a ventilator patient) should be changed weekly.

Based on observations, review of facility policy and staff interviews for 3 of 4 (3AB and 2CD units) medication rooms observed, the facility failed to ensure medication was labeled appropriately, controlled medications were safely stored and failed to ensure that food items were not stored in the medication rooms. The findings included: On 1/20/2026 at 3:00 PM, an observation with the nurse manager (RN#2) of the 3AB medication room identified two bottles of chlorhexidine gluconate 0.12% oral rinse on a shelf with other resident-specific medications. The bottles were noted to have torn resident labels that did not allow for the identification of the residents to whom the bottles belonged. Additionally, the medication refrigerator was noted to have a locked narcotics box that was affixed to a shelf in the refrigerator; however, the shelf was not permanently affixed to the refrigerator and was readily removable. The narcotics box contained five bottles of lorazepam (anti-anxiety) 3 milligrams (mg)/1 milliliter (mL). Three of the bottles were unopened and contained 30mL each, and two bottles were open and contained over 22mL each. An interview with RN#2 indicated she was not sure why the chlorhexidine gluconate had torn labels and medications that were no longer being used would be put on the side to be returned to the pharmacy or destroyed. RN#2 further indicated that she was not aware that the narcotics box would need to be permanently affixed to the refrigerator. On 1/21/2026 at 10:20 AM, an observation of the 3CD medication room with LPN#2 identified a food refrigerator with an egg sandwich and a peanut butter sandwich with resident room numbers. On one counter of the medication room, there were multiple individually packed shelf-stable fruit smoothies and crackers. The packet of smoothies and crackers had resident names and room numbers on them. There was also an open 1-pound packet of cream-filled chocolate sandwich cookies. The cookies were not individually wrapped and were in a self-sealing package; the adhesive of the self-sealing flap was worn and did not seal the cookies effectively. An interview with LPN#2 indicated that the refrigerator was used only for food and not for medications, and that the unit also had a food refrigerator in the unit's nourishment room. LPN#2 indicated that the sandwiches were for resident evening snacks but was not sure why the sandwiches were kept in the medication room versus the nourishment refrigerator. LPN#2 also indicated the fruit smoothies, crackers, and cookies were food items brought in by family for specific residents and were kept there for safekeeping. LPN#2 did not know how long the food items had been stored in the medication room. On 1/21/2026 at 11:35 AM, an observation of the 2CD medication room with LPN#6 identified a black colored mini refrigerator that contained an unopened 30mL bottle of morphine oral concentrate 20mg/5mL (a schedule 2 medication) and an unopened 30mL bottle of lorazepam 2mg/1ml oral solution. The mini refrigerator was sitting on a medication room counter, not permanently affixed, and was readily movable by the surveyor. An interview with LPN#6 indicated that the refrigerator does not have a lock box or separate compartment inside because the whole mini refrigerator was used for holding narcotics. On 1/22/2026 at 12:04 PM, an interview with the DNS identified the lock box and narcotics refrigerator had been addressed on 1/21/2026 after surveyor observations. Additionally, the DNS indicated that food items, including those belonging to residents, should have been stored in the nourishment room and not in the medication room. A review of the facility policy for Medication Storage identified that schedule 2 to schedule 5 medications must be maintained in a separately locked, permanently affixed compartment or cabinet. The facility policy for Medication Storage did not identify whether food would be stored in the medication rooms. The facility policy for Use and Storage of Food Brought to Residents by Family or Visitors identified that non-perishable foods stored in a resident's room must have been in an air-tight container or plastic food storage bag and that perishable food must have been stored in the nursing unit kitchen nourishment refrigerator.

Based on, observations, clinical record reviews, review of facility documentation, review of resident menu selections, review of facility policies, and staff interviews for 10 of 10 sampled residents (Residents #238, #82, #121, #55, #71, #183, #163, #174, #220, and #290), the facility failed to support residents in exercising their right to make choices regarding meals. The findings included: 1.Resident #220 had diagnoses that included heart failure, respiratory failure, and lymphedema. The quarterly MDS dated [DATE] identified Resident #220 had intact cognition and was independent with oral hygiene and feeding him/herself. The RCP dated 10/27/25 identified Resident #220 was obese with interventions that included providing diet per physician's order, obtain, provide, honor, and monitor food and beverage preferences. A physician's order dated 1/9/26 directed to provide a 2-gram sodium regular texture diet. Interview with Resident #220 on 1/15/2026 at 6:30 AM identified he/she completes weekly select menus and fills his/her daily meal selections. Resident #220 indicated he/she does not receive the foods circled or foods handwritten on the menus. Resident #220 indicated he/she requests sausage daily for breakfast, but he/she had not received sausage for approximately six months, despite continued requests. Resident #220 stated he/she has reported to the nurse aides and no staff member from dietary or nursing explained why the requested items were not provided. Resident #220 identified that the handwritten menu slips were not returned for comparison and did not match the typed meal tickets on trays. Observation on 1/15/26 at 8:00 AM identified Resident #220's breakfast tray did not include sausage, and the meal ticket did not list sausage in a typed or handwritten form. Interview with Resident #220 on 1/20/26 at 8:15 AM identified he/she still did not receive the sausage as requested. Resident #220 identified he/ she had not seen the dietician in many months. Resident #220 indicated that last week he/she requested a ham sandwich for dinner in addition to the main meal but never received it. Resident #220 identified every day on the prefilled out the select menus for dinner he/she crosses off the chef salad and handwrites in a small salad but continues to receive chef salad. Resident #220 indicated no dietary staff had spoken with him/her in several months. Observation on 1/20/26 at 8:20 AM identified Resident #220's breakfast tray on the overbed table, did not include sausage and the and the meal ticket did not have sausage typed on it or handwritten on it. Review of Resident #220's meal ticket dated 1/20/26 identified handwritten on the ticket: sausage for breakfast underlined 3 times, lunch add a small salad, and for dinner Resident #220 had crossed off chef salad, wrote the word delete next to it, and wrote in small salad. Interview with the Directory of Dietary (DOD) on 1/20/26 at 2:21 PM identified residents have select menus for each day of the week on separate pieces of paper, but they can fill out all 7 days for the next week. The DOD indicated the daily selection on the paper select menu slips go in a bucket at the nurse's station, then the dietary aide brings them to the kitchen and puts them in a pile. The DOD identified he or someone in the kitchen bring the menu slips to the front desk receptionist who is responsible the day before to input the requests for the next day in the meal tracker system. The DOD indicated a few residents requested their actual slips be returned because they had complained or had forgotten what they had requested for a meal. Interview with Resident #220 on 1/21/26 at 1:00 PM identified although he/she continues to do the select menu he/she does not receive the sausage with breakfast that he/she requests or the fresh fruit. Resident #220 indicated he/she writes it on the form he/she wants sausage on the select menu. Resident # 220 indicated he/she has asked the nurse aides for missing items and informed the nurse aides he/she did not get what he/she requested. Resident #220 indicated the nurse aides tell him/her they call the kitchen, but he/she still does not receive what he/she orders. Resident #220 indicated months ago he/she had spoken with the dietitian regarding these concerns, but nothing changed. Resident #220 indicated that he/she has not seen the dietitian or someone from the kitchen in months to discuss why he/she does not get the items requested on the select menu he/she fills out for every meal. Interview with Director of Dietary (DOD) on 1/21/26 at 1:50 PM identified sausage links and sausage patties are not an everyday item. The DOD indicated he was not aware Resident #220 was not receiving sausage, fresh fruit, or other handwritten requests. Interview with Dietitian #1 on 1/21/26 at 2:23 PM identified select menus are provided to the residents on Tuesdays so they can complete the menus for the following week. Dietitian #1 identified every Saturday which is two days before the service week begins, kitchen staff bring the upcoming week's menus to the front desk so the overnight receptionist can enter residents' selections into the select menu system, which guides food preparation. Dietitian #1 identified sausage is not offered every day, so the receptionist would need to add it in the comment section labeled as server notes for that meal ticket. Dietitian #1 stated if the receptionist does not put an item into the meal tracker program, she is responsible for notifying him of the resident request. Dietitian #1 stated the receptionist had not notified him about any of Resident #220's meal requests that were not put into the meal tracker system daily. Dietitian #1 indicated he had been notified he would have spoken with Resident #220 regarding his/her meal choices. Interview and review of Resident #220's handwritten meal tickets/menu with Dietitian #1 on 1/21/26 at 2:30 PM identified Resident #220's handwritten selected menu for 1/22/26 did not match the kitchen's typed out menu that the cook follows for 1/22/26. Dietitian #1 stated that Resident #220 would not receive any of the items he/she had written in because they did not appear on the kitchen menus for 1/22/26. Review of the Front Desk Training dated 8/17/23 identified menu rules were to notify the dietitians via phone or email if a resident is requesting to not receive a tray, a resident is asking for items that we do not offer, a resident is ordering an excessive amount of food, a resident frequently not ordering full meals, or any other questions you might have. Review of the Culinary and Nutrition Policy identified planned menus are developed and used to provide each resident with a nourishing, palatable, well-balanced diet that meets his/her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Reasonable efforts mean assessing individual residents' needs and preferences and demonstrating actions to meet those needs and preferences, including reviewing availability of procurement sources of each food item, identifying preparation methods and approaches, and determining whether purchasing and serving such items can occur. The facility will make a reasonable and good faith effort to develop a menu to meet residents' preferences. Residents provide input into menu development through resident council or separate food committee, interviews with residents, their families, by the food service director, registered dietitian or their designee. Resident food and beverage preferences are obtained directly from residents. Reasonable alternative food items that are reasonable and accommodate individual resident needs, intolerances, and preferences are available and offered to residents at each meal if the primary menu or immediate selections for a particular meal are not to the residents' liking. 2 a. Resident #238 's diagnoses included type 2 diabetes mellitus with circulatory complications, chronic kidney disease stage 3 with anemia, type 2 diabetes mellitus hypothyroidism and adjustment disorder with anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #238 was cognitively intact and required assistance with eating and oral hygiene. The MDS documented significant weight changes and the use of a therapeutic diet. The resident participated in assessment and goal setting at that time. A physician's order, dated 4/9/25, directed Resident #238 have a renal, non-dialysis, diet with regular/whole texture and thin consistency. A dietitian's note dated 5/1/25 documented a weight warning, noting a 15-pound weight loss in one month following a 15-pound gain the prior month. Despite intake concerns, there was no evidence that resident dissatisfaction with meals or food preferences was incorporated into the care plan or addressed through documented resident choice discussions. A dietitian's note dated 5/9/25 documented Resident #238 requested milk at breakfast and dinner, which was not included in the renal diet. The dietitian documented a compromise to provide four ounces of milk at breakfast and dinner and noted menus were updated; however, there was no evidence that this preference or related communication needs were incorporated into the resident plan of care. A dietitian's note dated 6/6/25 documented Resident #238 reported poor meal intake due to a dislike of meals being served, stating his/her appetite was intact, but the meals were unacceptable. There was no evidence addressing food preferences or meal choice communication occurred in the plan of care following this report. An email exchange dated 7/18/25 between front desk staff and Dietitian #1 reflected concerns that grilled cheese sandwiches and salads no longer appeared on Resident #238's menu due to renal diet restrictions. Although Dietitian #1 responded to the staff, there was no evidence that the residents were informed of these changes or involved in alternate meal selection. Care plan meetings held on 10/21/25 and 1/20/26 documented Resident #238 was invited but did not attend. Despite ongoing documented meal dissatisfaction, there was no evidence the interdisciplinary team incorporated the resident's food preferences, menu concerns, or communication needs into the care plan through alternate means. A quarterly MDS assessment dated [DATE] identified Resident #238 was cognitively intact and independent for eating, oral hygiene, and personal hygiene, and continued to receive a therapeutic diet. The resident participated in assessment and goal setting at that time. A care plan dated 1/15/26 included goals addressing nutritional status and renal disease. One focus, initiated 2/24/25, identified risk for malnutrition related to worsening renal disease, with goals to maintain adequate intake and weight stability. Interventions included honoring food and beverage preferences and monitoring intake; however, these interventions were last updated 2/26/24 and did not reflect subsequent documented concerns related to resident dissatisfaction with meals. A second focus addressed chronic renal failure related to kidney disease and diabetes, initiated 2/25/25 and revised 1/15/26, with dietary-related interventions last updated 2/25/25. The care plan did not include interventions to address meal dissatisfaction, menu substitutions, or communication with the resident about food choices. During an interview on 1/15/26, Resident #238 stated that meals ordered were not consistently received, portions were incorrect, disliked foods were repeatedly served, and requested alternatives were not provided. Resident #238 expressed frustration that food choices were not honored. A comparison of Resident #238's selected menus with meals served from 1/20/26 through 1/22/26 identified multiple instances in which requested food items were altered or substituted without evidence that the changes were discussed with the resident. Requested items such as grilled cheese sandwiches, ham, tomato, mashed potatoes, and bagels were replaced with tuna sandwiches, hamburgers, or reduced portions without explanation or documented resident communication. During an interview and menu review, on 1/20/26 at 2:28 PM, the Director of Dining Services identified substitutions provided to Resident #238 were inappropriate and should have been discussed with the resident and dietitian prior to implementation. The Director stated he was not made aware of the substitutions. During an interview and menu review on 1/21/26 at 2:55 PM, Dietitian #1 identified the facility lacked a consistent process to notify residents when meal selections were changed. The dietitian confirmed that discussions regarding repeated menu changes were not routinely documented and acknowledged Resident #238 had not been re-educated regarding menu restrictions recently, despite the identified issues. The dietitian further stated that front desk staff training did not clearly require notifying the dietitian or the Director of Dining Services when resident selections could not be filled, further confirming this when he provided the last documented discussion with Resident #238 from May of 2025 and the training to the front desk. A dietitian's note dated 1/21/26, completed after a surveyor inquiry, documented resident education regarding renal diet restrictions and implementation of diet liberalization to allow preferred foods. This intervention occurred after repeated undocumented substitutions had already occurred. Although Dietitian #1 was able to provide documentation of front desk staff training, dated 8/17/23, which directed staff to notify the dietitian when resident selections required changes. Subsequent Meal Suite system training dated 12/23/24 failed to reinforce these directives. Dietitian #1 confirmed that inconsistencies with communication and education may have contributed to failure to honor residents' choices for menu changes. a. Additional residents sampled, including #82, # 121, 55, 71, 183, 163, 174, and #290, all of whom expressed concerns about menu substitutions during the facility tour. Review of their clinical records identified inconsistent or absent evidence of discussions regarding food substitutions or preferences when selected foods were unavailable. A review of facility policies, including Menu Development and Nutrition Adequacy (July 2025), Residents' [NAME] of Rights (February 2024), and Culinary and Nutrition Policy (July 2023), directed that resident preferences be accommodated, substitutions discussed and documented, and care plans reflect resident goals and choices. The facility failed to ensure residents were supported in exercising their right to make choices regarding meals by failing to honor resident selections, inform residents of meal substitutions, incorporate resident preferences into the plan of care, and ensure staff were adequately educated to implement individualized menus.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 three residents (Resident #195), reviewed for change in condition the facility failed to ensure the physician was notified timely when the resident experienced a change in cardiac status and for 1 of 2 residents (Resident #227), reviewed for pain, the facility failed to ensure the physician was notified when a medication was not administered timely. The findings included: 1.Resident #195 had diagnoses that included heart failure, atherosclerotic heart disease with angina, and hypercholesterolemia. A physician's order dated 11/6/2021 directed to administer metoprolol succinate extended release 25 mg tablet give 1/2 tablet by mouth twice a day hold if systolic blood pressure is under 110 or heart rate is under 55. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #195 had a Brief Interview of Mental Status (BIMS) score of seven (7) indicative of severely impaired cognition, required setup assistance with personal hygiene, and was independent with bed mobility and transfers. The RCP dated 10/24/2025 identified Resident #195 had congestive heart failure. Interventions directed to give cardiac medications as ordered, monitor vital signs and notify medical doctor of significant abnormalities, and oxygen as ordered. Review of the vital signs report dated 1/5/2026 at 8:20 AM identified Resident #195 had a heart rate of 40 beats per minute with a regular rhythm, and on 1/5/2026 at 7:06 PM Resident #195 had a heart rate of 36 beats per minute with an irregular rhythm. Review of Resident #195's clinical record dated 1/5/2026 failed to reflect documentation that the APRN or physician was notified when Resident #195 experienced a change in his/her cardiac status on 1/5/2026 at 8:20 AM when noted with a heart rate of 40 beats per minute. Review of the facility's on-call telephone log dated 1/5/2026 identified the facility placed a call at 9:24 PM (13 hours and 4 minutes after the 1st episode of bradycardia) to APRN #4 and reported Resident #195's apical heart rate was between 35-40 beats per minute, and the resident was sent to the emergency room. Review of the hospital documentation dated 1/7/2026 identified Resident #195 arrived on 1/5/2026 at 11:19 PM with a heart rate in the 30's and found to be in complete heart block (a serious condition where electrical signals from the heart's upper chambers do not reach the lower chambers, leading to independent beating of the atria and ventricles and possible sudden cardiac arrest). Resident #195's lab results identified an elevated N-terminal pro B-type natriuretic peptide level (a laboratory measurement of stress on the heart to help diagnose or rule out heart failure) of 2693 picograms (pg)/milliliter (ml) (normal levels are below 125 pg/ml). Resident #195 was admitted to the hospital, received treatment, and placement of a dual-chamber pacemaker. Interview with LPN #5 on 1/20/2026 at 1:51 PM identified on 1/5/2026 at 8:20 AM Resident #195 was bradycardic (low heart rate) with a heart rate was 35-37 beats per minute, and his/her heart didn't sound right. LPN #5 stated she called LPN #2 into the room for assistance at which time Resident #195's heart rate increased to 40 beats per minute. LPN #5 identified she notified RN #2 (7 AM- 3 PM unit manager) that Resident #195 had a heart rate of 35-40 beats per minute. LPN#5 stated she did not notify the APRN because RN #2 (unit manager) stated she would notify the APRN. Interview with LPN #2 on 1/20/2026 at 2:07 PM identified she was called into Resident #195's room by LPN #5 for help because Resident #195's heart rate was very low. LPN #2 stated she advised LPN #5 to notify RN #2. Interview with RN #2 on 1/20/2026 at 2:31 PM identified she was notified by LPN #5 on 1/5/2026 that Resident #195's heart rate was 35-40 beats per minute. RN #2 indicated she assessed Resident #195, who seemed okay, and noted Resident #195's heart rate was maybe 60 beats per minute. RN #2 stated on 1/5/2026 she notified APRN #1 that Resident #195 was experiencing bradycardia but could not recall the time of notification. Interview with APRN #1 on 1/21/2026 at 12:08 PM identified on 1/5/2026 she was notified by RN #2 that Resident #195 had bradycardia . APRN #1 stated she was not Resident #195's provider and identified APRN #2 as the provider who should have been notified. Interview with the DNS on 1/21/2026 at 3:00 PM identified when a resident experiences a change in cardiac status, staff must notify the provider. The DNS stated both nurses and nurse supervisors are responsible for notification. The DNS stated she would have expected RN #2 to document the name of the provider she notified and the provider's response. Interview with APRN #2 on 1/22/2026 at 9:29 AM identified that she was not notified on 1/5/2026 that Resident #195 experienced a change in cardiac status. APRN #2 stated she would have expected notification. Interview with RN #5 ( 3 PM-11 PM supervisor) on 1/28/2026 at 3:59 PM identified on 1/5/2026 he was not notified during shift change report that Resident #195 had experienced a change in cardiac status. RN #5 stated he should have been notified, had he been notified, he would have instructed the nurses to closely monitor Resident #195. RN #5 identified in the evening on 1/5/2026, LPN #4 ( 3 PM-11 PM charge nurse) notified him that Resident #195's heart rate was in the 30's. RN #5 stated he assessed Resident #195, notified APRN #4, documented in the SBAR, and sent the resident to the hospital. Interview with LPN #4 (3 PM-11 PM charge nurse) on 1/28/2026 at 4:28 PM identified she was not notified during the change of shift report on 1/5/2026 that Resident #195 had experienced any change in cardiac condition on the first shift. LPN #4 stated had she been informed she would have monitored Resident #195 closely. Interview with APRN #4 on 1/30/2026 at 1:01 PM identified she had was not notified on 1/5/2026 by RN #2 that Resident #195 was noted with bradycardia. APRN #4 stated she first notified on 1/5/2026 at 9:24 PM by the facility that Resident #195 had a change in cardiac status and the resident was sent out to the hospital. Review of the facility Change in Condition Notification policy identified in part that the facility will inform the resident, resident's healthcare provider, and the resident's family/legal representative when there is a change in condition. The licensed nurse will notify the resident, resident's healthcare provider, and the resident's family/legal representative of the change in condition. The nurse will document all attempts, noting date and time. In the event of an emergency, the licensed nurse can transfer the resident to the hospital via 911. Physician/family notification must be documented in the electronic health record. 2.Resident #227's diagnoses included chronic pain and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #227 was cognitively intact and received pain medication on a scheduled and as needed (PRN) basis. The care plan dated 11/18/2025 indicated Resident #227 received pain medication therapy due to neuropathic pain and chronic pain. Interventions included: to administer medications as ordered by the physician, to monitor and documents side effects and effectiveness. A physician's order for January 1, 2026, through January 21, 2026, directed to administer Robaxin a 750 Milligrams (MG) tablet by mouth 3 times daily for muscle spasms. An interview and record review with the Director of Nursing Services (DNS) on 1/20/2026 from 1:00PM - 1:20 PM indicated the pain medication, Robaxin, was scheduled to be given 3 times/day at 8:00 AM, 12:00 Noon and 4:00 PM an hour before or after the scheduled time to be considered administered timely. However, during review of the Medication Administration Record (MAR) Audit Report noted on 1/01/2026 the 8:00 AM dose was given at 09:32 AM (32 minutes late). On 1/02/2026 the 8:00AM dose was given at 11:10 AM, (2 hours 10 minutes late) with the next dose due at 12 noon (in 50 minutes). The 12:00 noon dose was given to resident #227 at 1:02 PM (1 hour 51 minutes after the prior dose) with no documentation noted in the clinical record regarding the reason the Robaxin was given late. The DNS indicated it was possible the medication pass was taking longer than usual due to the influenza outbreak and the addition of 18 residents receiving additional preventative medication due to the outbreak. The DNS further indicated s/he would have expected the nurse, Licensed Practical Nurse (LPN) 8, to have notified the supervisor and physician/ Advanced Practice Registered Nurse (APRN) to notify administration regarding late administration. An interview with LPN #8 on 1/21/2026 at 10:41AM indicated Resident #227 did not agree with the 1 hour before or 1 hour after the scheduled medication time but instead expected the medication to be provided at the scheduled time not considering the time it takes to provide all residents with their medication. LPN #8 indicated Resident #227 was often angry when the nurse was not fast enough when providing medication. LPN #8 indicated during the outbreak s/he was able to complete the medication pass timely but during review of the Robaxin administration audit review ( the time the medication was signed by the nurse as given) the untimeliness of the 8:00 AM dose on 1/01/2026 and 1/02/2026 were noted without explanation as to why the medications were administered late without the supervisor and/or the physician being notified. On 1/21/2026 at 10:50 AM an interview with the Assistant Director of Nursing Services (ADNS) and DNS and review of the medication administration audit report verified the medication administration audit was the actual time the nurse signed the medication out and administered the Robaxin medication to Resident #227 and indicated the physician/APRN should have been notified. An interview and record review with APRN #3 on 1/21/2026 at 12:10 PM indicated s/he expected to be called if a medication was given outside the hour before or hour after the scheduled dose time. APRN #3 further indicated in this case since Resident #227 had an order for a PRN dose of the same medication, when LPN #8 provided the 12:00 noon dose 1 hour 51 minutes after the late 8:00 AM dose given at 11:10 AM s/he would not have expected any side effects like drowsiness as Resident #227 had built up a tolerance to pain medication, but s/he would have been expected notification and would have adjusted the times of the remaining doses. The facility policy labeled Medication Administration and Documentation- General, indicated medication must be given during a 2-hour window of 1 hour before and after the scheduled administration time, use prudent judgment by informing the physician in a timely manner when medications are held refused or otherwise not administered and document an explanatory note in the progress notes.

Based on clinical record review and staff interviews for 1 of 2 (Residents #10) reviewed for Activities of Daily Living, the facility failed to ensure staff complete a significant change in status assessment timely when the resident experienced a change in condition. The findings include:Resident #10's diagnoses included a neuromuscular disorder, pressure ulcers and diabetes mellitus.The quarterly MDS assessment dated [DATE] indicated Resident #10 was cognitively intact required set up and clean up for eating, superficial touching assistance for personal hygiene, partial moderate assistance for toileting and upper body dressing, dependent on staff for lower body dressing, supervision touching assistance for rolling left to right in bed and transfers, had one stage 3 pressure ulcer that was present on admission, and weight loss greater than 5 % in the last 30 days or 10% in the last 6 months.The quarterly MDS assessment dated [DATE] indicated Resident #10 was cognitively intact required to set-up and clean-up assistance from staff for eating, was dependent on staff for toileting, upper and lower body dressing), bed mobility (rolling left to right in bed), transfers and bathing/showering (all areas decline since the last assessment on 7/25/2025). The assessment also indicated Resident #10 had 2 stage 3 pressure ulcers (the development of one additional pressure ulcer since the last assessment on 7/25/2025. The care plan dated 11/06/2025 indicated Resident #10 had a deficit in the ability to complete self-care with interventions including to provide substantial/maximum assist of one person for bathing/showering, dressing, and toileting and to monitor document and report any changes including declines in function. An interview and record review with Registered Nurse (RN # 4) on 1/22/2026 at 12:10 PM indicted Resident #10 should have had a significant change MDS assessment completed in October 2025 due to the Activity of Daily Living (ADL) declines from the previous assessment and refusals for getting out of bed were contributing to the decline. Although RN#4 indicated s/he was new to the facility at the time of the last assessment in October 2025 the decline in ADL status was overlooked. She further indicated a significant change assessment would be completed at this time. The Resident Assessment Instrument (RAI) Manual for competing Resident assessments in the long-term care setting indicated in part a significant change is a major decline or improvement in a nursing home resident's health and or functional status that affects multiple areas and the change will not resolve on its own and requires an interdisciplinary team review and care plan revision to ensure care aligns with the resident's new needs.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #2) reviewed for Preadmission Screen Resident Review (PASRR), the facility failed to review and for 1 of 1 sampled resident ( Resident # 138), reviewed for positioning and mobility, the facility failed to revise the resident care plan in a timely manner. The findings included: 1.Resident #2 had diagnoses that included anxiety and major depression. Review of the PASRR Level 1 screen outcome dated 8/29/25 identified Resident #2 was approved for a 30-day hospital exemption for a suspected or confirmed PASRR condition of a mental health disability. The rescreening must occur by or before the 30th day if Resident #2 is expected to remain in the facility beyond the authorized timeframe. The RCP dated 9/6/25 identified Resident #2's PASRR was in progress. Interventions included PASRR services will be provided to the resident that include talking with the resident, treatment providers, and other supports about how to recognize the resident's mental health symptoms, monitor behaviors and symptoms carefully and contact the treating psychiatrist. The social worker progress note dated 9/8/25 at 3:11 PM written by SW #1's identified Resident #2's PASRR level 2 was completed, see the care plan for the recommended services. SW #1 identified Resident #2's referral was made to psychiatry with a request for an initial evaluation for treatment and management of mental health symptoms and medication management as needed. The admission MDS dated [DATE] identified Resident #2 had severely impaired cognition, without behaviors, hallucinations, or delusions, and not on any antidepressants. Review of the PASRR Level 1 screen outcome dated 9/15/25 identified Resident #2 did not require a Level 2 screen. Resident #2 had a current diagnosis of major depression and was not on any medications. The Level 1 screen indicated that a PASRR disability is not present because of the following reason: there is no evidence of a PASRR condition of intellectual or developmental disability or a serious behavioral health condition. If changes occur or there is new information a new screen must be submitted. Resident #2 had a current diagnosis of major depression but there are no indicators identified that would signify the need for further evaluation at this time. The RCP dated 12/30/25 identified Resident #2's PASRR was in progress. Interventions included PASRR services will be provided to the resident that include talking with the resident, treatment providers, and other supports about how to recognize the resident's mental health symptoms, monitor behaviors and symptoms carefully and contact the treating psychiatrist. Interview and clinical record review with SW #1 (Director of Social Services) on 1/21/26 at 8:58 AM was unable to provide documentation to reflect Resident #220's care plan was updated and revised on 9/15/25 and 12/15/25. SW #1 identified she was responsible for tracking all Level 1 and Level 2 PASRR's and for updating and revising care plans regarding PASRR updates. SW #1 identified Resident #2 was admitted with a diagnosis of major depression and on 9/8/25 given a 30-day hospital exempt stay. SW #1 indicated on 9/15/25 she resubmitted Resident #2's PASRR but never reviewed the results until today 1/21/26. SW #1 stated on 9/15/25 and 12/15/25 she should have updated Resident #220's care plans. Review of the Comprehensive Care Plan Policy (CPCCP) identified the interdisciplinary team will utilize the comprehensive person-centered care planning process to address resident strengths, needs and/or problems as identified on the admission discharge summary, as well as other professional assessments and orders from the healthcare provider, dietary team, therapy, social services and PASRR, and MDS. The CPCCP is developed to include information necessary to properly care for the residents and will address the residents' preference, goals, desired outcomes, and the plan for discharge. Although requested, a PASRR policy was not provided. 2.Resident #138's diagnoses include contracture of the right wrist and elbow, legally blind, bilateral hearing loss and dementia. An Advanced Registered Practice Nurse (APRN) progress note dated 8/15/2025 indicated upon exam, Resident #138 had contracted upper and lower extremities and directed to monitor changes in mobility and function. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #138 had severe cognitive impairment, had limitation of range of motion on the right and left sides of the body including the upper and lower extremities and was dependent on staff for all activities of daily living. The care plan dated as reviewed on 9/1/2025 indicated Resident #138 had a deficit in self-care due to deconditioning due to a displaced right intertrochanteric proximal femur fracture requiring surgical repair. Interventions included helping with all aspects of activities of daily living therapy to evaluate, to monitor/document/report any signs or symptoms of developing immobility or worsening of any functional limit or contractures blood clot formation skin breakdown or fall related injuries. The care plan further indicted Resident #138 had the behavior of calling out, yelling and screaming related to dementia and agitation. Interventions include: to administer medications ordered, speak in a calm manner and to explain all procedures. The care plan indicated an actual/potential risk for pain due to a right hip fracture An APRN note dated 9/09/2025 indicated Resident #138 was being seen for severe muscle stiffness of the legs and the facility staff's inability to take blood pressure due to extremity stiffness and to give Baclofen 5 MG via the G-tube 3 times per day for muscle relaxing. An APRN progress note dated 9/12/2025 indicated Resident #138 on a follow-up visit had severe muscle stiffness not only of the arms but of the legs and indicated the muscle relaxant, Baclofen, should be continued. An observation on 1/15/2026 at 11:15 AM identified Resident #138 asleep in bed with his/her right hand bent at the wrist and fingers curled inward with no splints visible in the room or on resident. An interview and clinical record review on 01/21/2026 9:38 AM with the therapy Director Occupation Therapy (OT) 1, indicated Resident #138 was last treated by the therapy department from 8/18/2025-09/10/2025 upon admission to the facility. Splints were attempted but due to extreme resistance within the contractures attempting to apply/trial splints took 2 persons with maximum assistance, and it was determined the risk of skin issues/injury outweighed the benefit and the recommendation for the use of muscle relaxant medication was discussed with nursing. An interview and clinical record review with the unit manager/supervisor RN #5, on 1/21/2026 at 10:08 AM indicated Resident #138 had contractures of the upper and lower extremities but could not find any direction as to what staff were to do about the contractures but had indicated Resident #138 had splints in the past, and although the Nurse Aide ( NA) care card mentions to turn and reposition Resident #138 every 2 hours but failed to mention the resident having any contractures. On 1/21/2026 at 10:23 AM an interview and record review with RN #4 the MDS Director and LPN #7 an MDS nurse both indicated nothing was in the care plan regarding Resident #138 having contractures. However, the hip fracture care plan mentioned to monitor the formation and worsening of contractures further indicating the care plan needed to be updated to include all contractures and how the contractures affect all other aspects of Resident #138's care and well-being including the risk for skin breakdown and pain. On 1/21/2025, after surveyor inquiry, the MDS Director, RN # 4, revised Resident #138's care plan to include having the potential for altered musculoskeletal status due to a history of joint surgery and contractures of the right wrist and elbow with interventions including providing medication as ordered and therapy to evaluate and treat as indicated

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 three residents (Resident #195) who had a change in condition, reviewed for hospitalization, the facility failed to ensure care and services were provided in accordance with professional standards. The findings include:Resident #195 had diagnoses that included heart failure, atherosclerotic heart disease with angina, and hypercholesterolemia.The physician's order dated 11/6/2021 directed to administer Metoprolol succinate (medication used to treat high blood pressure) extended release (ER) 25 mg tablet give 1/2 tablet by mouth twice a day hold if systolic blood pressure is under 110 or heart rate is under 55. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #195 had a Brief Interview of Mental Status (BIMS) score of seven (7) indicative of severely impaired cognition, required setup assistance with personal hygiene, and was independent with bed mobility and transfers. The RCP dated 10/24/2025 identified Resident #195 had congestive heart failure. Interventions directed to give cardiac medications as ordered, monitor vital signs and notify medical doctor of significant abnormalities, and oxygen as ordered.Review of the vital signs report dated 1/5/2026 at 8:20 AM identified Resident #195 had a heart rate of 40 beats per minute with a regular rhythm. Review of Treatment Administration Record (TAR) dated 1/5/2026 at 9:00 AM identified LPN #5 did not administer Metoprolol Succinate ER 25 mg.Review of the hospital documentation dated 1/7/2026 identified Resident #195 arrived on 1/5/2026 at 11:19 PM with a heart rate in the 30's and found to be in complete heart block (a serious condition where electrical signals from the heart's upper chambers do not reach the lower chambers, leading to independent beating of the atria and ventricles and possible sudden cardiac arrest). Resident #195's lab results identified an elevated N-terminal pro B-type natriuretic peptide level (a laboratory measurement of stress on the heart to help diagnose or rule out heart failure) of 2693 picograms (pg)/milliliter (ml) (normal levels are below 125 pg/ml). Resident #195 was admitted to the hospital, received treatment, and placement of a dual-chamber pacemaker.Interview with LPN #5 on 1/20/2026 at 1:51 PM identified on 1/5/2026 at 8:20 AM Resident #195 was bradycardic (low heart rate) with a heart rate was 35-37 beats per minute, and his/her heart didn't sound right. LPN #5 stated she called LPN #2 into the room for assistance at which time Resident #195's heart rate increased to 40 beats per minute. LPN #5 identified she notified RN #2 (7 AM- 3 PM unit manager) that Resident #195 had a heart rate of 35-40 beats per minute. LPN#5 stated she did not notify the APRN because RN #2 (unit manager) stated she would notify the APRN. Interview with RN #2 on 1/20/2026 at 2:31 PM identified she was notified by LPN #5 on 1/5/2026 that Resident #195's heart rate was 35-40 beats per minute. RN #2 indicated she assessed Resident #195, who seemed okay, and noted Resident #195's heart rate was maybe 60 beats per minute. RN #2 stated on 1/5/2026 she notified APRN #1 that Resident #195 was experiencing bradycardia but could not recall the time of notification. Interview with APRN #1 on 1/21/2026 at 12:08 PM identified on 1/5/2026 she was notified by RN #2 that Resident #195 had bradycardia . APRN #1 stated she was not Resident #195's provider and identified APRN #2 as the provider who should have been notified.Interview with the DNS on 1/21/2026 at 3:00 PM identified when a resident experiences a change in cardiac status, a change in condition should be initiated include an RN assessment and the physician should be called. The DNS stated on 1/5/26 when Resident #195 was initially noted with bradycardia RN #2 should have completed an SBAR form and documented in the clinical record. Interview with APRN #2 on 1/22/2026 at 9:29 AM identified that she was not notified on 1/5/2026 that Resident #195 experienced a change in cardiac status. APRN #2 stated she should have been notified. Interview with RN #5 ( 3 PM-11 PM supervisor) on 1/28/2026 at 3:59 PM identified on 1/5/2026 he was not notified during shift change report that Resident #195 had experienced a change in cardiac status. RN #5 stated he should have been notified, had he been notified, he would have instructed the nurses to closely monitor Resident #195. Interview with LPN #4 (3 PM-11 PM charge nurse) on 1/28/2026 at 4:28 PM identified she was not notified during the change of shift report on 1/5/2026 that Resident #195 experienced a change in cardiac status during the first shift. LPN #4 stated had she been informed she would have monitored Resident #195 closely. Interview with APRN #4 on 1/30/2026 at 1:01 PM identified she had not been notified on 1/5/2026 by RN #2 that Resident #195 was noted with bradycardia. APRN #4 stated she first notified on 1/5/2026 at 9:24 PM by the facility that Resident #195 had a change in cardiac status and the resident was sent out to the hospital.Review of the facility Change in Condition Notification policy identified in part that the facility will inform the resident, resident's healthcare provider, and the resident's family/legal representative when there is a change in condition. The licensed nurse will notify the resident, resident's healthcare provider, and the resident's family/legal representative of the change in condition.

Based on clinical record reviews, facility policy, facility documentation, observations and interviews for 2 of 2 residents (Resident #49, Resident #269), reviewed for accidents the facility failed to ensure safety alert devices were removed in accordance with the physician's orders and for 1 of 2 residents (Resident #227) reviewed for pain, the facility failed to ensure staff administered medication timely and failed to update the physician (provider) for further instructions. The findings included: 1. Resident #49's diagnoses included dementia, non-traumatic subarachnoid hemorrhage, and difficulty in walking. The RCP dated 1/9/2025 identified Resident #49 was at risk for elopement. Interventions directed an elopement evaluation per facility protocol and placement on a secure unit. The admission MDS assessment dated [DATE] identified Resident #49 had a Brief Interview of Mental Status (BIMS) score of nine (9) indicative of moderately impaired cognition, exhibited wandering behavior one to three days a week, required supervision with chair/bed-to-chair transfers, and was independent with using a manual wheelchair for locomotion. A physician's order dated 1/15/2025 directed to check expiration date on the Wander Guard on the day shift for 7 days. A physician's order dated 1/25/2025 directed to discontinue checking expiration date on the Wander Guard. Observation on 1/15/2026 at 7:32 AM identified Resident #49's had a Wander Guard on his/her left ankle. Observation on 1/16/2026 at 9:57 AM identified Resident #49 had a Wander Guard on his/her left ankle. Interview and observation with LPN #2 on 1/16/2026 at 9:59 AM identified Resident #49 had a Wander Guard in place on his/her left ankle. LPN #2 stated Resident #49 no longer needed the Wander Guard on his/her left ankle because he/she resided on the secure unit. LPN #2 identified when the physician's order directed to discontinue Resident #49's Wander Guard the night shift was responsible for the removal. LPN #2 could not explain why Resident #49 still had a Wander Guard on his/her left ankle. Interview and observation with RN #2 on 1/20/2026 at 9:22 AM identified Resident #49 had a Wander Guard on his/her left ankle. RN #2 identified when the physician's order directs to discontinue a Wander Guard, she is responsible for removing the resident's Wander Guard. RN #2 stated she did not remove Resident #49's Wander Guard because she was not aware Resident #49's Wander Guard had been discontinued since 1/25/2025. 2. Resident #269 diagnoses included dementia, traumatic subarachnoid hemorrhage, and difficulty in walking The quarterly MDS assessment dated [DATE] identified Resident #269 had a BIMS score of six (6) indicative of severely impaired cognition, did not exhibit wandering behavior, and independent with transfers and ambulation. The RCP dated 12/23/2025 identified Resident #269 was at risk for elopement. Interventions included an elopement evaluation per facility protocol, placement on a secure unit, and that the Resident would not go outside without constant supervision. The care plan failed to include placement of a Wander Guard (a bracelet used as part of a safety alert system). A physician's order dated 3/28/2025 directed to check functioning of Wander Guard every night shift for monitoring. A physician's order dated 8/14/2025 directed to discontinue checking function of Wander Guard every night shift for monitoring. Observation on 1/16/2026 at 10:48 AM identified Resident #269 had a Wander Guard on his/her right ankle. Interview and observation with LPN #3 on 1/16/2026 at 10:49 AM identified Resident #269 had a Wander Guard on his/her right ankle. LPN #3 identified she was aware Resident #269 had a Wander Guard because she checks it daily. LPN #3 stated she was not aware Resident #269's Wander Guard order had been discontinued since 8/14/2025. Interview with the DNS on 1/20/2026 at 12:04 PM identified if a physician's order directs to discontinue a Wander Guard the device should be removed. The DNS could not explain why Resident #49 and Resident #269's Wander Guards had not been removed. The DNS stated Resident #49 and Resident #269's Wander Guards should have been removed on the dates the physician's orders directed to discontinue. Review of the facility Wander Guard/Secure Care Alarm policy identified in part for Residents with a Wander Guard, the device will be checked for placement every shift and documented on the Treatment Administration Record (TAR). The device will be checked daily by the licensed nurse and documented on the TAR. Expiration dates of the Wander Guard transponders will be checked weekly and documented on the TAR. 2.Resident #227's diagnosis included chronic pain and major depressive disorder. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #227 was cognitively intact and received pain medication on a scheduled and as needed (PRN) basis. The care plan dated 11/18/2025 indicated Resident #227 received pain medication therapy due to neuropathic pain and chronic pain. Interventions included: to administer medications as ordered by the physician and to monitor and documents side effects and effectiveness. A physician's order dated January 2025 directed to administer Robaxin a 750 Milligrams tablet by mouth 3 times daily for muscle spasms. An interview and record review with the Director of Nursing Services (DNS) on 1/20/2026 from 1:00PM - 1:20 PM indicated the pain medication, Robaxin, was scheduled to be given 3 times/day at 8:00 AM, 12:00 Noon and 4:00 PM an hour before or after the scheduled time and to be considered administered timely. During review Medication Administration Record Report on 1/01/2026 the 8:00 AM dose was given at 9:32 AM (32 minutes late). On 1/02/2026 the 8:00AM dose was given at 11:10 AM, (2 hours 10 minutes late) with the next dose due at 12:00 PM (in 50 minutes). The 12:00 noon dose was given to Resident #227 at 1:02 PM (1 hour 51 minutes after the prior dose) with no evidence noted in the clinical record regarding the reason the Robaxin was given late. The DNS indicated it was possible the medication pass was taking longer than usual due to the influenza outbreak and the addition of 18 residents receiving additional preventative medication due to the outbreak. The DNS further indicated s/he would have expected the nurse, Licensed Practical Nurse to notify the supervisor, physician/ APRN regarding the late administration. An interview with LPN #8 on 1/21/2026 at 10:41AM indicated Resident #227 did not agree with the 1 hour before or 1 hour after the scheduled medication time. The residents expected the medication to be provided at the scheduled time not taking into account the time it takes to provide all residents with their medication. LPN #8 indicated Resident #227 was often angry when the nurse was not fast enough when providing medication. LPN #8 further indicated during the outbreak s/he was able to complete the medication pass timely but during review of the Robaxin administration audit review ( the time the medication was signed by the nurse as given) the untimeliness of the 8:00 AM dose on 1/01/2026 and 1/02/2026 were noted without explanation as to why the medications were administered late without the supervisor and physician being notified. On 1/21/2026 at 10:50 AM an interview with the ADNS and DNS and review of the medication administration audit verified the medication administration audit was the actual time the nurse signed the medication out and administered it to Resident #227. They both indicated that the physician/APRN should have been notified. An interview and record review with APRN #3 on 1/21/2026 at 12:10 PM indicated s/he expected to be called if a medication was given outside the hour before or hour after the scheduled dose time. APRN #3 further indicated in this case since Resident #227 had an order for a PRN dose of the same medication, when LPN #8 provided the 12:00 noon dose 1 hour 51 minutes after the late 8:00 AM dose given at 11:10 AM s/he would not have expected any side effects like drowsiness as Resident #227 had built up a tolerance to pain medication, but s/he would have expected to be notified and would have adjusted the times of the remaining doses. The facility policy labeled Medication Administration and Documentation- General, indicated medication must be given during a 2-hour window of 1 hour before and after the scheduled administration time, use prudent judgment by informing the physician in a timely manner when medications are held refused or otherwise not administered and document an explanatory note in the progress notes.

Based on review of the clinical record, facility documentation, facility policy, and staff interviews for 1 of 4 residents (Resident #111) reviewed for nutrition, the facility failed to implement interventions for a resident with significant weight loss. The findings include:Resident #111 had diagnoses that include dysphagia, dementia, multiple sclerosis, and feeding difficulties.The physician's orders dated 6/4/2024 directed to provide a regular, whole texture, thin liquid consistency house diet.The Resident Care Plan (RCP) dated 10/9/2025 identified Resident #111 at risk for weight loss related to inadequate calorie intake and dementia. Interventions directed to notify the Registered Dietician, family, and Medical Doctor of significant weight changes, and obtain/record weights per facility protocol.Review of Resident #111's weight record dated 10/1/2025 identified weight was recorded as 153.4 pounds (lbs.).The quarterly MDS assessment dated [DATE] identified Resident # 111 had a Brief Interview of Mental Status (BIMS) score of five (5) indicative of severely impaired cognition, required supervision with eating and oral hygiene, and had no signs or symptoms of a swallowing disorder.Review of Resident #111's weight records identified on 10/31/2025 weight was recorded as 140.4 lbs., (13 lb. weight loss/8.5% loss over 1 month), on 11/3/2025 weight was recorded as 140.4 lbs., on 12/2/2025 weight was recorded as 142.2 lbs., on 1/3/2026 weight was recorded as 134 lbs. ( 8.2 lb. weight/5.7% loss over 1 month, and a 19.8 lb./12.8% loss over 6 months).Review of the clinical record dated 10/1/2025 through 1/3/2026 failed to reflect any additional physician orders for nutritional supplements, or interventions to address Resident #111's weight loss.Interview with RN #2 on 1/20/2026 at 9:47 AM identified Nutrition is responsible for monitoring residents with weight loss. RN #2 identified if a resident experiences a significant weight loss, Nutrition would notify nursing of the weight loss and place an order for a re-weight to confirm the weight loss. RN #2 stated that Nutrition did not address Resident #111's 8.5% weight loss in October 2025 or the 8.2% weight loss in January 2026.Interview with Dietitian #1 on 1/20/2026 at 10:36 AM identified he was aware Resident #111 had an 8.5% weight loss in October 2025. Dietitian #1 identified in October 2025 he did not implement interventions to address Resident #111's weight loss because he/she was thinking about Hospice services. Dietitian #1 stated Resident #111 was not placed on Hospice, and he forgot to follow up. Dietitian #1 stated had he implemented an intervention in October 2025 it could have slowed down Resident #111's weight loss.Review of the facility Weight Policy identified in part that significant weight changes will have verification of weight measurement for accuracy and documentation purposes. If verification of weight indicates significant weight change (1 month - 5%; 3 months - 7.5%; 6 months - 10%), the resident and/or family representative and the interdisciplinary care team (IDT) will be notified, and the plan of care will be revised as appropriate. Residents with significant weight changes will be added to weekly weights x four weeks or until the weight stabilizes as determined by the IDT.

Based on clinical record review, facility documentation review, facility policy review, and interviews for 1 of 5 residents (Resident #195) reviewed for change in condition, the facility failed to ensure the clinical record was complete and accurate to include an RN assessment. The findings include:Resident #195 had diagnoses that included heart failure, atherosclerotic heart disease with angina, and hypercholesterolemia.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #195 had a Brief Interview of Mental Status (BIMS) score of seven (7) indicative of severely impaired cognition, required setup assistance with personal hygiene, and was independent with bed mobility and transfers.The RCP dated 10/24/2025 Resident #195 had congestive heart failure. Interventions directed to give cardiac medications as ordered, monitor vital signs and notify medical doctor of significant abnormalities, and oxygen as ordered.Review of the vital signs report dated 1/5/2026 at 8:20 AM identified Resident #195 had a heart rate of 40 beats per minute with a regular rhythm, and on 1/5/2026 at 7:06 PM Resident #195 had a heart rate of 36 beats per minute with an irregular rhythm.Interview with LPN #5 on 1/20/2026 at 1:51 PM identified she noted on 1/5/2026 Resident #195 was bradycardic (low heart rate) with a heart rate between 35-40 beats per minute and notified RN #2. Interview with RN #2 on 1/20/2026 at 2:31 PM identified she was notified by LPN #5 on 1/5/2026 that Resident #195's heart rate was 35-40 beats per minute. RN #2 indicated she assessed Resident #195, who seemed okay, and noted Resident #195's heart rate was maybe 60 beats per minute. RN #2 stated she forgot to document an RN assessment in Resident #195's clinical record.Interview with the DNS on 1/21/2026 at 3:00 PM identified her expectation when a resident experiences a change in condition an RN assessment is completed and documented in the resident's clinical record. The DNS stated on 1/5/2026 that RN #2 should have documented in Resident #195's clinical record that she conducted an RN assessment.Review of the facility Change in Condition Notification policy identified in part the licensed nurse will conduct a complete physical/mental evaluation and document findings in the medical record. The resident's reactions to symptoms must be documented.

Based on clinical record reviews, review of facility policy, and interviews for one (1) of four (4) sampled residents (Resident #1) reviewed for an allegation of resident-to-resident abuse, Resident #1 was not provided the right to be free from physical abuse when Resident #1 was punched in the face by Resident #2 following an earlier verbal altercation between Resident #1 and Resident #2. The findings include:Resident #1's diagnoses included anxiety disorder, persistent mood disorder, and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) indicating Resident #1 was alert and oriented, utilized a wheelchair for mobility, and was able to self-propel independently once in the wheelchair. The resident care plan identified Resident #1 had the potential to be verbally aggressive, poor impulse coping, and poor boundary setting. Resident #2's diagnoses included quadriplegia, generalized anxiety disorder, and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) indicating Resident #1 was alert and oriented, utilized a wheelchair for mobility, and was able to self-propel independently once in the wheelchair. The resident care plan identified Resident #2 had the potential to be verbally aggressive. The nurse's progress note dated 12/7/25 at 2:02 PM identified Resident #1 was witnessed having a physical altercation with another resident across from the coffee shop on the main floor. The note indicated the residents were separated, an in-house emergency call was made, nursing responded and conducted a full assessment, 911 was called, and Resident #1 was transferred to the hospital. The nurse's progress note dated 12/7/25 at 4:39 PM identified a resident reported to staff that they witnessed Resident #2 wheel up to another resident (Resident #1) who was seated in a wheelchair in the Front Lobby and started punching another resident. The note indicated the incident was witnessed by other residents who informed the receptionist and she activated the in-house emergency response. The note identified Resident #2 was noted to have a blood stain to the left side of the nose area with a small abrasion. The note indicated after several attempts to transfer Resident #2 to the hospital for a psych evaluation, at approximately 4:12 PM Resident #2 was transferred to the hospital in restraints. The Facility Reported Incident form dated 12/7/25 identified at 1:20 PM staff were notified of a physical altercation between Resident #1 and Resident #2 near the front lobby. The report indicated a resident witnessed Resident #2 wheel up to Resident #1 who was seated in a wheelchair and Resident #2 started punching Resident #1 without provocation. The report identified Resident #2 stood up from the wheelchair and continued to hit Resident #1 with a closed fist on the right side of the face. The report was indicated Resident #1 was noted with bleeding from the left eye and nostrils, with redness and bruising to the outer area of the left eye. The investigation identified Resident #1 was punched in the face with a closed fist by Resident #2 on 12/7/25 at 1:20 PM while in the front lobby area, near the recreation room. The investigation indicated there had been a verbal altercation earlier that day, 12/7/25 when Resident #1 saw Resident #2 on his/her unit speaking with a staff member. The hospital Discharge summary dated [DATE] identified Resident #1 was admitted to the hospital on [DATE] with diagnoses of open fracture of the nasal bone, hematoma of the nasal septum, periorbital hematoma, and open fracture of the ethmoid bone (a square bone at the root of the nose). Interview with Resident #1 on 12/30/25 at 10:50 AM indicated he/she saw Resident #2 on the unit talking to an aide after lunch on 12/7/25 and did not want Resident #2 on the unit. Resident #1 indicated he/she left the unit, went downstairs to the front lobby area, and when downstairs, Resident #2 appeared, came up in his/her chair and tangled it up with mine. Resident #1 indicated he/she lifted his/her arm up to protect him/herself when Resident #2 approached and then was punched by Resident #2 to the left side of the face multiple times. Interview and review of the Facility Reported Incident report with Director of Nursing (DON) on 12/30/25 at 11:02 AM identified a verbal altercation between Resident #1 and Resident #2 occurred on 12/7/25 on the fourth floor and then led to physical contact in the front lobby area, Resident #2 punched Resident #1 in the face on 12/7/25 around 1:20 PM. The DON identified following the incident, Resident #2 no longer resided at the facility. Review of facility Abuse policy dated January 2023 identified abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish and directed that each resident has the right to be free from abuse and will not be subjected to abuse by anyone, including other residents. The facility identified the deficient practice and developed an immediate plan of correction for past noncompliance. DON/Designee will complete a 100% audit of residents with documented aggression independent with their mobility to ensure current care plan interventions are present, appropriate and individualized with behavioral monitoring in place.Nursing, aides, social services, recreation, and management were education on:Resident-to-resident altercation preventionAbuse reporting timelinesBehavioral health recognition and required documentationAlcohol use policy and recognizing signs and symptoms of impairmentIdentifying triggers and early escalation signsSupervision expectations for high-risk residentsHow and when to update the care planWhen to request a provider or Behavioral Health consultThe DON/designee will complete audits weekly for four weeks then monthly for two monthsNew incidents of aggression will be audited for timely reporting, investigation completion, throughout care plan review and implementation of appropriate interventionsFindings will be reported to QAPI monthly.Completion date December 21, 2025.

Based on review of the clinical record, facility documentation, and facility policy, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to reassess a resident's elopement/wander risk timely when resident had a change in condition and mobility status, resulting in an elopement from the facility. The findings include: Resident #1's diagnoses included dementia, psychotic disturbance, mood disturbance, anxiety, and a history of a fall with a laceration to the head.Review of hospital Discharge summary dated [DATE] identified admission after a witnessed fall at home with head strike and head laceration. History of dementia, family reported often sleeps in a recliner and gets in and out of the recliner throughout the night. Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time and situation, required maximum assistance of two (2) staff for transfers, and unable to determine gait at the time of assessment, and ambulation was not identified. Wander assessment dated [DATE] identified Resident #1 did not have the physical ability to leave the facility. Further, question A.3. asked is the resident cognitively impaired AND have the physical ability to leave the building: was answered No. The Resident Care Plan (RCP) dated 9/15/2025 identified self-care deficit related to weakness, and ADL deficit. Interventions directed assist with ADLs, and Resident #1 was non-ambulatory. Physical Therapy assessment dated [DATE] identified Resident #1 had poor standing balance with a rolling walker, required extensive assistance of two (2) staff for transfers, ambulation was not attempted due to safety concerns, and previously ambulated independently. Physical Therapy assessment dated [DATE] identified Resident #1 was able to ambulate 10 to 15 feet with extensive staff assistance. Physical Therapy assessment dated [DATE] identified Resident #1 was able to ambulate 30 feet with minimal assistance. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1's preferred language was Spanish, had a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicative of severe cognitive impairment, required extensive assistance of two (2) with bed mobility and transfers, used a wheelchair and did not ambulate. Nurses note dated 9/21/2025 at 2:13 AM identified Resident #1 was ambulating in room, not able to sleep, agitated at times, and difficult to redirect. Nurses note dated 9/21/2025 at 8 PM identified Resident #1 was found wandering in other resident rooms multiple times during the evening, redirected to room, and request for APRN psychiatry evaluation. APRN note dated 9/22/2025 at 10:15 AM identified Resident #1 was seen for an alleged verbal threat made to roommate (Resident #6). Resident #6 reported that Resident #1 was wandering around the room and opened his/her bedside table drawer and began going through it, and shortly after Resident #1 said I will kill you. Resident #1 has a history of dementia and has been known to get in and out of bed throughout the night. Plan transfer to hospital for evaluation. APRN note dated 9/23/2025 at 9 AM identified Resident #1 returned from the hospital on an antibiotic for a urinary tract infection. History of dementia and Resident #1 has been known to wander around her room and the facility which contributed to recent incident with roommate, an no current concerns of threatening ideations. Physical Therapy assessment dated [DATE] identified Resident #1 was able to ambulate 100 feet with supervisor or touch assist. Nurses note dated 9/27/2025 at 7:07 AM identified agitated with care, refused meds and blood sugar monitoring. Record review failed to identify reassessment of elopement risk when Resident #1 exhibiting agitation and wandering behaviors. Review of facility reportable event dated 9/27/2025 at 2:30 PM identified LPN #1 reported he was going to provide care and told Resident #1 he would be right back, and left the room to obtain supplies. LPN #1 returned to the room approximately two (2) minutes later and did not find Resident #1. LPN #1 alerted staff on the unit and a facility code (code yellow for missing resident) was paged to search for Resident #1. Resident #1 was located outside the facility building walking on the side walk and was returned to his/her room with no injuries identified. A new elopement evaluation was completed, a wander guard bracelet was applied, and placed on one-to-one (1:1) observation until transfer to secure unit. Nursing note dated 9/29/2025 at 2:16 PM identified a BIMS assessment was repeated with assistance of an interpreter due to a suspected language barrier. Resident #1 was alert and cooperative throughout the assessment, and score was 14 out of 15, indicating alert and oriented. Following completion of interview, the resident became distracted by television and subsequently developed anxiety related to its content, cognition appeared to vacillate once anxiety set in. Review of facility summary report dated 10/1/2025 identified follow-up BIMS indicated Resident #1 was alert and oriented. Further, Resident #1 stated that he/she reported wanting to visit his/her child who lived nearby. Record review identified Resident #1 was discharged from facility on 9/29/2025. Interview and review of facility documentation on 10/9/2025 at 1:16 PM with DNS and Administrative Assistant identified a wander re-assessment should have been completed when Resident #1 was found not sleeping, wandering into other resident's rooms, wandering in his/her room, going through his/her roommate's belongings, needing redirection, and had signs of agitation over several days (9/20 to 9/27/2025). Further, the DNS indicated a BIMS reassessment completed on 9/29/2025 identified Resident #1 was alert and oriented, and Resident #1 was discharged to home on 9/29/2025 around 5 PM. Review of facility Elopement Policy directed in part; a risk evaluation will be done on new admissions with a change in resident's condition.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #3) reviewed for behaviors, the facility failed to ensure the care plan was reviewed and revised with appropriate interventions to manage behaviors for a resident who expressed suicidal ideations with intent. The findings include:Resident #1 had diagnoses that included suicidal ideation, paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression.The physician's orders dated 6/7/2025 directed to monitor the number of behavior occurrences of restlessness, withdrawn, sadness, agitation, intervention, and outcome every shift.The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (BIMS score of 15), was occasionally incontinent of bowel, presence of an indwelling foley catheter, dependent with personal hygiene, toileting, required substantial assistance with eating, toileting, required touching assistance with transfers, and independent with bed mobility.The Resident Care Plan (RCP) plan dated 6/18/2025 identified Resident #1 has a behavior problem with suicidal ideation related to paranoia history of multiple hospitalizations due to homicidal and suicidal ideations. Interventions directed to administer medications as ordered, monitor and document side effects and effectiveness, encourage the resident to express feelings appropriately, anticipate and meet the resident's needs, approach and speak in a calm manner, divert attention, remove from an overstimulating environment, caregivers provide the opportunity for positive interaction, attention, stop and talk with h/her as passing by, and assist the resident to develop more appropriate methods of coping and interacting. The care plan failed to identify a concern related to Resident #1's suicidal ideations with intent and include personalized interventions to manage behaviors.The nurse's note dated 6/29/2025 at 11:42 P.M. written by Registered Nurse (RN) #2 identified that Resident #1 verbalized that h/she wanted to hurt h/herself with h/her a weighted silverware knife. RN #2 indicated Resident #1 was alert, verbal, with no evidence of distress and handed the knife over. RN #2 identified the on-call provider was notified and Resident #1 was transferred to the ER for a Psych evaluation.The nurse's note dated 6/30/2025 at 2:01 P.M. written by Licensed Practical Nurse (LPN) #4 identified Resident #1 returned from the hospital with no acute issues noted.Review of the clinical record failed to identify any revisions to the plan of care for Resident #1 on 6/30/2025.Review of APRN #1's note dated 7/1/2025 at 8:00 A.M. identified Resident #1 was seen for follow up visit h/she is back from a recent acute hospitalization for suicidal ideations. APRN #1 indicated Resident #1 exhibits attention seeking behaviors which include placing self on the floor and claiming seizure activity. APRN #1 identified Resident #1 would likely benefit from a structured psychiatric therapeutic environment.The nurse's note dated 7/9/2025 at 11:16 P.M. written by LPN #3 identified at approximately 10:50 P.M. Resident #1 notified LPN #3 that h/she was hearing voices in h/her head telling h/her to kill people. LPN #3 indicated he notified the supervisor, RN #4. The nurse's note dated 7/10/2025 at 12:31 A.M. written by RN #4 identified that Resident #1 was a danger to self or others and a suicidal potential.The nurse's note dated 7/10/2025 at 10:29 P.M. written by RN #2 identified Resident #1 returned to the facility from the hospital post evaluation due to suicidal ideation. RN #2 indicated the psychiatrist cleared Resident #1 and Resident #1 has no intent to harm self or others.Review of the clinical record failed to identify revisions to the plan of care for Resident #1 on 7/10/2025.Interview and clinical record review with the Director of Nursing (DNS) on 8/13/2025 at 10:51 A.M. identified on 6/29/2025 and 7/9/2025 following Resident #1's expressions of suicidal ideations with intent to harm self the care plan was not revised to address and manage the behavior. The DNS identified she was not sure Resident #1's care plan needed to be updated with new intervention and if it needed to be updated, she was not sure why it was not updated.Review of the facility baseline/comprehensive person-centered care plan policy dated 3/2023; in part, identified the comprehensive person-centered care plan will be reviewed and revised episodically, as the plan of care changes, and at the time of hospital readmission to ensure that the plan reflects resident's current status.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to remove environmental hazards and implement safety interventions for a resident with expressed suicidal ideation and intent. The resident was transferred to the emergency department (ED) 4 times over a 38-day period for expressions of suicidal ideations with intent. The findings include:Resident #1 had diagnoses that included suicidal ideation, paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression. Review of the undated Kardex Report identified Resident #1 requires supervision and assistance with self-feeding after set-up with intermittent verbal cues for attention to task with one staff. The physician's orders dated 6/7/2025 directed to monitor the number of behavior occurrences of restlessness, withdrawn, sadness, agitation, intervention, and outcome every shift. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, was occasionally incontinent of bowel, presence of an indwelling foley catheter, dependent with personal hygiene, toileting, required substantial assistance with eating, toileting, required touching assistance with transfers, and independent with bed mobility.The Resident Care Plan (RCP) plan dated 6/18/2025 identified Resident #1 had a behavior problem with suicidal ideation related to paranoia history of multiple hospitalizations due to homicidal and suicidal ideations. Interventions directed to administer medications as ordered, monitor and document side effects and effectiveness, encourage the resident to express feelings appropriately, anticipate and meet the resident's needs, approach and speak in a calm manner, divert attention, remove from an overstimulating environment, caregivers provide the opportunity for positive interaction, attention, stop and talk with h/her as passing by, and assist the resident to develop more appropriate methods of coping and interacting. The nurse's note dated 6/29/2025 at 11:42 P.M. written by Registered Nurse (RN) #2 identified Resident #1 verbalized that h/she wanted to hurt h/herself with a weighted silverware knife. RN #2 indicated Resident #1 was alert, verbal, with no evidence of distress and handed the knife over. RN #2 identified the on-call provider was notified and Resident #1 was transferred to the ER for a Psych evaluation. The nurse's note dated 6/30/2025 at 2:01 P.M. written by Licensed Practical Nurse (LPN) #4 identified Resident #1 returned from the hospital with no acute issues noted. Review of the clinical record failed to identify any revisions to the plan of care or mitigation of the environmental risk factors for Resident #1 on 6/30/2025. Review of APRN #1's note dated 7/1/2025 at 8:00 A.M. identified Resident #1 was seen for follow up visit secondary to a recent acute hospitalization for suicidal ideations. APRN #1 indicated Resident #1 did not exhibit any evidence of acute psychosis. APRN #1 indicated Resident #1 exhibits attention seeking behaviors which includes placing self on the floor and claiming seizure activity. APRN #1 identified Resident #1 would likely benefit from a structured psychiatric therapeutic environment. The nurse's note dated 7/9/2025 at 11:16 P.M. written by LPN #3 identified at approximately 10:50 P.M. Resident #1 notified LPN #3 that h/she was hearing voices in h/her head telling h/her to kill people. LPN #3 indicated he notified the supervisor, RN #4. The nurse's note dated 7/10/2025 at 12:31 A.M. written by RN #4 identified Resident #1 as a danger to self or others and a suicidal potential. RN #4 identified that Resident #1 was sent out to the emergency room. The nurse's note dated 7/10/2025 at 10:29 P.M. written by RN #2 identified Resident #1 returned to the facility from the hospital after an evaluation due to suicidal ideation. RN #2 indicated the psychiatrist cleared Resident #1 and Resident #1 has no intent to harm self or others. Review of the clinical record failed to identify any revisions to the plan of care or mitigation of the environmental risk factors for Resident #1 on 7/10/2025.The facility's accident and incident report dated 7/22/2025 at 8:05 P.M. identified Resident #1 exited h/her room holding a butter knife and observed rubbing it against h/her wrist while stating h/she wanted to harm h/herself. Resident #1 was immediately placed on one to one, an order obtained to transfer Resident #1 to the ED for evaluation. Review of the clinical record failed to identify the safety risk of Resident #1 having access to knives or silverware on 7/22/2025. The nurse's note dated 7/23/2025 at 1:43 P.M. written by LPN #1 identified Resident #1 returned to from the hospital with a no harm letter. Review of APRN #2's note dated 7/23/2025 at 8:30 A.M. identified Resident #1 was evaluated today after a hospital visit for increased suicidal ideation and self-harm by attempting to cut h/herself with a butter knife as evidenced by superficial scratches to h/her arms. APRN #2 indicated Resident #1 denies any suicidal ideation and was able to commit to safety. APRN #2 identified Resident #1's medications were not changed in the emergency department, will continue current medication regimen, and monitor for any changes in mental status and behavior. The social service assessment note dated 7/24/2025 at 2:52 P.M. written by Social Worker (SW) #3 identified Resident #1 was readmitted to the facility from the hospital due to active thoughts of suicidal ideation. SW #3 identified Resident #1's suicidal ideation behaviors have increased. SW #3 indicated she sent a referral regarding Resident #1 to explore options for higher level of mental health treatment. The facility's summary dated 7/28/2025 identified on 7/22/2025 Resident #1 was seen rubbing the knife against h/her wrist and verbalized intent to harm h/herself citing distress related to the lack of contact with h/her brother, a nursing assessment revealed no evidence of skin breakdown, redness, or injury to the wrists or surrounding area. Resident #1 was transferred to the ED, returned to the facility with documentation indicating 'no harm' determination, no injuries were noted, no additional treatment or recommendations were provided by the hospital. During follow-up at the facility Resident #1 acknowledged taking the butter knife from h/her roommate's meal tray. The plan of care was updated with interventions that included, staff were directed to retrieve and secure all silverware from Resident #1 and h/her roommate, following meals to prevent access.Review of APRN #2's note dated 8/6/2025 at 9:30 A.M. identified Resident #1 was seen today due to reported increased hallucinations and suicidal ideations. APRN #2 identified Resident #1 reported after a phone call h/she started having auditory hallucinations commanding h/her to kill h/herself with a plastic knife and Resident #1 expressed a desire to go to the hospital. APRN #2 indicated that Resident #1 was placed on a one-to-one observation until h/she was transferred to the hospital for further evaluation. The nurse's note dated 8/6/2025 at 2:39 P.M. written by RN #5 identified Resident #1 reported h/she had auditory hallucinations telling h/her to hurt self by cutting h/her wrist with a knife. RN #5 identified Resident #1 was transferred to the hospital. The nurse's note dated 8/7/2025 at 3:05 P.M. written by RN #5 identified Resident #1 returned from the emergency room with a no harm letter after being sent out for suicidal ideations with auditory hallucinations that told h/her to hurt h/herself. RN #5 indicated Resident #1 feels h/she is in a better place and the auditory hallucinations have subsided. Interview with the Director of Nursing (DNS) on 8/13/2025 at 10:51 A.M. identified that after Resident #1 returned from the 7/22/2025 hospitalization for expressions of suicidal ideations, Resident #1's roommate's room was changed (per the roommate's request) and all cords and phone charger were removed from Resident #1's room. The DNS identified that Resident #1 had access to silverware including butter knives because it did not pose a safety risk despite prior expressions of suicidal ideations because Resident #1 had never acted h/her suicidal ideations. Observation of Resident #1's room on 8/13/2025 at 11:50 A.M. identified a corded call light was present in Resident #1's room. A follow-up interview with the DNS on 8/13/2025 at 12:13 P.M. identified Resident #1's corded call light had not been removed. The DNS identified that the cords and phone charger were removed due to an increase in Resident #1's suicidal ideations, but it was not indicated to remove the corded call light.Interview with APRN #2 on 8/13/2025 at 12:33 P.M. identified on 7/23/2025 she observed superficial scratches on Resident #1's arms that may have been from Resident #1 rubbing the butter knife on h/her arms. APRN #2 indicated Resident #1 having access to knives and metal silverware did not pose a safety risk despite prior expressions of suicidal ideations and visible scratches to Resident #1's arms.Interview and review of Resident #1's meal ticket with the Dietary Director on 8/13/2025 at 2:05 P.M. identified that on 7/30/2025 Resident #1's meal ticket was revised to include no knives but he did not know why he was notified to stop sending knifes up on Resident #1's meal tray.Observation of Resident #1's room on 8/14/2025 at 6:40 A.M. identified the corded call light was removed from Resident #1's room and a handheld bell was on the table. Observation of Resident #1's room on 8/14/2025 at 6:40 A.M. identified the corded call light was removed from Resident #1's room and a handheld bell was on the table. Interview with NA #6 on 8/14/2025 at 9:50 A.M. identified she notified the Dietary Supervisor on 7/30/2025 to stop providing knives for Resident #1 as h/she frequently tells her that h/she does not need knives to eat h/her meals.Interview with MD #1 (Medical Director) on 8/14/2025 at 7:33 A.M. identified that Resident #1 having access to metal silverware including butter knives did not pose a safety risk despite Resident #1's expressions of suicidal ideations.Subsequent to surveyor inquiry, the DNS identified on 8/13/2025 she removed Resident #1's corded call light, Resident #1 was provided with a handheld bell, and on 8/13/2025 Resident #1's care plan was revised with a new intervention that directed no knives with meals. Review of the facility behavioral management program policy dated 10/2022; in part, identified the goal is to provide a person-centered approach to care that maintains a safe/supportive environment and is directed toward understanding, preventing, and relieving a resident's emotional distress.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for accidents, the facility failed to ensure the resident received supervision assistance during mealtime in accordance with the plan of care which resulted in a choking incident. The findings include: Resident #2 's diagnoses included hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebral infarction (death of brain tissue/stroke) affecting the right dominant side, dysphagia (difficulty swallowing), aphasia (language disorder), apraxia (motor disorder), epilepsy and dementia without behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a staff assessment for Mental Status conducted identifying both short-term and long-term memory problems indicative of severely impaired cognition and required setup and cleanup assistance with eating, substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 3/4/25 identified Resident #2 had dysphagia related to a stroke. Interventions included ensuring all meals and fluid intake occurred under staff supervision and providing speech therapy services as ordered. A Speech Therapy Discharge summary dated [DATE] identified that Resident #2 had been on speech services starting 3/12/25 and was discharged on 3/27/25. The summary identified Resident #2 required supervision/assistance at mealtime due to swallowing safety 0-25 percent (%) of the time and to facilitate safety and efficiency. The summary identified that the Resident #2 ' s prognosis (expected outcome) was good with consistent staff follow-through A nurse's note dated 4/1/25 at 4:30 PM identified Resident #2 began coughing and choking while eating lunch, the Heimlich maneuver was performed and a code was called for immediate assistance to the room. The facility Reportable Event (RE) Form dated 4/1/25 identified that at 12:15 PM, Resident #2 had a choking episode, during lunch, in his/her room. The RE identified that upon entry to Resident #2 ' s room, NA #5 observed Resident #2 coughing and turning red in color. The RE identified that another NA went to notify the nurse and that the Advanced Practice Registered Nurse (APRN #2) was nearby during the incident and intervened by successfully performing the Heimlich maneuver. The RE identified Resident #2 ' s diet was downgraded immediately, speech therapy was notified to screen Resident #2, orders were obtained for vital signs and lung sounds every four (4) hours, to obtain bloodwork and a chest x-ray, and for supplemental oxygen as needed and a hospice consult. The facility Summary Report dated 4/2/25 identified the RCP directed supervision during meals but the supervision requirements were not effectively communicated by the Speech Therapist (ST) to the care team and was not implemented. Following the incident, the ST would be required to document all dietary and supervision changes in the therapy Activities of Daily Living (ADL) evaluation immediately and then the Assistant Director of Nursing Services (ADNS) would be responsible for reviewing and locking the evaluation confirming the receipt of updates from the ST. The summary identified there would be written communication/documentation from the ST to nursing for changes made to the RCP and nursing would communicate the changes to the NA's every shift for 24-hours following the changes. Interview with APRN #2 on 4/15/25 at 12:28 PM identified that on 4/1/25 Resident #2 appeared to be choking. She indicated Resident #2 was rigid and it took multiple staff to lean him/her forward in his/her customized wheelchair, to assist with the Heimlich maneuver, and Resident #2 continued to cough and expel copious amounts of secretions. APRN #2 identified that a code was called, and a male staff member responded and stood Resident #2 up. Resident #2 then coughed up chicken, continued to cough, and his/her lung sounds were still not clear. She reported Resident #2 was encouraged to continue coughing and he/she eventually coughed up another piece of chicken which ceased the coughing. Interview with ST #1 on 4/15/25 at 1:18 PM identified that Resident #2 was referred to ST in March 2025 for weight loss and to ensure his/her diet was appropriate. She reported Resident #2 was discharged from ST services on 3/27/25 with an unchanged regular texture diet and thin liquids, and indicated she had no concerns. She identified that if new diet orders were placed, she would have verbally communicated the new orders to the charge nurse but since the diet remained unchanged and the RCP already identified Resident #2 required supervision for meals, she did not verbally notify the charge nurse of the strategy recommendations. She identified that when she re-evaluated Resident #2 following the 4/1/25 choking incident, Resident #2 had an evident decline to include new left sided weakness, facial droop, and Resident #2 was not triggering a swallow at all. Interview with NA #6 (accompanied by the DNS) on 4/15/25 at 1:30 PM identified that on 4/1/25, she was in the hallway passing lunch trays when NA #5 called her from Resident #2's doorway stating Resident #2 was choking and needed help. NA #6 reported she observed Resident #2 coughing and turning red and she then alerted LPN #1. NA #6 identified she knew Resident #2 well and he/she had always been a setup for meals, not requiring staff supervision. Interview with NA #5 (accompanied by the DNS) on 4/15/25 at 1:41 PM identified she was responsible for providing care for Resident #2 during the 7:00 AM to 3:00 PM shift on 4/1/25 and was regularly assigned to provide care for Resident #2. NA #5 identified that, according to the Resident Care Card (RCC) (quick-reference sheet used by NAs which lists information about daily care needs), Resident #2 was a setup only for meals. NA #5 reported that on 4/1/25, she went to check on Resident #2, after feeding another resident, and when she observed Resident #2 from the hallway, he/she was sitting in the wheelchair with his/her mouth open and tongue sticking out. NA #5 reported that LPN #1 came into the room immediately and they attempted looking into Resident #2 ' s mouth, but he/she would not allow them to perform a finger sweep. NA #6 identified that APRN #2 came in to assist and LPN #1 then performed the Heimlich maneuver from the front of Resident #2, which dislodged a one-inch cubed shaped piece of chicken but Resident #2 continued to cough so they called a code for additional assistance. Interview with NA #4 on 4/15/25 at 2:33 PM identified she delivered Resident #2's lunch tray on 4/1/25, and Resident #2 wanted to eat in his/her room while in his/her customized wheelchair. NA #4 reported Resident #2 was a meal setup per the RCC, so she cut the chicken into one-inch pieces, ensured Resident #2 had everything he/she needed and then left the room. Interview with LPN #1 on 4/16/25 at 11:41 AM identified that on 4/1/25 NA #5 reported to her that Resident #2 was choking. She identified that she floats to work on all the facility units and was unsure of Resident #2 ' s meal assistance level at the time of the incident. Interview with the DNS on 4/15/25 at 1:55 PM identified that the RCP directed Resident #2 required supervision for meals. The DNS indicated she thought Resident #2 was a setup only, as he/she was on a regular texture diet with thin liquids. Interview with ADNS #2 on 4/15/25 at 2:04 PM identified she was unaware that Resident #2 required supervision assistance with meals prior to the 4/1/25 choking incident and was also unaware that the RCP directed supervision with meals since 2017. She identified that during the incident investigation it was identified that the RCP interventions, to include supervision with eating, were initially entered incorrectly, so did not appear on the RCC. She reported that subsequent to that finding, the facility did a whole house audit to ensure all RCPs were reflected on RCCs. Interview with the DNS, ADNS #1, ADNS #2 and RN #6 (Regional nurse) on 4/15/25 at 2:21 PM identified that they initiated a Plan of Correction (POC) immediately on 4/1/25 regarding the choking incident with Resident #2 including reviewing emergency response procedures, both Speech Therapy and nursing staff responsibilities involving the 'Therapy ADL evaluation', a written Care Plan revision communication tool to be implemented to ensure critical care plan changes are communicated effectively, mandatory training for all direct care staff to include dysphagia management, dietary modifications and meal supervision, the implementation of competency assessments to ensure that staff understand choking prevention protocols and intervention strategies and meal supervision audits. The facility will also monitor clinical alerts in the electronic health record and review NA documentation regarding meal consumption and any changes/difficulties that residents have exhibited, review residents with a diagnosis of dysphagia to ensure Care Plans and Speech Therapy recommendations match and re-educate staff as needed and refer to Speech Therapy any residents in question. Additionally, they identified that for the pre-populated dysphagia Care Plan, under the interventions, it automatically says supervision for eating, but it doesn't automatically carry over to the Care Plan, stating that in their new Therapy ADL evaluation, when meal assistance/supervision is checked off, it automatically carries over to the [NAME]. Although requested, a facility policy for providing assistance with meals was not provided.

Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for two of four residents (Resident #177 & #69) who were at high risk for the development of pressure ulcers and who developed facility acquired pressure ulcers, the facility failed to ensure that resident specific comprehensive interventions were implemented, failed to assess the wound in a timely manner inclusive of description, measurements, and stage upon initial discovery of an opened area, and failed to provide consistent turning and repositioning to offload the sacrum contributing to the advanced worsening of the wound. The findings include: 1. Resident # 177's diagnoses included Alzheimer's dementia, contracture of left and right hands, gastrostomy, and functional quadriplegia. The physician's order dated 1/3/23 with an origination date of 7/27/22 directed to complete skin checks weekly and document skin checks in the nurse's notes and air mattress set to the most current weight and check setting and function every shift. The Braden Scale Assessment (used to predict risk for pressure ulcer development) dated 7/24/22 identified the resident had a score of 10 which is indicative of the resident being at high risk for the development of a pressure ulcer. The annual MDS assessment dated [DATE] identified Resident #177 had severe cognitive impairment, was totally dependent for transfers, hygiene, toileting, and dressing, was always incontinent of bladder and bowel, was at risk for the development of pressure ulcers but did not currently have a pressure ulcer. The Resident Care Plan (RCP) dated 1/26/23 identified Resident #177 was at high risk for skin breakdown related to dementia, incontinence, history of pressure ulcers and immobility. Care plan interventions directed to apply protective skin barrier cream, pressure reducing cushion and mattress and two persons for turning and repositioning. Review of the RCP failed to identify resident specific interventions related to the positioning of the resident. Review of the weekly skin checks documented in the nurse notes from 1/6/2023 through 2/6/23 identified Resident #177 had no notable skin issues. Review of the turning and repositioning task nurses' aide documentation from 1/6/23 through 2/6/23 identified Resident #177 was not consistently repositioned every two hours (the form is formatted in two-hour increments of time). The nurse's note dated 2/7/23 at 3:48 PM identified Resident #177 had a resident care plan meeting with the interdisciplinary team present. Resident #177 and his/her responsible party were invited but chose not to participate in the care plan meeting. The note further identified Resident #177 had been stable medically and nutritionally throughout the last quarter. The nurse's note dated 2/7/23 at 9:54 PM written by LPN #2 identified Resident #177 had an open area in the same location as a previous pressure ulcer wound. The nurse's note did not contain any further information concerning the opened area. There were no measurements documented and no specific area identified. A Dietician's note dated 2/9/23 at 11:12 AM identified Resident #177 had a new stage 3 pressure ulcer wound to the coccyx. The note further identified the resident would have a liquid protein supplement twice per day added to his/her diet. The Situation, Background, Assessment, Recommendation (SBAR) nurse's note dated 2/9/23 at 12:28 PM (written by the unit manager (RN) identified Resident #177 had a stage 3 pressure ulcer wound to the coccyx that measured 1.0 centimeter (cm) in length by 1.0 centimeter (cm) in width. The note further identified the resident did not appear to be in distress or discomfort at that time. The wound nurse, nurse practitioner and family were updated. The physician's order dated 2/9/23 directed to cleanse the coccyx area with normal saline, pat dry then apply Calcium Alginate (wound treatment) followed by gauze dressing on a daily basis and as needed. The Braden scale assessment dated [DATE] identified the resident was at a very high risk for the development of a pressure ulcer (there were no documentation of a Braden scale assessments completed between 7/24/23 and 2/9/23 when the resident was identified as having a stage 3 pressure ulcer). Review of the clinical record failed to identify the open area identified on 2/7/23 was assessed by a registered nurse, or that a physician/APRN was notified or that a treatment was put in place prior to 2/9/23 (two days after the area was noted). The RCP dated 2/9/23 identified Resident #177 had a pressure ulcer related to contracture, history of pressure ulcers, immobility, and sensory impairment. Care plan interventions directed for a dietician evaluation, monitor the wound for signs of symptoms of infection, weekly wound evaluation per protocol, treatment as ordered by the physician, and turn and reposition. The nurse's note dated 2/10/23 at 7:00 AM identified Resident #177's wound dressing to the coccyx was clean, dry, and intact and had no signs and symptoms of pain and nurse's aide repositioning the resident every two hours. The initial wound evaluation and management summary dated 2/14/23 completed by the Wound Specialist identified Resident #177 had a stage 4 full thickness wound to the sacrum related to pressure. The wound size was documented as 1.2 cm in length by 1.0 cm in width and 0.4 cm in depth. The treatment plan directed: apply Calcium Alginate once a day for thirty days, limit sitting to 60 minutes, offload wound, reposition per facility protocol, and turn side to side in bed every 1 to 2 hours if able. The wound evaluation dated 4/4/23 identified the stage 4 pressure full thickness wound to the sacrum would benefit from debridement of the peri-wound macerated skin edge. The wound size was documented as 1.0 cm in length by 0.7 cm in width by 0.3 cm in depth. The treatment plan directed to apply gauze island with border once a day. The wound evaluation dated 4/25/23 identified the stage 4 to the sacrum was surgically debrided to remove devitalized epidermis and/or dermis and to remove dried exudate or debris. The wound size was documented as 1.5 cm in length by 0.9 cm in width by 0.2 cm depth. The treatment plan directed to apply collagen sheet and gauze island with border dressing daily. Further review of the wound evaluations conducted by the Wound Specialist (MD #1) along with the facility's Wound Nurse (LPN #4) identified that he assessed the wound on a weekly basis and performed debridement of the wound on 5/9/23, 5/16/23, 6/13/23, 7/11/23, 8/15/23, 9/12/23, and 10/10/23, 11/9/23, and 12/19/23. The wound evaluation 1/2/24 identified the stage 4 to the sacrum was surgically debrided to remove biofilm. The wound size was documented as 1.7 cm in length by 1.8 cm in width by 0.9 cm in depth with undermining at 11:00 o'clock. The treatment plan included the application of a collagen sheet and gauze island with border dressing daily with a recommendation for diathermy therapy. Review of the weekly wound evaluations for the period of 2/14/23 to 1/2/24 identified the recommendations to limit sitting to 60 minutes, offload the wound and reposition per facility protocol, turn side to side in bed every 1 to 2 hours if able. Review of the RCP and the treatment administration record failed to identify the implementation of the recommendation for the 1-to-2-hour side to side repositioning and the offloading of the wound. Observation on 1/7/24 at 9:30 AM identified Resident #177 lying in bed on his/her back with the head of the bed raised to approximately 30 degrees, continuous tube feeding in place and the alternating air loss mattress was set at 350 lbs. Review of the clinical record identified Resident #177's weight was documented as 178 pounds on 1/8/24. Review of the nurse aides' turning and repositioning documentation dated 1/7/24 identified Resident #177 was positioned on his/her back from 4:00 AM to 3:59 PM (approximately 12 hours passed before Resident #177 was turn to his/her right side). Observation on 1/8/24 at 9:30 AM identified Resident #177 lying in bed on his/her back with the head of the bed raised to approximately 30 degrees with the continuous tube feeding in place and the alternating air loss mattress setting was noted to be set at 350 lbs. Intermittent observations every hour on 1/8/24 between 9:30 AM and 2:00 PM (4 hours and 30 minutes) identified Resident #177 lying in bed, on his/her back with the head of the bed raised to approximately 30 degrees, continuous tube feeding in place and the alternating air loss mattress set at 350 lbs. Review of the NA turning and repositioning documentation for 1/8/24 identified Resident #177 was positioned on his/her back from 5:38 AM to 1:12 PM (approximately 7 hours). Further review identified there was no documentation completed to indicate the resident's position from 1:12 PM to 7:29PM. At 7:29 PM, the documentation noted Resident #177 was repositioned to his/her left side. Observation of wound care on 1/8/24 at 2:00 PM with LPN #3 identified Resident #177 lying on his/her back, with the alternating air mattress set at 350 pounds (lbs.). Resident #177's sacrum had a foam dressing with a scant amount of drainage to the foam dressing. The dressing change was completed without incident and the setting of the air mattress remained at 350 lbs. and the resident remained positioned on his/her back with the head of the bed raised to 30 degrees. Interview with LPN #2 on 1/5/24 at 12:45 PM identified that she performed the weekly skin check on Resident #177 on 2/7/23 and identified the open wound to the coccyx. She further identified that Resident #177 had a history of a pressure ulcer in the same location. In addition, LPN #2 identified that she notified the nursing supervisor at that time but could not recall the nursing supervisor she notified. She noted that the nursing supervisor typically would assess the wound and obtain a treatment order. Interview with NA #3 (NA for 7-3 shift) on 1/8/24 at 1:00 PM identified Resident #177 was totally dependent for all care including turning and repositioning. She also identified that Resident #177 was non-verbal and compliant with care. She identified Resident #177, needed to be turned and repositioned at least every 2 hours and was also aware that he/she had a pressure ulcer on his/her bottom. She further noted that she documents the resident's position in the computerized task section of the NA documentation. Interview with LPN #3 (charge nurse for 7-3 shift) on 1/8/24 at 2:30 PM identified Resident #177 at high risk for skin breakdown because of the history of pressure ulcers, current stage 4 open wound to the sacrum and immobility. She further noted she was responsible for ensuring the nurse aides turn and reposition Resident #177 at least every 2 hours but she could not identify when Resident #177 had last been turned and repositioned prior to completing the wound care and dressing change. Subsequently, LPN #3 repositioned Resident #177 on his/her left side. In addition, LPN #3 identified that the alternating pressure air mattress should be set between 150-200 lbs. depending on the resident's comfort, but she did not correct the setting at that time. Interview with LPN #4 (wound nurse) on 1/8/24 at 3:00 PM identified Resident #177 had a care plan for turning and repositioning every two hours, alternating air pressure mattress and protein supplement. The facility practice and/or policy is that when a new skin issue is identified, the charge nurse notifies the nursing supervisor and the nursing supervisor assess the characteristic or condition of the wound, provides an immediate treatment, and documents the assessment in the resident's clinical record. LPN #4 could not recall whether she was notified that Resident #177 had an open wound to the coccyx on 2/7/23. In addition, she could not identify documentation that the wound was assessed and/or that a treatment order was obtained prior to 2/9/23. She further identified that the wound nurse conducts the weekly wound rounds with MD #1 and is responsible for ensuring recommendations are implemented. She did not offer a reason as to why the recommendation for the resident to be positioned side to side while in bed to maintain off-loading of the sacrum was implemented. Interview with MD #1 (Wound Care Specialist) on 1/9/24 at 10:30 AM identified Resident #177's sacral wound was due to pressure and noted the resident was at high risk for skin breakdown because of his/her immobility, incontinence, co-morbidities, and history of pressure ulcers in the same area. He identified the sacrum was difficult to heal because of the previous history of a pressure wound to the same area and frequent pressure ulcers to the same location make it more difficult to heal due to the formation of scar tissue. He further identified that the alternating air mattress was not a replacement for frequent repositioning, and the facility should continue to turn and reposition the resident to offload the pressure to the sacrum. In addition, MD #1 identified that he conducts wound rounds at the facility on a weekly basis accompanied by the Wound Nurse. He also noted that frequent offloading is the responsibility of the nursing staff. In addition, MD #1 identified that the facility should follow the manufacturer's guidelines for the proper setting of the alternating air pressure mattress to promote the healing of the pressure ulcer injury and to prevent further skin injury. Interview and review of clinical record with the DNS on 1/9/24 at 2:30 PM identified that the facility process was the charge nurse would notify the nursing supervisor when there was a new onset of open wound and the nursing supervisor should assess the wound, immediately notified the physician to obtain an appropriate treatment and it should be documented in the nurse's note. Review of nurse's note and physician's orders from 2/7/23 through 2/9/23 with the DNS failed to identify documentation that Resident #177's sacral wound was assessed by an RN on 2/7/23 or that a treatment was put in place. Continued interview and review of the clinical record with the DNS on 1/9/24 at 3:00 PM identified that residents at high risk for pressure ulcer development should be turned and repositioned every two hours at a minimum and when needed more frequently. She further identified Resident #177's plan of care directs to turn and reposition every two hours and document the position. The DNS further noted that the nurses are responsible for ensuring that the nurses' aides turn and reposition the resident at least every two hours. The documentation of the turning and repositioning should be entered into the task section under NA documentation. Review of the NA documentation on 1/7/24 and 1/8/24 with the DNS identified Resident #177's was not consistently receiving the turning and repositioning every two hours in accordance with the resident's plan of care. Further, the DNS identified that the facility air pressure mattress was set based on the resident's current weight and there should be a physician's order to set the air mattress with the resident weight and check for the setting and function of the mattress every shift in the TAR. She also identified that her licensed staff should ensure that correct setting of the air pressure mattress to ensure the correct setting and the function of the air mattress. Review of the manufacturer guidelines for the specific alternating pressure system with low air loss mattress utilized by Resident #177 identified it was designed to treat and prevent wounds by facilitating blood circulation and decreasing the pressure of each tissue contact area. The weight button was to adjust based on the patient's weight. The scale was only for an approximation and adjust the weight setting when the mattress was too soft or too firm to suit each patient's needs. It is still recommended that the patient be repositioned periodically while using this mattress. The facility policy for Guideline for use of Support Surfaces identified the usage of the support surfaces would be based on the interdisciplinary team recommendations. The correct setting would be set by the nurse based on the resident's current weight and comfort level, monitoring of the support surface inflation would be done by the nurse every shift and documented in the TAR and a support surface does not replace the need to turn and reposition and/or offload heels based on the resident risk factors for developing pressure injuries. The policy for Pressure Injury Prevention Protocol identified that based on a comprehensive evaluation of the resident, the facility ensures that a resident receives care consistent with professional standards of practice to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical state demonstrates that they are unavoidable. A resident with pressure injuries receives necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing. 2. Resident #69's diagnoses included cerebral infarction, persistent vegetative state, functional quadriplegia. The quarterly MDS assessment dated [DATE] identified Resident #69 had severe cognitive impairment, required total dependence on staff for all activities of living, was always incontinent of bowel and bladder functioning, and utilized a feeding tube for nutrition. The assessment further identified the resident was at risk for the development of pressure ulcers with no current pressure ulcers identified. The Resident Care Plan dated 1/15/23 identified Resident #69 had an increased risk of skin breakdown with interventions that directed to provide protective skin care as needed, and skin treatments as needed, incontinence care as needed. The care plan further identified a self-care performance deficit with interventions that included two staff for turning and repositioning in bed. Review of the NA positioning documentation identified the following: On 2/18/23 the resident was positioned on his/her back from 6:00 PM to 8:00 AM (14 hours) On 2/19/23 the resident was positioned on his/her back from 4:00 PM to 2:00 AM (10 hours) On 2/21/23 the resident was positioned on his/her back from 4:00 AM to 8:00 AM (4 hours) and from 4:00 PM to 2:00 AM (10 hours) On 2/22/23 the resident was positioned on his/her back from 4:00 AM to 8:00 AM (4 hours) The wound assessment dated [DATE] completed by LPN #4 (wound nurse) identified Resident #69 had an open area to the sacrum that measured 2.5 centimeters in length by 0.5 centimeters in width and no depth recorded. Treatment included Triad Hydrophilic wound dressing paste to the area twice per day. The Braden Scale Assessment (used to predict risk for pressure ulcer development) dated 2/22/23 identified the resident was at high risk for the development of pressure ulcers. Review of physician's orders identified an order dated 2/22/23 that directed to apply Triad hydrophilic wound dress paste apply to sacrum topically every day and evening shift. The orders further identified that the order for Triad hydrophilic was discontinued on 3/1/23. In addition, the wound physician's order for house barrier cream was not transcribed or added to the treatment record. The wound physician's (MD #1) assessment dated [DATE] identified a non- pressure area to the sacrum measuring 1.5 centimeters (cm) in length by 0.6 cm in width by 0.1 cm in depth. The treatment plan included house barrier cream to be applied every shift (3x/day) for 16 days. The wound physician's assessment dated [DATE] identified that he would not be overseeing the care of the resident's wound and noted the wound measured 1.5 cm by 0.6 cm by 0.1 cm and would be followed by the facility's wound nurse. Review of physician's orders failed to identify an order for barrier cream and review of the treatment administration record failed to identify that eh order was transcribed or followed. Review of the clinical record failed to identify further assessments or treatment of the sacral wound after 3/21/23. Interview with LPN #4 (the current infection control nurse and former wound nurse) on 1/10/24 at 10:00 AM identified that she was the nurse that worked with the wound physician and was responsible for monitoring the wound once the wound physician conceded care. She further noted that she could not locate any subsequent monitoring of the wound after 3/21/23; although, LPN #4 indicated further follow up would have been warranted. In addition, LPN #4 noted she had no documentation of any further assessments of the wound, including measurements or documentation that the wound healed or worsened and/or what treatment was in place after 3/1/23. LPN #4 further indicated she had no idea how this oversight could have happened and noted Resident #69 did not have behaviors inclusive of resistance to care and/or declining care. The nurse's note dated 6/4/2023 at 6:27 PM (written by RN supervisor) indicated the resident had a reopening of an old closed sacral wound. The note described the area as superficial with redness and no signs or symptoms of infection. The note further identified that the physician was notified, and order given for triad paste to sacrum three times daily for five days. Review of the clinical record failed to identify wound measurements or the outcome of the wound. There was no indication of when the wound healed/resolved. Review of the weekly skin assessments for the period of 3/7/23-6/4/23 failed to indicate any concerns with the resident's skin although the resident had the presence of wounds in March. Further interview with LPN #4 (the current infection control nurse and former wound nurse) on 1/10/24 at 10:00 AM identified that Resident #69 should be turned and repositioned every two hours. After review of the NA documentation for turning and repositing, LPN #4 noted that it was inappropriate for the resident to be left for several hours in the same position. Review of the weekly skin assessments completed for August/2023 did not indicate any concerns with the resident's skin. A physician's order dated 8/22/23 directed to start Mepilex (a bordered foam dressing used to treat pressure ulcers. Leg and foot ulcers and traumatic wounds) to the sacrum and to change every three days. Review of the clinical record failed to identify nurses' notes or wound assessments that identified a reason for the order of Mepilex. The skin and wound evaluation dated 8/29/23 completed by LPN #4 identified Resident #69 had a facility acquired unstageable pressure ulcer to the sacrum that measured 2.9 cm in length by 2.2 cm in width by 0.5 cm in depth. The assessment further noted an order for Santyl (used to remove damaged tissue from chronic skin ulcers and severely burned areas). The physician's order dated 8/31/23 directed Santyl external ointment applied to sacral wound every day. The care plan identified the added interventions after the identification of the unstageable pressure ulcer wound that included: provide incontinence care as needed, provide protective skin care, air mattress according to most current weight, avoid constrictive clothing, skin treatments as needed. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of the care plan failed to identify specific resident centered interventions related to the unstageable pressure ulcer The wound physician's evaluation completed on 9/5/23 identified the wound was from trauma/injury and noted the measurements as 2.5cm by 2.0 cm by 0.1cm with light serous exudate, and fifty percent granulation tissue. The note further noted that the wound had persisted from March/2023. The wound physician's evaluation completed on 10/10/23 identified the resident had a stage 4 pressure wound on the sacrum, that measured 4.1cm by 1.6 cm by 0.9 cm. Recommendations identified limit sitting to 60 minutes, offload wound, reposition per facility protocol, and turn side to side in bed every 1 to 2 hours as able. Review of the wound notes identified that MD #1 has consistently monitored the wound on a weekly basis since 9/5/23. The wound physician's evaluation completed on 1/2/24 identified the sacral wound measured 5.7 cm by 3.5 cm by 1.8 cm, with undermining of 3.6 cm noted at 7:00 o'clock, light serous exudate and 30%thick adherent devitalized necrotic tissue. Recommended the ruling out of osteomyelitis with x-ray, white blood cell count and ESR estimated sedimentation rate. Observation on 1/2/24 at 9:45 AM identified Resident #69 was lying on his/her right side in bed awake with the head of the bed elevated at approximately 30 degrees, with tube feeding running, and resident appeared to be diaphoretic. Observation on 1/2/24 at 11:50 AM identified Resident #69 was lying on his/her right side in bed appeared to be asleep with the head of the bed elevated at approximately 30 degrees, with tube feeding running her cheeks were red. The care plan dated 1/9/24 identified the resident had a stage 4 pressure ulcer to the sacrum, with interventions that included dietician evaluation as needed, monitor for signs and symptoms of wound infection, treatment as ordered and turn and reposition every one to two hours. Review of the NA turning and repositioning documentation for the period of December/2023 through January/2024 identified that Resident #69's position was not consistently changed every two hours and the resident was not kept on a schedule of side-to-side repositioning as recommended by the wound physician. Wound care observation on 1/9/24 at 10:23 AM identified the Resident #69 initially lying on the right side and was repositioned to the left side for wound care to be completed with LPN#2 (current wound care nurse). The wound appeared to be a stage 4 full thickness wound with light serous exudate that measured 5.5cm Length by 4.5cm Width by 2.cm Depth. Interview with LPN #5 on 1/9/23 at 2:30 PM indicated she did not recall the skin assessment completed on 8/29/23, however would only note new areas on her skin assessments and not old areas that the wound team knew about. LPN #5 did not identify how she would know if the wound had been previously identified and was being followed by the facility's wound nurse. Interview with MD#1 (wound physician) on 1/9/24 at 10:23 AM indicated the wound began approximately 10 months ago, and initially he diagnosed it as non-pressure ulcer wound due to the borders being irregular, which could indicate a traumatic tear, however he noted that the wound was a pressure area. He further identified that he could not speak to the how often the resident was turned and repositioned or if the patient was turned and repositioned due to the fact he was only in the building once a week for a short period of time. Interview with the DNS on 1/10/24 at 11:30 AM indicated that the NA turning and repositioning documentation was inappropriate because it shows a pattern of the resident not being turned and/or repositioned for hours at a time. It is also failed to identify that the resident is being turned side to side and being kept off of his/her back as recommended by MD #1. She further noted that wound documentation could not be located to ascertain the progression of the sacral wound after 3/21/23 and after 6/4/23. The DNS noted that documentation should be completed concerning the resolution of a wound. Review of the facility policy Pressure Injury Prevention Protocols dated 3/2023 directed the facility to prevent pressure injuries begin with identification of the resident's risk of developing a pressure injury based on a comprehensive evaluation of the resident's skin integrity and any predisposing factors and reposition in bed per care plan. 47402

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two sampled residents (Resident #199) reviewed for falls, the facility failed to appropriately monitor the placement of a pelvic positioning belt on an adaptive wheelchair to ensure safety, leading to a subsequent fall that resulted in an injury. The findings include: Resident #199 's diagnoses included fifth lumbar vertebra fracture, left femur fracture, low back pain and abnormal posture. A fall risk assessment dated [DATE] identified Resident #199 was at high risk for falls due to history of falling, confusion, and impaired gait. The physician's order dated 11/9/23 identified Resident #199 required a two person assist for bed mobility and transfers via the Hoyer lift (mechanical lift). The quarterly MDS assessment dated [DATE] identified Resident #199 had severe cognitive impairment and was totally dependent for transfers, toileting, hygiene, dressing, was non-ambulatory and utilized a wheelchair for mobility. The physician's order dated 11/28/23 directed Resident #199 to be out of bed to the adaptive wheelchair with a pelvic positioning belt as a part of a 24-hour positioning plan. The Resident Care Plan (RCP) dated 12/19/23 identified Resident #199 was at risk for falls with interventions that directed non-skid socks/non-slip soles on shoes, place resident in common area, ensure urinal within reach and neurological checks per facility protocol. The Situation, Background, Assessment, Recommendation (SBAR) nurse's note dated 1/4/24 at 4:03 PM identified Resident #199 was found on the floor near his/her bed laying on his/her right side and bleeding from the back of the head. Neurological assessment performed, and pressure applied to the back of the head. Resident #199 denied pain and blood pressure was elevated at 157 (systolic)/ 87 (diastolic). Resident #199 was sent to the hospital for further evaluation. The hospital discharge summary dated 1/4/24 at 7:51 PM identified Resident #199 was treated in the emergency department for a head injury and scalp laceration and noted that the wound to the scalp was closed with surgical staples. The reportable event report dated 1/4/24 at 9:53 PM identified Resident #199 fell from his/her adaptive wheelchair, was bleeding from the top of the head, reported that he/she was trying to pick up something on the floor. The report further noted that the resident was sent to the hospital to be evaluated. The nurse's note dated 1/4/24 at 11:18 PM identified Resident #199 returned from the hospital emergency department via stretcher in stable condition with four staples in place to the top of the head. The note further identified that the Computed Tomography (CT) scan of Resident #199's head was negative for bleeding in the brain. In addition, the note identified Resident #199 had full range of motion to the lower and upper extremities, pupils were equal, round, and reactive to light and accommodation (PERRLA) with strong hand grasps. Resident #199's family was updated on his/her return from the hospital. Interview and observation with NA #1 (NA for 7-3 shift) on 1/8/24 at 11:30 AM identified Resident #199 utilized a pelvic positioning belt to his/her wheelchair and she had not observed Resident #199 remove the seatbelt while seated in the wheelchair. NA #1 who was able to communicate in the same language as Resident #199 asked him/her to remove the seatbelt. Resident #199 was unable to remove the seatbelt and communicated to NA #1 that he/she did not have enough strength in his/her fingers to push the button to release the seatbelt. NA #1 further identified that she did not feel Resident #199 would have fallen from the wheelchair if the seatbelt was properly placed. Interview with RN #1 (unit manager) on 1/8/24 at 11:50 AM identified she was called go to Resident #199 room on 1/4/24 because he/she was on the floor. She identified Resident #199 had fallen from the adaptive wheelchair. She further identified that she did not feel Resident #199 could remove the seatbelt on his own and noted that if the seatbelt was in place, the resident would not have fallen from the wheelchair. In addition, RN #1 identified that during the course of her investigation into the fall, she had not ascertained whether the seatbelt had been properly placed prior to the resident's fall. Interview with NA #2 (NA for 3-11 shift) on 1/8/24 at 2:00 PM identified that she was assigned to care for Resident #199 on 1/4/24 and noted that she had placed the resident's seatbelt on him/her. She further identified that Resident #199 could remove the seatbelt and could not recall if she had reported this ability to the charge nurse. Review of occupational therapy notes identified Resident #199 received treatment for the period of 11/13/23 to 11/26/23. Interview with OT #1 on 1/9/24 at 12:05 PM identified that she evaluated and treated Resident #199 for the adaptive wheelchair due to his/her poor trunk control and noted the use of the pelvic positioning belt was to help the resident to maintain his/her proper posture while sitting in the wheelchair. OT #1 further identified that Resident #199 was unable to self-remove the seatbelt because he/she did not have the strength in the fingers to push the button to release the seatbelt latch. In addition, she evaluated the resident that day and reaffirmed Resident #199 did not have the strength to release the seatbelt on his/her own. She also noted that the resident would not have fallen from the wheelchair if the pelvic positioning seatbelt was properly in place. Interview with LPN #1(charge nurse on Resident 199's unit) on 1/9/24 at 12:20 PM identified Resident #199 utilized the pelvic positioning seatbelt to maintain his/her position while seated in the wheelchair. He further noted that he had never witnessed the resident remove the belt but had observed the seatbelt to not be secured at times. In addition, he identified that if the belt was properly secured, the resident would not have fallen from the wheelchair. Interview with the DNS on 1/9/24 at 2:30 PM identified she investigated Resident #199's fall and noted NA #2 told her that Resident #199 was able to remove his/her seatbelt. The DNS did not identify that this information was expressed by any other staff member or that she had confirmed this information herself. In addition, she noted that when a resident can remove the seatbelt, there is a care plan that is put in place for the staff to check the resident's ability to remove the belt. She further noted that this resident did not have a plan in place to monitor his/her ability to self-remove the seatbelt. She further identified that the resident would not have fallen from the wheelchair if the pelvic positioning belt had been properly placed and secured. The Fall Prevention Program policy identified that the purpose of the program is to reduce the incidence of falls for residents identified at high risk. It further noted that the facility would review the resident's medical records, evaluate interventions, and develop further interventions as necessary to prevent falls.

Based on clinical record reviews, review of facility documentation, review of the ambulance run sheet, review of facility policy and interviews, for one of three sampled residents (Resident #1) who had a diagnosis of difficulty swallowing and a recent history of aspiration, the facility failed to implement aspiration precautions and one (1) to one (1), supervision during meals, the resident experienced a choking episode, and required emergency intervention. As a result Immediate Jeopardy was identified. The finding includes: Resident #1's diagnoses included dysphagia (difficulty swallowing), cognitive communication deficit, mild cognitive impairment, acute respiratory failure with hypoxia, and cardiac arrest due to underlying cardiac condition. The hospital discharge summary dated [DATE] identified during the hospitalization on [DATE], Resident #1 experienced a cardiac arrest due to hypoxia, had concerns for aspiration with interventions that included thick nectar liquids and assistance with eating. Upon discharge Resident #1 was to advance to thin liquids, provide one (1) to one (1) assistance to maintain aspiration precautions specified as remain upright during oral intake, slow rate, small bites/sips one at a time, and continue speech therapy at the rehabilitation facility. The facility's pre-admission screen form dated [DATE] identified Resident #1 was to continue a regular diet with thick nectar liquids and strict aspiration precautions (slow rate, small bites/sips one at a time, upright during PO intake, no talking when eating, and 1 to1 assistance). The admission physician's order dated [DATE] directed a heart healthy diet, mechanical soft, dysphagia level 3 texture, and thin liquid consistency. The initial Resident Care Plan dated [DATE] identified Resident #1 had an activities of daily living self-care performance deficit. Interventions directed set-up assistance by staff with eating. The plan of care failed to include strict aspiration precautions and one (1) to one (1) assistance when eating. The nurse aide care card identified Resident #1 required set-up assistance by staff with eating. The speech therapy evaluation and plan of treatment form dated [DATE] identified the hospital report indicated full supervision during meals and continue speech therapy to upgrade the diet and provide cognitive treatment. Resident #1 presented with at the least mild oral pharyngeal dysphagia characterized by tongue pumping, delayed A-P transit (anterior to posterior bolus movement) and immediate and delayed coughing on mild thick liquids. Resident #1 demonstrated aspiration on thin liquids and penetration on all other liquids and solids. Resident #1 presented with at least moderate to severe cognitive-linguistic deficit characterized by decreased arousal, impaired repetitive and expressive language, impulsivity, disorientation, and problem solving. At this time recommend a mechanical soft, mild thicken liquid diet with full supervision, and continued dysphagia treatment and diagnosis to assess if appropriate to upgrade diet. The 5-day Minimum Data Set assessment dated [DATE] identified Resident #1 sometimes made self-understood (ability was limited to making concrete requests), sometimes understood others (responded adequately to simple, direct communication only), had moderate cognitive impairment, required extensive one (1) person assistance with eating, and was holding food in his/her mouth/cheeks or held residual food in the mouth after meals. The change in condition evaluation form dated [DATE] at 6:00 PM identified Resident #1 was observed to be unresponsive after dinner, slumped over, no respirations were observed, and CPR was performed. An automated external defibrillator (AED) was applied, instructions given, no response, 911 was notified and responded, and Resident #1 was transferred to the hospital. The Emergency Medical Services (EMS) run sheet dated [DATE] identified upon arrival at 5:53 PM Resident #1 was laying supine on floor with staff members performing CPR. Staff identified Resident #1 was eating dinner prior to going into a cardiac arrest, Resident #1 was placed on the cardiac monitor with an initial rhythm of pulseless electrical activity (PEA), Resident #1's airway was obstructed with food, cleared with a finger sweep and suction and Resident #1 was intubated. Interview with the ,d+[DATE]PM charge nurse, Licensed Practical Nurse (LPN) #2, on [DATE] at 4:20 PM identified on [DATE] he transcribed Resident #1's admission orders, reviewed the hospital documentation and medications. LPN #2 indicated he was aware Resident #1 was on aspiration precautions, and required 1:1 assistance with meals, was a feed, however he did not write the 1:1 supervision as an order, he verbally conveyed the need for the 1:1 supervision and aspiration precautions to the 11PM-7AM oncoming nurse whom he could not recall. LPN #2 identified if a resident was on mildly thick liquids, the nurses knew it meant aspiration precautions and the nurses needed to monitor if a resident was coughing. LPN #2 indicated he usually did not transcribe 1:1 supervision as on order. Interview with Speech Therapist #1 on [DATE] at 11:39 AM identified Resident #1 had refused solid food during her evaluation on [DATE], since Resident #1 did not have any solids, she downgraded Resident #1's diet back to a mechanical soft diet with full supervision from his/her caregiver. Speech Therapist #1 indicated full supervision meant a nursing staff member was to be with Resident #1 at all times when Resident #1 was eating. Speech Therapist #1 identified her recommendations were written in her speech therapy note and although she wrote an order for the new diet, she only verbally told someone in person her recommendations regarding the full supervision, and she could not recall who she spoke with, a nurse or a nurse aide. Speech Therapist #1 identified the process for speech therapy recommendations was to place an order for the diet in the facility electronic physician's order system, give verbal instructions to the nursing staff and post a sign in the resident's room regarding the new recommendations while eating. Speech Therapist #1 indicated she was unable to retrieve the posting she placed in Resident #1's room. Interview with the ,d+[DATE]PM charge nurse, Licensed Practical Nurse, LPN #1, on [DATE] at 12:34 PM identified on [DATE], (after 5:00 PM) she observed Resident #1 near the nurse's station sitting in his/her wheelchair with a tray table when a nurse aide delivered his/her dinner tray. LPN #1 indicated a nurse aide alerted her that something was not right, with Resident #1. As she approached the resident she observed the meal tray in front of him/her with approximately 75% of the dinner was gone. LPN #1 indicated Resident #1 was sitting up in the wheelchair with food in his/her mouth and his/her head was tilted to the side. LPN #1 identified she could not feel a pulse, grabbed the crash cart along with the AED, one (1) or two (2) nurse aides helped her to assist Resident #1 to the floor, one (1) of the nurse aides called the code blue and she started CPR. LPN #1 indicated the Emergency Medical Technicians (EMT) arrived, were able to find Resident #1's pulse and transferred Resident #1 to the hospital. LPN #1 indicated there were nurse aides around that area where Resident #1 was sitting, however she could not say if any staff members were siting with Resident #1 while he/she was eating. LPN #1 identified the Speech Therapist would inform the nursing staff of any new recommendations and the speech therapist would be the one to put the order in the record for the diet and 1 to 1 supervision and the nurse needed to confirm the new orders. Interview with a ,d+[DATE]PM nurse aide, Nurse Aide (NA) #1, on [DATE] at 1:20 PM identified she gave Resident #1 his/her dinner tray on [DATE] while Resident #1 was sitting in the wheelchair at the nursing station. NA #1 indicated although no one was sitting with Resident #1 while he/she was eating, the staff checked on Resident #1 a few times as they were passing by Resident #1 delivering trays on the unit. NA #1 indicated she went to check on Resident #1 and noticed that Resident #1 was drooling, and she asked her coworkers who were in the dining room/lounge if Resident #1 was all right. NA #1 identified LPN #1 was also coming around the corner, LPN #1 pushed Resident #1 into the dining room/lounge, called a code blue and started CPR. NA #1 indicated she asked LPN #1 if Resident #1 needed to be fed and LPN #1 replied Resident #1 ate by him/herself. NA #1 identified she was unaware Resident #1 required full supervision while eating. Interview with the Director of Nursing (DON) on [DATE] at 1:40PM identified the admission nurse failed to transcribe the orders to include aspiration precautions and one to one with meals. The DON stated the expectation for speech therapy was to verbally communicate to nursing staff the recommendations and to also put the order in the facility electronic physician's order system for the diet as well as for the full supervision with meals. The DON indicated the speech therapist cannot bypass the order because that was the way everybody finds out about the new recommendations. The DON identified once the Speech Therapist placed an order in the in the facility electronic physician's order system, nursing would confirm the order and update the care plan and nurse aide care card. Interview with NA #2 on [DATE] at 2:50 PM identified Resident #1 ate by him/herself and did not require supervision. On [DATE], Resident #1 was at the nurse's station because he/she was a fall risk and one of her coworkers, NA #1 or NA #3, removed Resident #1's dinner tray. A few minutes later somebody stated he/she does not look good, LPN #1 was called, Resident #1 was placed on the floor and CPR was started by LPN #1. Interview with NA #3 on [DATE] at 3:26PM identified Resident #1 was not being watched while he/she was eating on [DATE] and he/she was at the nurse's station because he/she tried to climb out of bed and we did not want him/her to fall. Interview with the Director of Nursing (DON) on [DATE] at 2:20 PM identified the facility staff did not utilize the word full supervision in nursing, the facility used the definition of supervision as providing oversght, encouragement, and cueing. On [DATE] the facility provided the Department with an action plan to address the Immediate Jeopardy that includes: Education for licensed nursing personnel regarding reviewing the discharge summary and W10 for newly admitted residents and having special dietary instructions put in as an order, The education includes updating the care plan and CNA Kardex to reflect the special dietary instructions. Education for speech therapists when making dietary recommendations and entering orders that give clear and concise directions. Daily audits of discharge summaries and W10s for new admissions will be conducted daily for one week, 3x/wk for one week, then weekly, and daily audits of speech therapy evaluation recommendations and orders will be completed daily for one week, 3x/wk for one week, then weekly.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure a resident was protected from an alleged sexual abuse when Resident #3, with known wandering, intrusive and sexual behaviors was noted in Resident #2's room for 12 minutes and Resident #2 was noted to be visibly upset and exposed from the waist down. The findings include: 1. Resident #3's diagnoses included chronic kidney disease, diabetes mellitus, dementia and disorder of adult personality and behavior. The annual Minimum Data Set (MDS) form dated 11/3/2022 identified Resident #3 had severe cognitive impairment, ambulated independently, and had behaviors not directed toward others such as hitting, public sexual acts, pacing, disrobing, or verbal/vocal symptoms one (1) to three (3) of the prior seven (7) days. The facility reportable event form and investigation dated 11/4/2022 identified staff observed Resident #3 approach a female resident and touch her right breast. Both parties were immediately separated, and Resident #3 was placed on a one-to-one observation, psychiatry was updated to visit with resident. Corrective action plan identified staff to assist with no contact boundaries and notify provider of increased intrusive behavior towards female peers. The Resident Care Plan (RCP) dated 11/07/2022 identified Resident #3 had psychosocial well-being problems and an incident with a peer on 11/4/2022. Interventions directed for behavioral interventions: 1:1 initiated after immediate separation from peer, close observation checks every 15-minutes, psychiatry and social services to follow up, medication review, staff assist with no contact boundaries and notify provider of increased intrusive behavior towards peers, and to provide redirection of increased intrusive behaviors towards female peers. Further clinical record review identified the every 15-minute checks were discontinued during 11/2022. 2. Resident #1's diagnosis included Alzheimer's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was able to be interviewed, had severe cognitive impairment, required limited assist of one staff for bed mobility, and was frequently incontinent of bowel and bladder. The RCP dated 12/28/2022 identified an impaired cognitive function. Interventions directed to anticipate needs. Psychiatry note dated 1/23/2022 identified Resident #1 was seen after return from the hospital related to an incident on 1/22/2023, and was alert and oriented to self only. The note further indicated Resident #1 was a poor historian and in no distress. 3. Resident #2's diagnoses included malignant neoplasm of brain, Alzheimer's Disease, dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was able to be interviewed, had severe cognitive impairment, ambulated independently, required limited assist of one staff for bed mobility, and was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 12/15/2022 identified Resident #2 had impaired cognitive function or impaired thought processes related to dementia. Interventions directed to ask yes/no questions to determine the resident's needs, cue, reorient and supervise as needed, assist with resident needs, such as supervision/assistance with all decision making, and to administer medications as ordered and monitor/document for side effects and effectiveness. The nurse's note dated 1/22/2023 at 4:49 AM identified during the early night, Resident #3 was observed leaving Resident #2's room and Resident #2 was noted to be upset, but unclear of any incident in the room. The APRN was notified, and new orders were obtained to transfer Resident #2 to go to the hospital for further evaluation. The facility incident report and investigation dated 1/22/2023 identified video footage was submitted to the local police department that identified Resident #3 entered Resident #2's room at 12:03 AM and exited at 12:15 AM on 1/22/2023 (Resident #3 was fully clothed and did not appear to have his/her clothing out of place). NA #1 entered Resident #2's room, and identified the bed sheets were turned down, Resident #2's johnny was pulled up and a incontinent brief was off, exposing Resident #2 from below the waist. The report further identified Resident #2 was upset, but could not state a reason clearly. The hospital indicated no signs of trauma, and a rape kit was not completed. Although requested, video footage was unable to be viewed during survey due to the video storage time/date to be viewed had lapsed. Review of the hospital discharge summary for Resident #3 dated 1/24/2023 identified Resident #3 was brought to the emergency department related to being visualized exiting a room occupied by two female residents. A NA was recently in resident's room and had put blankets over both residents prior to the incident. The facility identified when Resident #3 was observed exiting resident's room, she went in and found both residents were uncovered. Resident #2 was found with his/her johnny coat rolled up and under chest area and sheets pulled down to end of bed. Resident #2 was exposed and naked from the waist down. Resident #1 was found with a pull-up/brief intact, however, the sheets/covers were pulled down to end of bed. Interview with RN #1 (Unit Manager) on 2/9/2023 at 11:35 AM identified Resident #3's behaviors should be monitored when he/she was around female peers and should be separated when in close contact with previous resident's that Resident #3 had an incident with. Although RN #1 could not explain what had occurred when Resident #3 was unsupervised in Resident #1 and #2's room, and Resident #1 and #2 were found exposed after Resident #3 left the room, RN #1 indicated Resident #3 should not have been able to be in Resident #1 and #2's room unsupervised. Interview with NA #1 on 2/9/2023 at 12:20 PM identified upon the start of the 11:00 PM to 7:00 AM shift on 1/22/2023, NA #1 performed rounds on all her residents. NA #1 indicated at the start of her shift she assisted Resident #1 and #2 with toileting needs and afterwards for bed/sleeping. NA #1 identified when she left Resident #1 and #2's room after all care was performed both residents' were in bed, dressed and bed covers placed appropriately over both residents for sleep. NA #1 reported before midnight (unsure of the time), Resident #3 came out of his/her room and requested a beverage, per his/her usual routine. NA #1 gave Resident #3 a beverage and continued with care for other residents. NA #1 identified at about 12:15 AM, as she was charting, she observed Resident #3 walk out Resident #1 and #2's room. NA #1 indicated she immediately went into Resident #1 and #2's room and observed the covers were off (pulled down) on both Residents #1 and #2. Resident #1 was awake and was bothered. Resident #1 indicated Resident #3 pulled the covers off him/her and informed NA #1 that he/she heard Resident #2 screaming. NA #1 noted Resident #2's depends/brief was on the floor, his/her johnny coat was bundled up to the upper chest area, and his/her peri-area was exposed and was visually reddened. Resident #2 was unable to articulate what happened but while pointing to his/her perineal area, verbalized why did he/she do that to me? NA #1 indicated Resident #2's perineal area was visually red, and Resident #2 appeared visibly upset at the situation. NA #1 further identified she was unaware of any other related incidents involving Resident #3 in the past related to resident-resident incidences. Interview with RN #2 on 2/9/2023 at 1:15 PM identified she was the shift supervisor when the incident occurred on 1/22/2023. RN #2 indicated Resident #2 was upset when she assessed Resident #2, but Resident #2 was shaking and was unable to verbalize what had occurred when Resident #3 was in the room or why he/she was upset. RN #2 further indicated the residents may have been scared when Resident #3 was in the room and they were exposed. Interview with SW #1 on 2/9/2023 at 2:35 PM identified Residents #1, 2 and #3 were unable to verbalize what had occurred on 1/22/2023 when Resident #3 was in Residents #1 and 2's room. SW #1 further indicated during follow up visits with the residents, the residents were unable to recall the incident. SW #1 further indicated staff should be mindful of the resident's whereabouts on the unit and re-direct Resident #3 if in close contact with residents involved in this and previous altercations. Interview with the DON on 2/9/2023 at 10:15 AM identified the DON could not explain what had occurred when Resident #3 was unsupervised in Resident #1 and #2's room, and Residents #1 and #2 were found exposed after Resident #3 left the room. Review of facility Abuse Policy dated 1/2023 directed in part, each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. The Policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and included but was not limited to sexual harassment, sexual coercion, or sexual assault.

Based on clinical record review, review of facility documentation, review of facility policy and interviews for one of three sampled residents reviewed for mistreatment (R# 198) the facility failed to ensure the resident was free from neglect. The findings include: Resident # 198's [DIAGNOSES REDACTED]. A resident care plan dated 7/30/15 identified the resident as incontinent of bowel with intervention that included to provide incontinent care every 2 hours and as needed. Review of a grievance dated 9/01/15, written by Social Worker # 3 (SW#3), identified that R#198 rung his/her call bell at approximately 12:15 AM and informed his/her assigned CNA, NA#4, that he/she had a bowel movement and needed to be changed. The NA#4 told R#198 he/she would attend to him/her later. At approximately 2:00 AM, R # 198 rang the call bell again for pain medication and NA # 5 entered the room, soon followed by NA#4. NA#4 stated to R#198 I told you , to which R#198 said I rang for pain medication . The resident reported that he/she had also told NA#5 that he/she had a bowel movement and NA#5 told him/her that he/she would tell R#198's NA because he/she was assigned to the other side and couldn't help her, but would tell his/her nurse that he/she needed medication. At approximately 5:48 AM NA # 4 entered R # 198 ' s room to empty his/her Foley bag and at that time NA#4 changed R # 198 (5.5 hours without care). A grievance dated 9/09/15, written by SW#4 identified that R#198 had previously filed a grievance against a (3-11) NA#4. R#198 reports that NA#4 approached R#198 about the previous grievance and stating, are you trying to get me in trouble? R#198 reports he/she told NA# 4 that he/she was not trying to get him/her in trouble but he/she felt that, his/her job was not up to par . States NA#4 does not change/toilet every 2 hours, has sat in feces entire 11-7 shift, as was addressed in previous grievance. Action taken to resolve grievance/concern; staff will be reassigned to different resident due to personality differences with staff and resident. Interview with NA#4 on 3/03/16 identified that he/she was R#198's NA on 9/01/15 on the 11-7 shift. NA#4 identified that he/she did tell R#198 that he/she would be back to take care of R#198, because he/she was caring for another resident at the time. NA#4 indicated he/she could have told another CNA to care for R#198, but he/she did not think of it at the time, but had returned to the resident within 20-30 minutes. NA#4 indicated that he/she also changed the resident one more time during that shift. NA#4 further identified that a few days later he/she indicated to the resident, You nearly got me into trouble, I didn't neglect you, I was truly busy. Interview with NA#5, who also worked 11-7 shift on 9/01/15, identified that he/she could not recall if he/she had entered R#198's room on 9/01/15, but anytime the resident rings and asks to be changed, he/she answers the call bell and changes the resident. Interview with LPN#4 on 3/2/16 at 7:15 AM, who was the charge nurse on 11-7 on 9/01/15, identified that she/he did not recall that any issues with R#198's care was called to his/her attention. Review of a disciplinary notice written on 9/04/15 identified that NA # 4 received a warning for not responding to a resident call bell and not providing care in a timely manner. Review of the facility's Abuse policy, identified that all residents in the facility have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish and mental illness.

Based on observation, review of clinical records, interviews, review of facility documentation and policy and procedure for three of five residents (Residents #12, 15 and 16) that required a mechanical lift for transfer, the facility failed to perform mechanical lift transfers in accordance with facility policy and/or manufacturer's directions for use. The findings include: a. Resident #12's [DIAGNOSES REDACTED]. A quarterly Minimum Data Assessment ((MDS) dated [DATE], identified that the resident was in a persistent vegetative state and required two staff members for bed mobility, transfer, bathing, dressing and personal hygiene needs. Review of a facility accident/incident report, dated 5/26/14, identified that on 5/26/14 at 10:15 A.M. during a mechanical lift transfer from bed to wheelchair, Resident #12 fell to the floor landing on his/her bottom. A nurse's note authored by RN #5 dated 5/26/14 identified that upon arrival to the room, Resident #12 was observed lying on the floor on his/her back and the mechanical lift base was in the closed position. Resident #12 was log rolled onto a blanket, manually lifted back to bed, the physician was notified and ordered diagnostic tests including an x-ray of the left hip. Review of the x-ray results indicated Resident #12 sustained an angulated displaced left subtrochanteric fracture and was transferred to Hospital #2. Resident #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with CNA #3, on 6/5/14 at 1:42 P.M., identified that s/he requested CNA #4 assist with a Hoyer lift transfer on 5/6/14 at approximately 10:15 A.M. CNA #3 stated s/he positioned the mechanical lift under the resident's bed, hooked the lift up to the sling (which was in position under the resident) lifted the resident, opened the base of the lift, turned the lift towards the wheelchair and the lift tipped over sending the resident onto the floor. CNA #3 added that the arm to control the base of the lift was not in working order. CNA #3 failed to open the base prior to lifting the resident as directed by policy and the manufacturer's directions. Interview with CNA #4, on 6/5/14 at 2:22 P.M., identified that CNA #3 requested assistance to transfer Resident #12 on 5/26/14 from bed to wheelchair utilizing the Hoyer lift and during the transfer, the Hoyer tipped over and the resident fell to the floor. Interviews with RN #5, on 6/5/14 at 11:31 A.M. and 2:38 P.M., identified that upon inspection of the Hoyer lift following the incident, s/he observed that the arm to control the base of the lift and the base of the lift were in good working order, however, s/he removed the Hoyer lift from service until maintenance staff could evaluate the Hoyer. Interviews with the Director of Plant Operations, on 6/5/14 at 10:55 P.M. and 12:30 P.M., identified that the mechanical lift involved with Resident #12's fall was examined on 5/27/14 and it was determined that the lift was in working order although the lift still had not been inspected by the manufacturer. The Director produced documentation that the weekly preventative maintenance checks were completed on this lift. In addition, the Director demonstrated that when the lift is tipped over, if the base is in the locked open position, the base cannot automatically go to the closed position. Interview with the DNS, on 6/5/14 at 3:15 P.M., identified that the facility was still in the process of completing the investigation. b. Resident #15's [DIAGNOSES REDACTED]. An annual MDS, dated [DATE], identified that the resident had severely impaired cognition (BIMS Score of 3) and required two staff members for bed mobility, transfer, bathing, dressing and personal hygiene needs. Observation of care, on 6/5/14 at 10:10 A.M., identified that CNA #9 operated the mechanical lift and CNA #10 assisted him/her to transfer the resident from the bed to a wheelchair. During the transfer it was identified that CNA #9 opened the base of the lift after lifting the resident from the bed. Interview with CNA #9, on 6/5/14 at 10:20 A.M., identified that the lift base is to be opened prior to moving the lift and it is not necessary to open the base when lifting the resident from the bed. CNA #9 failed to utilize the Hoyer lift as directed by policy and the manufacturer's directions. c. Resident #16's [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], identified that the resident had severely impaired cognition and required two staff members for bed mobility, transfer, bathing, dressing and personal hygiene needs. Observation of care, on 6/5/14 at 10:15 A.M., identified that CNA #11 operated the mechanical lift and CNA #10 assisted him/her to transfer the resident from the bed to a wheelchair. During the transfer it was identified that CNA #11 opened the base of the lift after lifting the resident from the bed. Interview with CNA #11, on 6/5/14 at 10:15 A.M., stated s/he can only open the base "a little" when lifting the resident due to limited space under the bed. Subsequent to the aforementioned observations and interview with the Director of Staff Development, on 6/5/14 at 11:11 A.M., stated staff were educated to open the base of the mechanical lift prior to lifting the resident. Review of facility documentation, titled Portable Lifts Transfer Technique Competency dated 7/17/13 and 7/19/13 for CNA #3 and #4 respectively, identified that the base of the mechanical lift is opened prior to the resident being lifted. Review of facility policy and procedure, titled Portable Lifter, identified that the base of the mechanical lift is opened and locked at all times prior to the resident being lifted. Review of the manufacturer's directions, titled Invacare 450 and dated 2000, identified that the base of the mechanical lift is opened and locked at all times prior to the resident being lifted.

Based on a review of clinical records, interviews, review of facility documentation and policies, for one of three residents (Resident #1) who had abnormal laboratory results, the facility failed to ensure that the resident did not receive medication that was contraindicated to treat a critical potassium level which resulted in hospitalization for [DIAGNOSES REDACTED]. The finding includes: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of laboratory test results, dated 5/2/14, identified that the resident had a low potassium level of 2.9 millimoles per Liter (mmol/L with a reference range of 3.5 to 5.0 mmol/L) and a calcium level of 7.2 (normal range 8.4-10.2), APRN #1 was notified with a telephone order for Potassium 15 milliequivalents (mEq) to be administered now and a basic metabolic panel (which includes a potassium level) to be completed on 5/3/14. The basic metabolic panel results, dated 5/3/14, identified the resident's calcium level was 6.8 (decreased from 5/2/14) and the laboratory report noted that LPN #2 was informed of the critical potassium level of 2.6 mmol/L at 3:03 P.M. A telephone order dated 5/3/14 at 8:40 P.M. identified that RN #4 received an order from APRN #1 to administer Calcium 600 mg twice daily and recheck calcium level on 5/5/14. The clinical record failed to reflect that the critical potassium level was addressed. A telephone order dated 5/6/14 identified that APRN #2 requested a STAT potassium level be obtained. Review of the lab value dated 5/6/14 indicated a critical potassium level of 2.6 mmol/L. The record indicated that RN #2 received a telephone order from APRN #1, on 5/6/14 at 10:45 P.M., that directed staff to administer [MEDICATION NAME] (medication is classified as a potassium removing resin) 60 milliliters (ml) now and repeat in one hour then recheck the resident's potassium level in the morning. Review of the Medication Administration Record [REDACTED].M. and 1:15 A.M., LPN #1 administered [MEDICATION NAME] 60 ml. Review of APRN #2's progress note dated 5/7/14 (not timed) identified that s/he received a telephone call at approximately 9:10 A.M. from RN #6 reporting the resident had a potassium level of 2.6 on 5/6/14 and received two doses of [MEDICATION NAME] 60 ml by mouth on 5/7/14 at 12:15 A.M. and 1:15 A.M. A decision was made to immediately transfer the resident to the emergency room (ED) for evaluation. Review of the potassium level results, dated 5/7/14, identified that the laboratory called the facility and informed LPN #4 of a critical potassium level of 2.5 mmol/L at 11:00 A.M. Review of the Interagency Referral Form (W-10) that accompanied the resident to the hospital identified that Resident #1 was being transferred to Hospital #3 for evaluation of low potassium level due to patient receiving two doses of [MEDICATION NAME] 60 ml for a critical potassium level of 2.6 mmol/L. Review of the acute care hospital record dated 5/7/14 identified that the resident had a potassium level of 2.4 mmol/L at 11:45 A.M. The ED physician note, dated 5/7/14 at 12:32 P.M., noted the resident had a low potassium level and was given [MEDICATION NAME] in error. Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 remained hospitalized until 5/11/14. Interview with RN #2, on 6/3/14 at 3:20 P.M., stated s/he called APRN #1 on 5/6/14 to report Resident #1's critical potassium result of 2.6 mmol/L and believed that APRN #1 directed administration of [MEDICATION NAME] 60 milliliters (ml) now and repeat in one hour then check the potassium level in the morning. Although RN #2 identified that [MEDICATION NAME] is administered to lower a patient's potassium level, s/he failed to question this order and/or contact the medical provider for further direction. Interview with the DNS, on 6/4/14 at 11:15 A.M., identified that RN #2 obtained the two doses of [MEDICATION NAME] from the facility emergency box for administration. Record review and interview with LPN #1, on 6/4/14 at 10:05 A.M., stated s/he administered two doses of [MEDICATION NAME] 60 ml by mouth to Resident #1 on 5/7/14 at 12:15 A.M. and 1:15 A.M. Although LPN #1 stated [MEDICATION NAME] is prescribed for an elevated potassium level, s/he failed to question the order and/or contact the medical provider for further direction. Interview with APRN #1, on 6/4/14 at 1:15 P.M., stated s/he directed RN #2 to administer a Potassium supplement of 60 mEq by mouth now and in one hour (due to the absorption rate) due to the critical potassium level of 2.6 mmol/L with a follow up potassium lab to be completed in the morning. APRN identified that s/he did not direct RN #2 to write an order for [REDACTED]. Interview with MD #1, Resident #1's attending physician on 6/13/14 at 10:25 A.M., identified that for critical potassium level of 2.6 mmol/L, [MEDICATION NAME] administration would be contraindicated. Review of the Medication Order Transcription policy identified that the nurse shall clarify any medication order which appears potentially inaccurate or inappropriate for any reason. The nurse countersigning orders shall be responsible for checking accuracy and clarify any discrepancies immediately.

Based on clinical record review, review of facility documentation and interviews for 2 of 6 sampled residents reviewed for accidents (R#490, R#108) the facility failed to transfer the resident with the assistance of two and/or assess for LOA and/or smoking ability. The findings include: 1. Resident # 490's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The RCP dated 5/22/13 and the NA Floor Assignments identified the use of a Sara Lift for transfers with the assistance of two. Nurses Notes dated 7/14/13 identified at 9:20 PM the resident was observed with a deep laceration on the right calf. A pressure dressing was applied to contain the bleeding, the APRN was notified and the resident was transferred 911 to the ED for evaluation and treatment. A Hospital Surgical Consultation report identified a 15.0 cm full thickness laceration of the right calf with no apparent muscle damage. The laceration was surgically repaired using sterile technique and subsequently antibiotics was initiated. Review of facility documentation dated 7/16/13 identified that NA # 1 lifted the resident with the Sara Lift and while in an upright position provided the resident with incontinent care. NA#1 then proceeded to transfer the resident into the bed and noted blood on the resident's right pant leg. A laceration was found and the supervisor was notified. Further review of facility documentation identified that although resident's chair, bed and Sara lift were in good repair, blood was noted on the resident's bed frame. NA#1 reenacted the transfer and it was determined that the NA had the Sara lift too close to the bed and when lifting the resident, the resident's calf got caught on the bed frame. Additionally, the NA was terminated for transferring the resident with a Sara lift without two people present. Interview, review of the clinical record, and review of facility documentation on 3/05/13 at 11:15 AM with the DNS identified the expectation is that two staff members should be present during all mechanical lift transfers for safety. 2. a. Resident # 108's [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] identified the resident as moderately cognitively impaired and independence with Activities of Daily Living. A resident care plan dated 10/16/13 identified the resident as a smoker with interventions to evaluate residents smoking capability, and ongoing assessment of the resident's ability to handle the responsibility of smoking safely. A review of the clinical record failed to identified that the last smoking assessment was completed on 4/01/13. Interview with the Assistant Director of Nurses on 3/05/14 at 12:00 PM identified that that the facility should be completing smoking assessments on a quarterly basis along with the MDS calendar. Review of the Resident Smoking Policy identifies that any resident who smokes will have his/her level of independence in smoking assessed by the charge nurse with any change of condition, quarterly or with an annual assessment. b.) Review of a RN progress note dated 11/13/13 identified that the resident was on the sidewalk on the main street wheeling backwards into a delivery truck, and became stuck under the truck. However the resident was able to release himself before the driver went onto Main Street. Review of the clinical record failed to identify that R#108 had an LOA order, a LOA assessment or a care plan for unsupervised LOA. Interview with the Director of Nurses on 3/06/13 at 10:30 AM identified that she could not locate a LOA order or that the resident had been assessed for LOA. Review of the Safe Unsupervised Leave of Absence Policy identifies that it is the policy of this facility to allow residents the opportunity to go out on an unsupervised leave of absence with a physician order [REDACTED].