Every finding on record at Roscoe Gardens Skilled Nursing and Rehab

Based on observation, review of the medical record, interview, and review of facility policy, the facility failed to ensure resident privacy during medication administration.This affected one resident (Resident #45) of three observed for medication administration. Findings Include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included dementia, transient cerebral ischemic attack, atrial fibrillation, anemia, hypertension, chronic obstructive pulmonary disease, and overactive bladder.Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #45 had intact cognition.Observation of medication administration on 06/09/26 at 9:15 A.M. revealed Resident #45 was outside in the smoking tent. Licensed Practical Nurse (LPN) #200 prepared the medication for Resident #45 inside the building, took them outside to the smoking tent and handed Resident #45 the plastic cup of medication in front of the four other residents. LPN #200 did not ask Resident #45 if she had her permission to administer the medications in front of the other four residents. Resident #45 asked LPN #200 why she had to give the medication to her outside in the smoking tent and why she could not wait until she came back inside to take them. LPN #200 just explained to the resident she needed to take the medications. Resident #45 indicated she could not swallow the big white tablet (potassium chloride) and it needed to be broken in half. LPN #200 proceeded to use her bare hand and retrieve the big white tablet out of the plastic mediation cup and break it in half with her bare hands and give it back to the resident to take.On 06/09/26 at 9:17 A.M. an interview with LPN #200 verified she should have asked Resident #45 if she wanted her medication outside or wanted to wait until she came back inside.Review of the facility policy titled, Dignity, dated 09/22 revealed each resident should be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff were to promote, maintain and protect residents' privacy, including bodily privacy during assessments with personal care and during treatment procedures.This deficiency is based on an incidental finding discovered during the course of this complaint investigation.

Based on review of the medical record, review of the controlled substance administration record, interview, and review of the facility policy, the facility failed to ensure narcotic medications were signed out and administered by the same licensed nurse. This affected one resident (Resident #56) of three reviewed for medication administration. Findings Include: Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses Alzheimer's disease, anxiety disorder, hypertension, congestive heart failure, dementia, and metabolic encephalopathy.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #56 had severely impaired cognition and had a prognosis of less than six months. Review of the June 2026 physician's orders revealed Resident #56 had an order for lorazepam 1.0 milligrams every eight hours and every 12 hours as needed for restlessness for 90 days. Review of the June 2026 Medication Administration Record (MAR) revealed on 06/09/26 at 6:00 A.M. the lorazepam (brand name: Ativan), a controlled medication, 1.0 milligram was administered by Registered Nurse (RN) #107.However, review of the Individual Controlled Substance Administration record revealed Resident #56 was administered Ativan 1.0 milligrams on 06/09/26 at 6:57 A.M. by Licensed Practical Nurse (LPN) #200. On 06/09/26 at 11:10 A.M. an interview with Licensed Practical Nurse #200 verified she had signed out the lorazepam for Resident #56 when she was doing the shift-to-shift narcotic count with Registered Nurse #107 and Registered Nurse #107 had administered the medication to Resident #56 and signed it out on the MAR. On 06/09/26 at 12:07 P.M. an interview with the Director of Nursing revealed the nurse who prepared the medication should also be the nurse who administers the medication.Review of the undated facility policy titled, Administering Medications, revealed medication should be administered in a safe and timely manner and as prescribed. Step 15 revealed as required or indicated for a medication, the individual administering the medication would record in the resident's medical record.This deficiency represents non-compliance investigated under Complaint Number 3032271.

Based on observation, review of the medical record, interview, review of manufacture guidelines, and review of the facility policy, the facility failed to maintain a medication error rate of less than five percent when medications were not timely administered before meals as ordered, expired medications were administered, and insulin was administered without priming. Out of 36 opportunities for error, four errors were made to equal an error rate of 11.1 percent (%). This affected one resident (Resident #34) of three observed for medication administration.Findings Include: 1. a. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included diabetes, pemphigus vulgaris, bullous pemphigoid, ocular hypertension, chronic obstructive pulmonary disease, asthma, depression, pain in right knee, anxiety disorder, and insomnia.Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #34 had intact cognition. Review of the June 2026 physician's orders revealed Resident #34 had an order for Admelog SoloStar Pen 30 units subcutaneously before meals for diabetes and Novolog FlexPen subcutaneously per sliding scale before meals for diabetes. Observation of the glucometer reading on 06/09/26 at 8:00 A.M revealed the blood glucose level for Resident #34 was 324 milligrams per deciliter (mg/dL) and she would need 8 units of NovoLog per sliding scale. Resident #100 had already eaten 100 percent of her breakfast. Observation of medication administration with Registered Nurse (RN) #110 on 06/09/26 at 8:05 A.M. revealed she prepared medication for Resident #34. The medication screen was colored red for the NovoLog and Admelog insulins, indicating they were late. RN #110 administered both insulins at 8:20 A.M. after Resident #34 had already eaten 100 percent of her breakfast.An interview at 8:30 A.M. with Registered Nurse #110 verified she had given both insulins after the resident had already eaten her breakfast, despite the order for the insulins to be administered before meals. Review of the undated facility policy titled, Administering Medications, revealed medications should be administered in a safe and timely manner and as prescribed. Medications must be administered in accordance with the orders including any required time frames. b. Review of the Resident #34's physician orders revealed the resident had an order for Pepcid 20 milligrams (mg) two times daily for heartburn. Observation of medication administration on 06/09/26 at 8:05 A.M. revealed Registered Nurse #110 retrieved a bottle of Pepcid 10 mg out of the stock over the counter medication bottles in the top drawer of the medication cart and placed two tablets in the medication cup. The bottle had an expiration date of 02/2026.An interview at 8:30 A.M. with Registered Nurse #110 verified the bottle of Pepcid was expired, however she still administered the medication to Resident #110 even after verification with the surveyor that they were expired. Review of the facility's policy titled, Storage of Medication, dated 09/01/21 revealed the facility should store all drugs and biologicals in a safe, secure and orderly manner. Drugs and biological should be stored in the packaging, containers, or other dispensing systems in which they were received. The facility should not use discontinued, outdated or deteriorated drugs or biologicals.c. Review of the June 2026 physician's orders revealed Resident #34 had an order for Admelog SoloStar Pen 30 units subcutaneously before meals for diabetes.Observation of medication administration on 06/09/26 at 8:05 A.M. revealed Registered Nurse #110 placed a needle on the Admelog SoloStar Pen and turned the dial to 30 units and administered the 30 units to Resident #34 without priming the needle prior to administration. An interview at 8:30 A.M. with Registered Nurse #110 verified she had not primed the needle prior to administration. Review of the manufacture's instruction for the Admelog SoloStar Pen revealed in Step #3 to always do a safety test before each injection to make sure the pen is working correctly and to ensure the person gets the correct insulin dose. It stated to select two units by turning the dose selector until the dose pointer is at the two mark, press the injection button all the way in, and when the insulin comes out of the needle tip, the pen was working correctly. Step #4 was to then select the dose and Step #5 was to then inject your dose. This deficiency represents non-compliance investigated under Complaint Number 3032271.

Based on observation, review of the medical record, interview, and review of the facility policy, the facility failed to ensure controlled mediations were not pre-poured and stored in the top drawer of the unlocked medication cart, without being promptly administered to the resident. This affected one resident (Resident #56) of 13 residents (#3, #9, #12, #26, #32, #33, #35, #45, #46, #47, #48, #51, and #56) who had medication in the Buckeye Hall medication cart #1.Findings Include:Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses Alzheimer's disease, anxiety disorder, hypertension, congestive heart failure, dementia, and metabolic encephalopathy.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #56 had severely impaired cognition and had a prognosis of less than six months. Review of the June 2026 physician's orders revealed Resident #56 had an order for lorazepam (brand name: Ativan), a controlled medication, 1.0 milligrams every eight hours and every 12 hours as needed for restlessness for 90 days. Observation on 06/09/26 at 7:12 A.M. revealed both dayshift and nightshift nurses were sitting at the Buckeye Hall nurses station. The medication cart was unlocked sitting in front of the nurse's station. Further observation revealed in the top drawer of Buckeye Cart 1 was a white tablet in a medication cup with no name. An interview at this time with Licensed Practical Nurse (LPN) #200 revealed it was an Ativan for a resident (identified as Resident #56) who was not up yet. She indicated she had it ready in the top drawer because the resident was leaving the facility. LPN #200 verified at this time she should not have pre-poured the medication.On 06/09/26 at 12:07 P.M. an interview with the Director of Nursing revealed the nurses were not to pre-pour medication at any time. Review of the facility's policy titled, Storage of Medication, dated 09/01/21 revealed the facility should store all drugs and biologicals in a safe, secure and orderly manner. Drugs and biological should be stored in the packaging, containers, or other dispensing systems in which they were received. The facility should not use discontinued, outdated or deteriorated drugs or biologicals. This deficiency represents non-compliance investigated under Complaint Number 3032271.

Based on observations, review of the medical record, interview, and review of the facility policy, the facility failed to maintain proper infection control procedures during medication administration. This affected two residents (Resident #34 and #45) of three observed for medication administration. Findings Include:1. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included diabetes, pemphigus vulgaris, bullous pemphigoid, ocular hypertension, chronic obstructive pulmonary disease, asthma, depression, pain in right knee, anxiety disorder, and insomnia.Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #34 had intact cognition. Review of the June 2026 physician's orders revealed Resident #34 had an order for Admelog SoloStar Pen 30 units subcutaneously before meals for diabetes and Novolog FlexPen subcutaneously per sliding scale before meals for diabetes. Observation of medication administration on 06/09/26 at 8:05 A.M. revealed Registered Nurse (RN) #110 obtained the glucometer and bottle of test strips out of the top drawer of the medication cart and took them into the room of Resident #110. She placed the glucometer and the bottle of test strips directly on the resident's bed without a barrier, obtained the resident's blood sugar, then left the room and placed the glucometer and bottle of test strips on top of the medication cart without cleaning/sanitizing them. She proceeded to prepare the residents' medications. An interview on 06/09/26 at 8:30 A.M. with RN #110 verified she cross-contaminated the glucometer and bottle of test strips by placing them directly on the resident's bed, then on top of the medication cart without cleaning/sanitizing them. She stated she was going to clean them before she used them again. An interview on 06/09/26 at 12:07 P.M. with the Director of Nursing verified RN #110 should have placed a barrier prior to placing the glucometer and bottle of tests strips onto the resident's bed and she should have sanitized the glucometer after use. Review of the undated facility policy titled, Obtaining a Fingerstick Glucose Level, revealed the purpose of the procedure was to obtain a blood sample to determine the resident's blood glucose level. It also stated to ensure that blood glucose meters intended for reuse were cleaned and disinfected between resident use. Step three of the procedure indicated to place the blood glucose monitoring device on a clean field. Step eight indicated to clean and disinfect reusable equipment, parts and/or devices after each use per manufacturer's instructions. Step 11 indicated to replace the blood glucose monitoring device in storage after cleaning. 2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included dementia, transient cerebral ischemic attack, atrial fibrillation, anemia, hypertension, chronic obstructive pulmonary disease, and overactive bladder.Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #45 had intact cognition.Observation of medication administration on 06/09/26 at 9:15 A.M. revealed Resident #45 had indicated to Licensed Practical Nurse (LPN) #200 that she could not swallow the big white tablet (potassium chloride), and it needed to be broken in half. LPN #200 proceeded to use her bare hands, retrieve the tablet out of the plastic mediation cup and break it in half with her bare hands and gave it back to the resident to take.On 06/09/26 at 12:07 P.M. an interview with the Director of Nursing verified LPN #200 should not have touched the tablet with her bare hands. Review of the undated facility policy titled, Administering Medications, revealed medications should be administered in a safe and timely manner and as prescribed.This deficiency is based on an incidental finding discovered during the course of this complaint investigation.

Based on observation, medical record review, hospital record review, review of radiological studies, interview, and policy review, the facility failed to ensure appropriate care, services and interventions were in place to prevent the development of an avoidable pressure ulcer for Resident #8. Actual Harm occurred on 10/24/25 when Resident #8 developed an avoidable suspected deep tissue injury (DTI) (a severe pressure-related wound damaging skin and underlying soft tissues, often starting under intact skin as a bruise-like purple or maroon area, that rapidly deteriorates to reveal significant tissue death-necrosis) to the left heel following a fall with a fracture to the right fibula, which impaired the resident's mobility and increased her dependence and need for assistance with activities of daily living (ADL). The wound evolved to an unstageable pressure ulcer with eschar (a full-thickness skin loss where the wound's true depth is hidden by yellow, tan, gray, black, or brown tissue-slough and/or eschar, making it impossible to stage until the covering is removed) which required manual debridement (the removal of damaged tissue or foreign objects from a wound). The facility also failed to ensure air mattress settings were correct for Resident #7. This affected two residents (Resident #7 and Resident #8) of four residents reviewed for pressure ulcers. Findings include:1. Review of Resident #8's medical record revealed an admission date of 09/16/22 with diagnoses including dementia without behavioral disturbances, anxiety, major depressive disorder, and unspecified intellectual disabilities. Review of the care plan for Resident #8 dated 02/11/25 revealed the resident was at risk for impaired skin integrity related to incontinence and impaired mobility. Interventions including to apply protective barrier cream after incontinence episodes and as needed (PRN), assist resident with turning and repositioning as needed, complete Braden Scale (pressure ulcer risk assessment) PRN, complete skin inspection every seven to ten days and PRN, assist as needed, encourage resident to reposition self if able, if resident refuses intervention, medication/treatment per physician/NP/PA orders, notify nurse of any new areas of skin breakdown noted during bathing or daily care (redness, blisters, bruises, discoloration), notify physician/NP/physician assistant (PA) of new areas of impaired skin integrity, pressure redistribution mattress to bed, provide a non-irritating surface to reduce friction or shearing forces, and provide incontinence care PRN. Resident #8 had care plan for activities of daily living (ADL) initiated on 03/27/25 with a focus on ADL needs to be met and interventions to include assist with ADLs (i.e. dressing, grooming, personal hygiene, locomotion, oral care, etc.) as needed. Additionally, a care plan focus of the musculoskeletal status related to osteoporosis was initiated on 09/11/25 with interventions to include provide assistance with turning and repositioning as needed and allow ample time to reduce pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] stated Resident #8 used a walker for mobility and was a partial to moderate assistance for personal hygiene, dressing her upper body, and for personal care. The assessment noted the resident had no current pressure ulcers but was at risk for pressure ulcers. Review of the Braden Scale which scores a patient's risk for pressure ulcers from six (severe risk) to 23 (no risk), with lower scores indicating higher risk, based on six factors: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction & Shear. Total scores categorize risk as: 19-23 (No Risk), 15-18 (Mild Risk), 13-14 (Moderate Risk), 10-12 (High Risk), and less than nine (Very High/Severe Risk), guiding preventive interventions like repositioning, skin care, and nutrition support). The Braden Scale for Resident #8 dated 09/10/25 revealed a score of 17, mild risk. Review of Resident #8's functional tasks from 10/01/25 to 10/15/25 revealed Resident #8 was independent but also required staff supervision for transfers at times. Review of Resident #8's shower sheets dated 10/14/25, 10/17/25, 10/21/25, 10/22/25 and 10/24/25 revealed no documented evidence of any deep tissue injury (DTI) to the left heel or any redness or softness to the left heel. Review of the Fall Incident Report dated 10/15/25 at 10:00 P.M. revealed Resident #8 was standing with her rollator in her room and was heading towards the bathroom when she stopped, shook, and fell to the floor. The fall was witnessed and immediate bruising to the affected lower extremity was noted. Three staff members helped Resident #8 to bed. Review of Resident #8's functional tasks for 10/16/25 and 10/17/25 revealed Resident #8 was totally dependent on staff for transfers and refused breakfast. The functional task dated 10/17/25 revealed Resident #8 was not getting out of bed and refused breakfast. Review of the skin inspection dated 10/17/25 noted no new observed skin issues for Resident #8. Review of the X-ray findings for Resident #8's right ankle dated 10/17/25 revealed an oblique nondisplaced fracture of the distal fibula. Review of the emergency room documentation dated 10/17/25 revealed Resident #8 had a fall on 10/15/25 and had not been ambulatory for the past two days, with significant swelling and bruising with tenderness over the medial malleolus noted to the right ankle. The plan for discharge included orders for a sugar-tong splint, minimal weight-bearing, and to follow up with orthopedics. Review of the progress note dated 10/17/25 at 6:22 P.M. revealed Resident #8 returned from emergency room at 4:30 P.M. with a splint on the right leg. The nurse documented Resident #8 was non-weight bearing on the right leg and there was a referral to orthopedics dated 10/29/25. Review of Resident #8's medical record revealed there was no documented evidence of an updated Braden Scale completed after Resident #8 had the fracture and she was non-weight bearing. Review of Resident #8's medical record revealed there was no documented evidence of pressure ulcer interventions in place after Resident #8 became non-weight bearing after the fall with fracture until 10/22/25 when the resident received a new order for the heels to be elevated. Review of Resident #8's physician orders dated 10/22/25 revealed an order for the resident's heels to be elevated at all times as the patient will allow to prevent pressure ulcer due to increased immobility for prevention. Review of Resident #8's care plan for ADLs initiated on 10/22/25 and 10/23/25 revealed interventions to include one person assistance for bed mobility and toileting, independence with eating, staff to offer assistance with meal set-up if needed, and may use mechanical lift and two person assistance for transfers. Review of the Wound Evaluation dated 10/24/25 revealed Resident #8 had a new unstageable pressure ulcer noted to the left heel that measured 2.5 centimeters (cm) in length and four cm in width and it had unknown depth. The pressure ulcer was in-house acquired, there was no drainage, it was fragile and intact, and new orders were received. Review of Resident #8's care plan initiated on 10/24/25 revealed a care plan for impaired skin integrity as evidenced by a DTI to left heel related to impaired mobility with interventions for treatments per physician orders, wound consult PRN, complete Braden Scale PRN, complete wound evaluation to monitor progress of the resident's skin condition, and heel medix boot (a specialized medical device designed to prevent and treat pressure injuries in bedridden and non-ambulatory patients) to the left foot. Review of Resident #8's physician orders dated 10/24/25 revealed orders for a heel medix boot to the left foot with instructions for the medix boot placement to be checked twice a day. An order was also received to cleanse Resident #8's left heel, apply skin prep (protective barrier), then pad with an abdominal dressing (ABD) (a thick highly absorbent gauze dressing used for large or heavily draining wounds, offering padding, protection, and moisture absorption to prevent infection and promote healing) and wrap with a gauze bandage twice a day. Review of the physician order dated 10/27/25 revealed Resident #8 was to be repositioned frequently twice a day to off load (removing or significantly reducing pressure and weight from a specific body part, especially a foot or heel, to allow wounds or injuries to heal, prevent further tissue damage, infection, and complications by improving blood flow and tissue regeneration). The orders also stated Resident #8 was to be turned and repositioned with incontinence care and as needed. Review of the wound care progress note dated 11/07/25 by Wound Nurse Practitioner (WNP) #210 revealed the wound was still a DTI and measured three cm in length by three cm in width. The wound bed was closed with purple discoloration. Review of the significant change MDS assessment dated [DATE] revealed Resident #8 used a wheelchair for mobility and required substantial to maximum assistance for personal care, dressing her upper body, and for personal hygiene. The assessment noted the resident also had one unstageable pressure ulcer. Review of the wound care progress note dated 11/14/25 by WNP #210 revealed the improved DTI measured 2.5 cm in length by 1.5 cm in width. The wound bed was closed and necrotic. Review of the wound care progress note dated 11/21/25 by WNP #210 revealed the deteriorating DTI measured 2.8 cm in length by 1.8 cm in width. The wound bed was closed and necrotic. Review of the wound progress note dated 11/28/25 by WNP #210 revealed the improved DTI measured 2.5 cm in length by 1.5 cm in width. The wound bed was closed and necrotic. Review of the wound progress note dated 12/05/25 by WNP #210 revealed the unchanged DTI measured 2.5 cm in length by 1.5 cm in width. The wound bed was closed and necrotic. Review of the psychiatry progress note dated 12/09/25 by NP #280 revealed when Resident #8 was asked about her overall wellbeing, she reported feeling bad and attributed this to her legs, specifically pointing to bilateral heel wounds. Review of the Braden Scale dated 12/11/25 revealed a score of 15 which indicated Resident #8 was at moderate risk for pressure ulcers. Review of the progress note dated 12/16/25 at 3:02 P.M. revealed a conversation with Resident #8's family. Staff stated that Resident #8 had experienced a decline in overall functional status. Therapy services reported little progress in treatment and there was a recent weight loss. Resident #8 refused meals, care, and to get out of bed or chair frequently. Hospice was discussed and the resident's family was agreeable. Review of the wound care progress note dated 12/19/25 by WNP #210 revealed the deteriorating DTI measured 2.5 cm length by 1.5 cm in width. A Bioburden debridement (process of removing microorganisms such as bacteria and fungi and the slimy film they create on the surface of a wound) was performed for the DTI. During an interview on 12/17/25 at 10:26 A.M., Registered Nurse (RN) #120 stated when she came in for the night shift on 10/16/25, an unknown Certified Nursing Assistant (CNA) told her that Resident #8 was complaining of pain. RN #120 stated she noticed Resident #8 had swelling and bruising to her right ankle, so she called the on-call physician and received an order for an x-ray. The x-ray was completed on 10/17/25 which revealed an acute fibula fracture to the right ankle. Additionally, RN #120 stated she had not observed Resident #8 getting up out of bed or walking on her own since the fall on 10/15/25. During an interview on 12/17/25 at 11:18 A.M., Licensed Practical Nurse (LPN) #169 stated after the fall, Resident #8 was fearful and refused to leave her room because her right leg was swollen and painful. During an interview on 12/18/25 at 3:31 P.M., NP #200 stated she was not notified of any redness or softness to Resident #8's left heel until she was first notified of a deep tissue injury (DTI) on 10/24/25. During an interview on 12/18/25 at 4:03 P.M., NP #210 stated she examined Resident #8 on 10/24/25 and noted a DTI which, without a diagnosis of blood clots or decreased circulation, would be considered avoidable. During an interview on 12/22/25 at 8:37 A.M., CNA #175 stated Resident #8 did not want to be touched after the fall and required two-person assistance, when previously, Resident #8 had been independent with walking. CNA #175 stated the pressure ulcer was probably just from the way Resident #8 was lying because pillows were only being used under the resident's feet to elevate them before the pressure ulcer was noticed. After the pressure ulcer was noticed, Resident #8's foot was wrapped and a boot was used. During an interview on 12/22/25 at 8:51 A.M., CNA #90 stated Resident #8's mobility changed significantly after the fall and Resident #8 would not let anyone touch the right broken extremity. CNA #90 stated Resident #8 was independent with walking and would go to the dining room and participate in activities and now she did not walk or go to activities at all but sat in her recliner watching television. CNA #90 stated Resident #8 did not get out of bed for at least a week after the fall. During an interview on 12/22/25 at 9:32 A.M., the Director of Nursing (DON) verified there was no documentation that Resident #8's heels were offloaded and that the resident was turned every two hours, from after the fall on 10/15/25, leading up to the wound on 10/24/25. During interview on 12/22/25 at 10:17 A.M. with Regional RN #320 verified Resident #8's mattress was just a regular mattress, and not a pressure redistribution mattress per the care plan dated 02/11/25. During an observation on 12/22/25 at 10:22 A.M., Resident #8 had a foam mattress on her bed. At the time of the interview, the Assistant Director of Nursing (ADON) confirmed the observation and stated a foam redistribution mattress was a soft foam mattress which had firm foam at the sides and soft foam in the middle which went from top to bottom. The ADON stated that if a resident had a pressure ulcer that was Stage 3 or higher, then the resident would have an air mattress (pressure redistribution mattress). The ADON confirmed Resident #8's mattress was a foam redistribution mattress and not a pressure redistribution mattress. During an interview on 12/22/25 at 11:14 A.M., the ADON stated she had mentioned an air mattress several times for Resident #8 to the DON and to the person who ordered the supplies, but that she never received one for Resident #8. The ADON stated she knew a DTI was unstageable and required an air mattress. The ADON verified that Resident #8 did not have a diagnosis of blood clots or decreased circulation. The ADON confirmed Resident #8 had a significant decline since her fall. During an interview on 12/22/25 at 12:03 P.M., the DON verified Resident #8's DTI was unstageable and the resident should have an air mattress. The DON stated she just ordered an air mattress. During an observation on 12/16/25 at 3:28 P.M., Resident #8's left heel had a DTI that was black and round, and approximately the size of a fifty-cent piece. During an interview on 12/22/25 at 2:52 P.M., the Medical Director (MD) stated Resident #8 was independent before the fall in October 2025 and had declined over the last few months and was just admitted to hospice last week. The Medical Director stated the most significant decline after the fall included skin breakdown and the resident's overall decline escalated after the fall. During an interview on 12/23/25 at 3:07 P.M., CNA #116 stated Resident #8 did not move her legs in bed and she would try to move her upper body, but Resident #8 could not turn herself. CNA #116 stated that most of the time Resident #8 did not have a pillow under her feet or feet elevated when she was lying in bed after her fall. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, undated, revealed the nursing staff will assess and document an individual's significant risk factors for developing pressure sores. Staff will review and modify the care plan as appropriate. 2. Review of the medical record revealed Resident #7 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hypertensive heart disease with heart failure, displaced fracture of right femur, severe-protein-calorie malnutrition, and anxiety. The record indicated the resident weighed 151 pounds. Review of Resident #7's physician order dated 10/21/25 at 3:47 P.M. revealed Resident #7 was admitted to hospice with the diagnosis of hypertensive heart disease with heart failure. Review of Resident #7's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had cognitive impairment. The MDS also revealed Resident #7 was dependent on staff for rolling from lying on back, to left and right side, and returning to lying on back on the bed. Review of Resident #7's physician order dated 11/03/25 at 5:05 P.M. revealed an air mattress was ordered and the function was to be checked every shift. Review of Resident #7's plan of care dated 11/05/25 revealed Resident #7 was at risk for impaired skin integrity related to limited mobility secondary to a history of right hip fracture, incontinence, and requiring hospice services. An intervention included an air mattress was ordered by hospice. Observations on 12/15/25 at 2:56 P.M.,12/16/26 at 10:50 A.M., and 12/18/25 at 8:35 A.M. revealed Resident #7's air mattress was on the firm setting. An interview on 12/18/25 at 8:20 A.M. hospice Registered Nurse (RN) #240 verified Resident #7's air mattress should only be on the firm setting when care, such as incontinence care, was provided while the resident was in bed. An interview on 12/18/25 at 8:33 A.M. Director of Nursing (DON) verified Resident #7's air mattress was on the firm setting. The DON verified the air mattress should be set based on the resident's weight of 151 pounds.

Based on observations, interviews, review of facility policy, and review of the United States Department of Agriculture (USDA) website, the facility failed to store and serve food under sanitary conditions. This had the potential to affect all 59 residents residing in the facility, who ate food from the kitchen. Findings Include:1. Observation of the kitchen on 12/15/25 from 8:55 A.M. to 9:14 A.M. revealed in the over the tray foodservice serving area, there were two dirty exhaust fans with a large amount of a brown and gray fuzzy substance on them. The white paint on the ceiling over the food serving area was also chipping and bulging from the ceiling. An interview with [NAME] #117 on 12/15/25 at 9:06 A.M. confirmed the presence of a brown and gray fuzzy substance on the exhaust fans and the presence of chipping ceiling paint over the food serving area. An interview with Dietary Director #74 on 12/15/25 at 9:08 A.M. confirmed the presence of a brown and gray fuzzy substance on the exhaust fans and the presence of chipping ceiling paint over the food serving area. 2. Observation of the internal temperature on the tray line prior to food service on 12/18/25 at 10:17 A.M. revealed that the plain chicken holding temperature was 130 degrees Fahrenheit. The holding temperature of the mechanical soft chicken was 153 degrees Fahrenheit. A follow up observation of the internal temperature on the tray line prior to food service on 12/18/25 at 11:55 A.M. revealed that the holding internal temperature for the plain chicken was 110 degrees Fahrenheit. The holding internal temperature for the mechanical soft chicken was 128 degrees Fahrenheit. An interview with [NAME] #117 on 12/18/25 at 11:55 A.M. confirmed that the holding temperatures for the plain chicken and mechanical soft chicken were in the temperature danger zone.Review of the September 2021 facility policy titled, Food Handling, revealed that the temperature danger zone for potentially hazardous foods is 41 degrees to 135 degrees Fahrenheit. Review of the USDA Food and Inspection Service webpage revealed that leaving food out too long at room temperature can cause bacteria to grow at dangerous levels that can cause illness. Bacteria grow most rapidly in the range of temperatures between 40 degrees and 140 degrees Fahrenheit. This range of temperatures is called the Danger Zone. Food placed in preheated steam tables or warming trays should be kept above 140 degrees Fahrenheit.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure smoking regulations were being adhered to in accordance with NFPA 101 - 2012 Edition, Section 19.7.4 per the regulations. This deficient practice had the potential to affect all 59 residents residing in the facility. Findings Include: Observation on 12/18/25 during a tour of the facility at 8:56 A.M. with the Director of Maintenance (DM) #131 noted the designated smoking area in the central enclosed courtyard was not being properly maintained. Thirty-seven cigarette butts were on the ground. Three butts were in a pine bush and had burned some of the needles. A cigarette receptacle was also present. An interview with the DM #131 verified the findings at the time of observation. An interview with the Administrator on 12/17/25 at 3:23 P.M. revealed that smokers were expected to use the two available fireproof cigarette receptacles to dispose of their cigarette butts after smoking. Review of the facility policy dated September 2022 titled, Smoking Policy, revealed that the smoking area will comply with applicable Federal, State and local laws regarding smoking and smoking safety.

Based on record review, observation, interviews, review of the National Institutes of Health (NIH) instructions on how to use a nebulizer, and facility policy review, the facility failed to ensure Resident #7's oxygen was administered as ordered. This affected one (Resident #7) out of six residents reviewed for respiratory care. The facility also failed to ensure oxygen tubing was dated for Resident #6, Resident #26, Resident #27, Resident #44, and Resident #70. This affected five (Resident #6, #26, #27, #44, and #70) out of six residents reviewed for respiratory care. The facility census was 59.Findings include:1. Review of the medical record revealed Resident #7 was admitted on [DATE] and 08/27/25 with diagnoses including hypertensive heart disease with heart failure, displaced fracture of right femur, severe-protein-calorie malnutrition, and anxiety. Review of a plan of care dated 08/19/25 revealed Resident #7 had impaired respiratory status. Interventions included to monitor vital signs and pulse oximetry, and provide oxygen as needed when resident exhibits signs and symptoms of difficulty breathing such as shortness of breath, cyanosis, and low oxygen saturation levels. Review of vital sign documentation revealed Resident #7's last oxygen saturation recorded was on 10/21/25. Review of the physician order dated 10/25/25 at 4:41 P.M. revealed Resident #7 was ordered oxygen at two to four liters per minute via nasal cannula as needed to maintain oxygen saturation at 90% or greater and/or shortness of breath. Review of the medication administration record (MAR) for December 2025 revealed no documentation of oxygen being used as needed and no documentation of Resident #7's oxygen saturation levels. An observation on 12/15/25 at 2:56 P.M. and 12/16/26 at 10:50 A.M. revealed oxygen was being administered to Resident #7 at three liters per minute via nasal cannula. An interview on 12/18/25 at 8:37 A.M. with the Director of Nursing (DON) verified oxygen was being administered without documentation on the MAR. The DON verified there was no documentation of Resident #7's oxygen saturation level before and after the use of oxygen and how many liters of oxygen was being administered. Review of the Oxygen Administration policy, dated September 2021, revealed problems may occur if the patient fails to comply with the doctor's orders or receives inadequate instruction. The initial need is determined by documented hypoxemia or a physician order. 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease, and anxiety disorder. Review of Resident #6's care plan dated 03/21/25 revealed that Resident #6 was at risk for impaired respiratory status related to COPD. Interventions included administering oxygen as needed. Review of Resident #6's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicative of intact cognition. She was assessed as receiving oxygen. Review of Resident #6's physician orders dated 12/01/25 revealed that she had orders for four liters of oxygen per minute via nasal cannula, may titrate to keep saturations at or above 91%. Resident #6's physician order dated 12/07/25 revealed that oxygen tubing should be changed on a weekly basis. Observation on 12/15/25 at 9:43 A.M. revealed that Resident #6's oxygen tubing was not dated. An interview with Registered Nurse (RN) #92 on 12/15/25 at 10:41 A.M. confirmed that Resident #6's oxygen tubing was not dated. 3. Review of the medical record for Resident #26 revealed an admission date of 12/29/23 with diagnoses including COPD, type two diabetes mellitus, iron deficiency anemia, anxiety disorder, hypertension, dementia, depressive disorder, dysphagia, and polyneuropathy. Review of an order dated 06/04/25 for Resident #26 stated oxygen: may use two to four liters per minute at bedtime via Continuous Positive Airway Pressure (CPAP) machine as needed, to maintain oxygen saturations above 92% until assessed by respiratory. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #26 had a BIMS score of 13 out of 15, indicating the resident had no cognitive deficit. Observation on 12/15/2025 at 11:11 A.M. revealed Resident #26 in his room sitting on his bed with oxygen in his nose via nasal cannula. Licensed Practical Nurse (LPN) #135 confirmed there was no date on the oxygen tubing at the time of the observation. 4. Review of the medical record for Resident #27 revealed an admission date of 11/01/24 with diagnoses including COPD, acute and chronic respiratory failure with hypoxia, heart failure, chronic kidney disease stage four, supraventricular tachycardia, hypertension, cardiomyopathy, atrial fibrillation, and need for assistance with personal care. Review of an order dated 12/08/24 for Resident #27 stated change oxygen tubing and set up weekly every night shift every Sunday. Review of an order dated 07/29/25 for Resident #27 stated oxygen at two liters peer minute via nasal cannula ever shift related to COPD and acute and chronic respiratory failure with hypoxia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #27 had a BIMS score of 15 out of 15, indicating the resident had no cognitive deficit. Observation on 12/15/2025 at 11:11 A.M. of Resident #27 lying in his bed receiving oxygen via nasal cannula. LPN #135 confirmed there was no date on the oxygen tubing at the time of the observation. 5. Review of the medical record for Resident #44 revealed an admission date of 06/14/22 with diagnoses including COPD, dementia, iron deficiency, hyperlipidemia, chronic respiratory failure with hypoxia, hypertension, gastro-esophageal reflux disease, major depressive disorder, and obstructive sleep apnea. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #44 had a BIMS score of 12 out of 15, indicating the resident had a moderate cognitive deficit. Review of an order dated 12/04/25 for Resident #44 stated oxygen at two liters per minute via nasal cannula as needed for shortness of breath. Observation on 12/15/2025 at 11:12 A.M. of Resident #44 lying in bed with her oxygen on via nasal cannula and no date on the tubing. LPN #135 confirmed there was no date on the oxygen tubing at the time of the observation. 6. Review of the medical record for Resident #70 revealed an admission date of 04/14/24 with diagnoses including COPD, cerebral infarction, morbid obesity, hyperlipidemia, obstructive sleep apnea, hypertension, atrial fibrillation, congestive heart failure, asthma, gastro-esophageal reflux disease, chronic kidney disease stage three, and acute respiratory hypercapnia. Review of an order dated 02/18/25 for Resident #70 stated Bilevel Positive Airway Pressure (BiPAP) at home settings (11/seven) at bedtime and with naps as needed. Additionally, there was an order dated 02/19/25 for Resident #70 which stated BiPAP: remove in morning. Clean the mask and equipment after use in the morning. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #70 had a BIMS score of 15 out of 15, indicating the resident had no cognitive deficit. Review of an order dated 12/11/25 stated DuoNeb solution 0.5-2.5 3 milligrams/3milliliters (mL) (Ipratropium-Albuterol) one vial inhale orally via nebulizer every eight hours as needed for cough, wheezing, or shortness of breath. Observation on 12/15/2025 9:45 A.M. of Resident #70 sitting up in bed, with her bedside tray in front of her. Resident #70's nebulizer mask and tubing were lying on the nightstand beside her bed attached to the nebulizer machine. and the tubing had no date on it. Resident #70's BiPAP facemask was lying on top of the BiPAP machine, and there was no date on the tubing, and the BiPAP facemask was not covered. LPN #135 confirmed there was no date on the nebulizer tubing or the BiPAP tubing at the time of the observation and verified the BiPAP facemask was not covered. LPN #135 stated the facemask should be stored in a plastic bag when not in use. Review of the National Institutes of Health (NIH) https://www.nhlbi.nih.gov/sites/default/files/publications/How-to-Use-a-Nebulizer-21-HL-8163.pdf publication number 21-HL-8163 titled How to use a nebulizer, dated October 2021, stated in between uses to store the nebulizer parts in a dry, clean plastic storage bag. Keep each person's medicine cup, mouthpiece or mask, and tubing in a separate labeled bag to prevent the spread of germs.

Based on record review, observations, staff interviews, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to follow infection control procedures while serving food to residents under contact precautions. This affected two (Residents #21 and 26) out of five residents reviewed for infection control. Also, the facility failed to properly clean the glucometer and place a barrier between the glucometer and a potentially contaminated surface. This affected one (Resident #60) of one resident observed for blood glucose check on the Sycamore hallway and had the potential to affect the five additional (Residents #4, #5, #17, #32, and #54) identified by the facility that had blood glucose checks on Sycamore hallway. Additionally, the facility failed to have proper personal protective equipment (PPE) in place for Resident #13 under enhanced barrier precautions (EBP). This affected one (Resident #13) of three residents under EBP in the Sycamore hallway and had the potential to affect 13 additional (Residents #2, #3, #4, #8, #12, #13, #16, #36, #37, #45, #49, #51, and #58) identified by the facility with orders for EBP. The facility census was 59.Findings include:1. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and had diagnoses that included Clostridioides difficile (C. diff) infection. Review of Resident #21's care plan dated 12/15/25 revealed that Resident #21 had a recurrent C. diff infection. Interventions included contact isolation, which included all meals to be provided in her room. Review of Resident #21's physician orders dated 12/15/25 revealed that they were under contact isolation precautions for C. diff infection. Observation of lunch meal pass on 12/17/25 at 11:53 A.M. revealed that Certified Nursing Aide (CNA) #73 did not don PPE to enter Resident #21's room, and CNA #73 was observed to be within one foot of Resident #21 while setting up her meal tray. An interview with CNA #73 on 12/17/25 at 11:54 A.M. confirmed that CNA did not don any PPE prior to entering Resident #21's room and getting within one foot of Resident #21. 2. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] and had diagnoses that included C. diff infection. Review of Resident #26's physician orders dated 12/10/25 revealed that he was under contact isolation related to C. diff infection. Observation of lunch meal pass on 12/15/25 at 11:55 A.M. revealed that CNA #117 did not don gloves or a gown when entering Resident #26's room to deliver his meal. CNA #117 was observed to be within one foot of Resident #26 while setting up his lunch meal. An interview with CNA #117 on 12/15/25 at 11:58 A.M. confirmed that he did not wear PPE to enter Resident #26's room and that he was within one foot of Resident #26. Review of an undated facility policy titled, Isolation-Initiating Transmission-Based Precaution, revealed that transmission-based precautions include contact precautions. Transmission-based precautions will be implemented by ensuring that PPE is available so that everyone entering the room can access what they need. Review of the CDC's Infection Control website revealed that wearing a gown and gloves for all interactions that may involve contact with the patient is recommended. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. 3. Review of the medical record revealed Resident #60 was admitted on [DATE] with diagnoses that included type II diabetes and chronic pain. Review of the plan of care dated 11/29/25 revealed Resident #60 had an impaired metabolic status related to diabetes. Interventions included administering medications and treatments as indicated by the physician, monitoring labs/diagnostic testing per physician orders, and monitoring glucose levels per physician orders. Review of a physician order dated 12/03/25 revealed Resident #60 was to have blood glucose levels checked before meals and bedtime. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 was cognitively intact. An observation on 12/17/25 at 8:11 A.M. revealed Licensed Practical Nurse (LPN) #169 went into Resident #60's to check the resident's blood glucose levels. LPN #169 laid the blood glucose monitoring device on Resident #60's overbed table without a barrier. After checking Resident #60's blood glucose, LPN #169 took the blood glucose monitoring device back out and laid it directly on the medication cart. LPN #169 ripped off half a bleach wipe and wiped off the blood glucose monitoring device and laid it back on the medication cart without a barrier. LPN #169 stated the wipes were very wet and the blood glucose monitoring device needed to be wet for two minutes. On 12/17/25 at 8:18 A.M. LPN #169 verified the directions on the bleach wipes revealed the blood glucose monitoring device was to be visible wet for three minutes. LPN #169 also verified she laid the blood glucose monitoring device on Resident #60's overbed table and medication cart without a barrier. Review of the undated policy titled Obtaining a Fingerstick Glucose Level policy revealed the blood glucose monitoring device is to be placed on a clean field. Following the manufacturer's instructions, clean and disinfect reuseable equipment, parts, and/or devices after each use. 4. Review of the medical record revealed Resident #13 was admitted on [DATE] with diagnoses including alcohol dependence, dysphagia, anxiety, schizophrenia, and chronic viral hepatitis C. An observation on 12/17/25 at 8:57 A.M. revealed emergency (rain) ponchos were located in the PPE cart outside Resident #13's room. A sign hanging outside Resident #13's room revealed the resident was on EBP. LPN #169 and CNA #73 verified the emergency ponchos did not cover the staff's arms and were not appropriate PPE. Review of the facility policy titled Enhanced barrier Precautions (EBP) dated 01/2024, revealed EBPs are an infection control method used in the facility to reduce transmission of multi-drug-resistant organisms (MDROs). EBP refers to the use of gown and gloves during high-contact care activities for residents with any of the following known infection or colonization with a resistant organism when contact precautions do not otherwise apply, chronic wounds, or indwelling medical devices.

Based on observation, record review, interview, and policy review, the facility failed to ensure privacy was maintained while Resident #17 was being taken to the shower room. This affected one (Resident #17) out of one reviewed for dignity and respect. Facility census was 59. Findings include:Review of the medical record revealed Resident #17 was admitted on [DATE] with diagnoses that included Parkinson's disease, diabetes, and anxiety disorder.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact and required substantial/maximal assistance for showering and bathing. An observation on 12/16/25 at 1:44 P.M. revealed Certified Nursing Assistant (CNA) #124 was transporting Resident #17 from his room to the shower room in a shower chair. Resident #17 was wearing a gown that covered the front of the resident, though a side view of Resident #17 revealed the resident's buttocks and genitals were able to be seen below the hole in the seat in the shower chair. An interview on 12/16/25 at 1:44 P.M. with CNA #124 verified Resident #17's buttocks and genitals were able to be seen when Resident #17 was observed from the side. Review of the Shower/Tub Bath policy dated 09/2021 revealed when transporting the resident to and from the bath area ensure that the resident is covered and his or her privacy is maintained.

Based on observation and interview, the facility failed to maintain a safe environment. This affected one resident (#4) of four sampled for environment. The facility census was 59.Findings Include: Review of Resident #4's medical record revealed an admission date of 07/20/22, a re-entry date of 07/07/24 and diagnoses including but not limited to diabetes, dysphagia, heart failure, chronic obstructive pulmonary disease, osteomyelitis, schizoaffective disorder, schizophrenia, peripheral vascular disease, anxiety disorder, major depressive disorder and hypertension. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Further review of the MDS revealed the resident was independent or required set up assistance with eating, bed mobility, transfers and wheelchair mobility, required partial/moderate assistance with toilet hygiene and showering or bathing, had an indwelling catheter and was occasionally incontinent of bowel. An observation on 12/17/25 at 9:10 A.M. revealed Resident #4's bed was positioned to the left of the door with the head of the bed against the same wall as the door and a space between the left side of the bed and the wall of about six inches. The resident's call light was attached to the call light box positioned on the wall at the foot of the resident's bed. The call light box was partially covered by a plastic cover with approximately a third of the call light box uncovered and unused wires covered by a wire nut and electrical tape was visible in the open area of the call light box. In an interview on 12/17/25 at 9:14 A.M. with Certified Nursing Assistant (CNA) #73 confirmed that Resident #4's call light was attached to the call light box at the foot of the resident's bed and the call light box was partially covered by a plastic cover with approximately a third of the call light box uncovered and unused wires covered by a wire nut and electrical tape visible in the open area of the call light box.

Based on resident record review, staff interview, and review of facility policy, the facility failed to provide a bed hold letter to a resident and failed to notify the Ombudsman when the resident discharged to the hospital. This affected one resident (Resident #3) out of three residents reviewed for discharges. The facility census was 59 residents.Findings Include:Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] and had diagnoses that included vascular dementia, and displaced fracture of neck of right femur. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was assessed as having a Brief Interview for Mental Status (BIMS) score of 14, indicative of intact cognitive status. Review of Resident #3's nursing progress notes dated 08/20/25 revealed that he had a fall and was discharged to the hospital for an evaluation. Review of Resident #3's medical record revealed that he was hospitalized from [DATE] to 08/24/25. There was no documented evidence of a bed hold letter provided or evidence of Ombudsman notification in the medical chart. An interview with Business Office Manager #71 on 12/18/25 at 11:33 A.M. confirmed there was no evidence that a bed hold notice letter had been given to Resident #3 or their representative, nor was there evidence that the Ombudsman had been notified about Resident #3's hospitalization. Review of a facility policy dated September 2021 titled, Bed-Holds and Returns, revealed that prior to a transfer, written information will be given to the residents and the resident representatives that explains the bed hold policy.

Based on observation, record review, interview, and policy review, the facility failed to ensure Resident #7's fingernails were trimmed and cleaned. This affected one (Resident #7) out of three reviewed for activities of daily living. Facility census was 59.Findings included:Review of the medical record revealed Resident #7 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hypertensive heart disease with heart failure, displaced fracture of right femur, severe-protein-calorie malnutrition, and anxiety.Review of Resident #7's plan of care dated 08/06/25 revealed Resident #7 had an activity of daily living (ADL) self-care performance deficit. Interventions included to assist the resident with activities of daily living such as dressing, grooming, personal hygiene, locomotion, and oral care. Review of Resident #7's physician order dated 10/21/25 at 3:47 P.M. revealed Resident #7 was admitted to hospice with diagnosis of hypertensive heart disease with heart failure. Review of Resident #7's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had cognitive impairment. The MDS also revealed Resident #7 was dependent on staff for personal hygiene. Review of Resident #7's bathing documentation dated 12/03/25 and 12/06/25 revealed Resident #7's fingernails were not trimmed. Bathing documentation dated 12/10/25 revealed hospice bathed Resident #7 and trimmed his fingernails. Bathing documentation dated 12/10/25 revealed Resident #7's fingernails were not trimmed. An observation on 12/15/25 at 2:56 P.M. and 12/16/26 at 10:50 A.M. revealed Resident #7 had long fingernails. An interview on 12/18/25 at 8:20 A.M. with Hospice Triage Registered Nurse (RN) #240 revealed hospice aides did not trim resident fingernails as part of activities of daily living care. An interview on 12/18/25 at 8:37 A.M. with the Director of Nursing verified Resident #7 had long fingernails that needed trimmed.An interview on 12/18/25 at 9:01 A.M. with Hospice RN #242 verified hospice aides could not trim resident fingernails. Review of the undated policy titled Activities of Daily Living revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently including appropriate support and assistance with hygiene.

Based on observation, record review, interviews, and policy review, the facility failed to ensure timely care and services were provided to Resident #8 who had a fall which resulted in a fracture. This affected one resident (#8) out of five reviewed for accidents. Additionally, the facility failed to ensure appropriate catheter care was provided for Resident #7 when the resident's indwelling urinary catheter drainage bag was not properly positioned or secured in accordance with facility policy and accepted catheter care standards. This deficient practice affected one resident (#7) of two residents reviewed for catheter care. The facility reported ten residents with indwelling urinary catheters. Facility census was 59.Findings include: 1. Review of Resident #8's medical record revealed an admission date of 09/16/22 with diagnoses including, but not limited to dementia without behavioral disturbances, anxiety, major depressive disorder, and unspecified intellectual disabilities. Review of Resident #8's care plan dated 02/11/25 revealed the resident had impaired communication related to intellectual disabilities, dementia and usually understood with slurred and mumbled speech. Interventions included to allow the resident ample time to comprehend what is being said and allow for a response, pay attention to the residents body language, and use simple and direct communication (yes/no questions) to promote understanding. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] stated Resident #8 used a walker independently for mobility and required partial to moderate assistance for personal hygiene, dressing her upper body, and for personal care. Review of the Fall Risk Evaluation dated 09/10/25 revealed Resident #8 was at a high risk for falls. Review of the Fall Incident Report dated 10/15/25 at 10:00 P.M. revealed Resident #8 was standing with her rollator in her room and was heading towards the bathroom when she stopped, shook, and fell to the floor. The fall was witnessed and immediate bruising to the affected lower extremity was noted. Three staff members helped Resident #8 to bed. Review of the Fall Risk Evaluation dated 10/15/25 revealed Resident #8 was at a high risk for falls. Review of the bed mobility functional tasks for October 2025 revealed Resident #8 went from being independent/one person supervision to extensive staff assistance after the fall on 10/15/25, and total staff dependence that required two-person assistance with transfers on 10/16/25. Resident #8 was independent with walking ten feet on 10/15/25 prior to the fall, and after 10/16/25, Resident #8 did not walk again according to the task report. Resident #8 remained an extensive staff assist or dependent on staff for transfers since the fall on 10/15/25. Review of the progress note dated 10/16/25 by Nurse Practitioner (NP) #200 revealed she was asked to examine Resident #8 for bilateral lower extremity edema related to a recent fall. NP #200 stated Resident #8 had Thrombo-Embolic Deterrent (TED) hose on her feet during the examination and ordered Furosemide (a diuretic) 20 milligrams (mg) for swelling. Review of the progress note dated 10/17/25 at 5:50 A.M. revealed Resident #8 was favoring her right ankle and did not want to stand to transfer. Resident #8 fell on [DATE] and there was a concern for a possible fracture. The on-call physician was notified, and an order was received for a right ankle x-ray. Review of the progress note dated 10/17/25 at 6:06 A.M. revealed Resident #8 had limited range of motion to the right foot and ankle, and it was painful to stand. Review of the X-ray findings for Resident #8's right ankle dated 10/17/25 revealed an oblique nondisplaced fracture of the distal fibula. Review of the emergency room documentation dated 10/17/25 revealed Resident #8 had a fall on 10/15/25 and had not been ambulatory for the past two days, with significant swelling and bruising with tenderness over the medial malleolus noted to the right ankle. The plan for discharge included orders for a sugar-tong splint, minimal weight-bearing, and to follow up with orthopedics. Review of the progress note dated 10/17/25 at 6:22 P.M. revealed Resident #8 returned from emergency room at 4:30 P.M. with a splint on the right leg. The nurse documented Resident #8 was non-weight bearing on the right leg and there was a referral to orthopedics dated 10/29/25. Review of the orthopedic note dated 10/29/25 revealed due to limited mobility, the quality of the images was suboptimal, making it a challenge to determine if there was an additional fracture in the medical malleolus bone. A computed tomography (CT) scan of the ankle will be ordered to provide a more comprehensive view of the bone structure. This would guide the decision on weight-bearing restrictions and whether the boot could be removed. Resident #8 was to be non-weight bearing in the boot. Review of the CT scan dated 10/31/25 revealed Resident #8 had a right tri-malleolar ankle fracture which consisted of three fractures to include the distal fibula, posterior malleolus, and medial malleolus bones. During an interview on 12/17/25 at 10:26 A.M., Registered Nurse (RN) #120 stated when she came in for the night shift on 10/16/25, an unknown Certified Nursing Assistant (CNA) told her that Resident #8 was complaining of pain. RN #120 stated she noticed Resident #8 had swelling and bruising to her right ankle, so she called the on-call physician and received an order for an x-ray. The x-ray was completed on 10/17/25 which revealed an acute fibula fracture to the right ankle. Additionally, RN #120 stated she had not observed Resident #8 getting up out of bed or walking on her own since the fall on 10/15/25. During an interview on 12/17/25 at 11:18 A.M., Licensed Practical Nurse (LPN) #169 stated after the fall, Resident #8 was fearful and refused to leave her room because her right leg was swollen and painful. Interview on 12/17/25 at 12:36 P.M. with NP #200 revealed she saw Resident #8 on 10/16/25 because she had a fall and had some swelling to her legs. NP #200 confirmed Resident #8 had on TED hose at the time of the examination and stated she looked at Resident #8's forefoot and noted some bruising. Additionally, NP #200 confirmed she only examined the forefoot and not the ankle visibly as she did not remove the TED hoses. NP #200 stated Resident #8 did not communicate in a clear way that she was in pain or hurting. Furthermore, NP #200 stated if she had known that Resident #8 had swelling, bruising and was non-weight bearing, then she would have ordered an x-ray on 10/16/25 instead of on 10/17/25. Observation and interview on 12/17/25 at 12:31 P.M. with Resident #8 revealed she was lying in bed. Resident #8 was asked if she remembered when she fell and she nodded yes. Resident #8 was asked if her leg hurt when she fell and she nodded yes. Resident #8 was asked if she told the nurse her leg was hurting right after the fall, and she nodded her head yes while she moaned and pointed to her right leg. Review of the facility Falls policy dated September 2021 which stated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific tasks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 2. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses that included hypertensive heart disease with heart failure, chronic diastolic congestive heart failure, chronic kidney disease stage three-B, benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, paroxysmal atrial fibrillation, anemia, and anxiety disorder. Review of Resident #7's physician orders revealed an order dated 08/28/25 for an indwelling Foley catheter. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired and required substantial to maximal assistance with toileting hygiene and transfers and was unable to independently manage catheter care, indicating reliance on staff for proper catheter management. Review of Resident #7's care plan dated 11/10/25 identified interventions related to the management of an indwelling Foley catheter, including ensuring proper positioning and securing of the urinary drainage bag to reduce the risk of infection, catheter tension, and other complications. The care plan also addressed the resident's extensive functional dependence and need for staff assistance with all catheter-related care. On 12/16/25 at 10:48 A.M., observation of Resident #7 revealed the resident was in bed with an indwelling urinary catheter. The urinary drainage bag was observed hung on the bedside adjustable bed rail, rather than secured on a stationary hook or stand. The drainage bag was positioned on the side of the bed facing the door and was not covered. On 12/18/25 at 10:20 A.M., a subsequent observation of Resident #7 revealed the urinary drainage bag remained hung on the adjustable bed rail and continued to be positioned on the side of the bed facing the door, without a cover. At the time of this observation, the resident's door was open, increasing the visibility of the drainage bag from the hallway. On 12/18/25 at 9:37 A.M., an interviewed the Director of Nursing (DON) confirmed the drainage bag was hung on the bed rail and stated this placement was not consistent with facility policy. The DON further confirmed the catheter drainage bag was not properly hung or stored as required. The DON stated the facility currently had ten residents with indwelling urinary catheters. Review of the facility's undated catheter care policy required urinary drainage bags to be properly secured, kept off the bed, positioned below bladder level, and managed in a manner that reduces the risk of complications, including infection, catheter tension, and contamination.

Based on medical record review, review of resident diet slips, interview, and observation, the facility failed to ensure timely initiation of nutritional supplement recommendations and failed to ensure nutritional supplements were available and received as ordered. This affected two residents (#3 and #8) of three residents reviewed for nutrition.Findings include:1. Review of Resident #8's medical record revealed an admission date of 09/16/22 with diagnoses including, but not limited to dementia without behavioral disturbances, anxiety, major depressive disorder, and unspecified intellectual disabilities. Review of Resident #8's care plan dated 01/03/25 revealed the resident was at risk for altered nutritional status related to dementia, anxiety, communication problems, and on 11/07/25 it was updated to include an altered diet texture, unplanned weight loss and poor intakes. Interventions included provide feeding/dining assistance as needed and provide nutritional supplements as ordered by the physician. Review of the Nutritional assessment dated [DATE] revealed Resident #8 had a regular diet, with thin liquids and consumed 50 percent (%) to 100% of meals. Resident #8 came to the dining room to eat, there were no meal issues, and no nutrition recommendations noted at this time. Review of Resident #8's Nutritional progress note dated 10/24/25 revealed a skin alteration was present and the treatment nurse was following with a treatment in place. Med pass (liquid supplement) was added to aid in wound healing, the residents weight stable, and the resident was receiving weekly weights for close monitoring. Review of Resident #8's order dated 10/24/25 revealed an order for House Supplement (med pass) 120 milliliters (ml) two times a day for prevention. Review of Resident #8's weekly weights revealed on 10/03/25, Resident #8 weighed 163.4 pounds (lbs.), on 11/01/25 she weighed 162.6 lbs., on 11/08/25 she weighed 147.1 lbs., on 11/15/25 she weighed 146.6 lbs., on 11/22/25 she weighed 142.8 lbs., and on 12/16/25 she weighed 132.8 lbs. Review of the Speech evaluation for Resident #8 dated 10/28/25 recommended a puree diet, thin liquids, and close supervision. Review of Resident #8's physician orders revealed an order dated 10/28/25 for a puree diet texture, thin liquids consistency, encourage small bites, and recommend the dining room for meals. Additional orders dated 11/08/25 revealed orders for a Magic Cup (a specific brand of high calorie, high protein nutritional frozen dessert) two times a day for nutrition due at 7:00 A.M. and 7:00 P.M. Review of Resident #8's nutritional progress note dated 12/04/25 stated Resident #8's weight loss was expected as the resident had had inadequate intakes, required total dependence on staff for the Magic Cup and house supplements, and would recommend increasing house supplements and an appetite stimulant. Review of Resident #8's medical record revealed orders for increasing house supplements and an appetite stimulant were not initiated from 12/04/25 through 12/17/25. Review of Resident #8's nutritional progress note dated 12/12/25 recommended Remeron (an appetite stimulant) for Resident #8. Review of Resident #8's medical record revealed an order for Remeron was not initiated. Review of the progress note dated 12/16/25 at 3:02 P.M. revealed a conversation with Resident #8's family. Staff stated that Resident #8 had experienced a decline in overall functional status. Therapy services reported little progress in treatment and there was a recent weight loss. Resident #8 refused meals, care, and to get out of bed or chair frequently. Hospice was discussed and the resident's family was agreeable. Review of Resident #8's nutritional progress noted dated 12/17/25 revealed a 18.73% weight loss since October 2025, no Remeron and a hospice consult was noted. The note, again, recommend increasing supplements. Review of the physician orders dated 12/18/25 revealed Resident #8 was ordered House Supplement 120 milliliters (ml) three times a day for supplement/wound healing. Review of the Medication Administration Record for December 2025 revealed the Magic Cup two times a day (at 7:00 A.M. and 7:00 P.M.) was checked off as received at 7:00 A.M. on 12/01/25, 12/02/25, 12/03/25, 12/06/25 through 12/18/25, 12/20/25, and 12/22/25. Additionally, the 7:00 P.M. order was checked off as received on 12/02/25, 12/03/25, 12/04/25, 12/06/25, 12/08/25, 12/09/25, 12/12/25, 12/14/25, 12/15/25, and 12/22/25. Observation on 12/18/25 at 8:22 A.M. revealed Resident #8 sitting in her wheelchair in the dining room with her meal tray present. Resident #8 had no Magic Cup on her tray and there was no substitution present for the absence of the Magic Cup. Interview on 12/18/25 at 8:22 A.M. with Certified Nursing Assistant (CNA) #119 confirmed Resident #8 did not get Magic Cup at breakfast per orders. Interview with [NAME] #117 on 12/18/25 at 12:10 P.M. confirmed that the facility did not have any Magic Cups in the building and no substitution was sent out in its place. [NAME] #117 stated that the facility had been out of Magic Cups for a while. Observation on 12/23/25 at 8:24 A.M. revealed Resident #8 was sitting in her recliner in her room with her meal tray in front of her. There was no Magic Cup on her tray and there was no substitution present for the absence of the Magic Cup. Interview on 12/23/25 at 11:00 A.M. with Registered Dietician (RD) #300 confirmed Resident #8 was supposed to be receiving house supplements three times per day, that it was initially recommended on 12/04/25, and the Magic Cup was to be received twice a day. RD #300 stated that the nurses gave the house supplement with medication pass and if there was no Magic Cup, the nurses could replace it with an appropriate stock supplement. RD #300 stated the truck did not send Magic Cups for the last two weeks. Additionally, RD #300 stated she had recommended Remeron, but was told the Nurse Practitioner (NP) wanted to wait and see what hospice recommended. Interview on 12/23/25 at 2:11 P.M. with the Director of Nursing revealed if there were no Magic Cups, then the staff would offer a pudding or rice of the same texture and that an alternative should always be offered if there was no house supplement or Magic Cup. Additionally, the Director of Nursing stated the staff would put in a progress note to indicate that there was an alternative offered to Resident #8. She confirmed there was no evidence in the medical record from October, November, or December 2025 indicating that Resident #8 had been offered an alternative for the lack of Magic Cups. Review of Resident #8's actual diet order/slip for the kitchen on 12/23/25 revealed no Magic Cup on the diet slip for Resident #8. Interview on 12/23/25 at 2:44 P.M. with Dietary Director #74 revealed the Magic Cup order was on Resident #8's diet order in the kitchen and the staff placed it on the tray for meals. Dietary Director #74 confirmed he did not know when the facility ran out of Magic Cups and verified that there were no Magic Cups in the facility at this time. Dietary Director #74 then verified Resident #8's Magic Cup order was no on the diet order/slip and that if it was not on the diet order/slip, then the kitchen staff had not been sending it on Resident #8's meal tray. Interview on 12/23/25 at 3:05 P.M. with CNA #116 revealed that most CNA's did not go to the kitchen and get a Magic Cup for Resident #8 if it was not on her meal tray. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] and had diagnoses that included vascular dementia, cerebral infarction, and type two diabetes mellitus. Review of Resident #3's nutrition care plan dated 04/16/25 revealed that Resident #3 was at risk for altered nutritional status related to diabetes mellitus, unplanned weight loss and malnutrition. Interventions included providing nutritional supplements as ordered by the physician. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that he was assessed as needing setup or clean-up assistance with his meals. He was assessed as having a Brief Interview for Mental Status (BIMS) score of 14, indicative of intact cognitive status. Review of Resident #3's physician orders dated 10/28/25 revealed that he had a Magic Cup supplement ordered three times daily for supplement with his meals. Review of Resident #3's Medication Administration Records (MAR) dated 11/21/25, 11/28/25, 12/05/25, 12/08/25, 12/12/25, and 12/13/25 revealed the resident did not have the Magic Cup supplement for other reasons. Review of Resident #3's weights revealed that his weight on 10/20/25 prior to the ordering of the Magic Cup was 221.3 pounds (lbs.) and that his weight on 12/02/25 had remained stable at 222.2 lbs. Review of Resident #3's nursing progress notes dated 11/21/25, 11/28/25, and 12/12/25 revealed that the kitchen did not send out Resident #3's Magic Cups. Observation on 12/18/25 at 8:03 A.M. revealed that Resident #3 did not receive his Magic Cup as ordered and no substitution was sent in its place. Observation on 12/18/25 at 12:08 P.M. revealed that Resident #3 did not receive his lunch Magic Cup as ordered. An interview with Certified Nursing Aide (CNA) #90 on 12/18/25 at 12:08 P.M. confirmed that Resident #3 did not receive his lunch Magic Cup as ordered. An interview with [NAME] #117 on 12/18/25 at 12:10 P.M. confirmed that the facility did not have any Magic Cups in the building and no substitution was sent out in its place. [NAME] #117 stated that the facility had been out of Magic Cups for a while. An interview with Registered Dietitian #300 on 12/18/25 at 12:22 P.M. revealed that Resident #3's weight had been stable since Magic Cups were ordered. The interview revealed that if the Magic Cup was out of stock in the facility, she would expect that a substitute would be sent in lieu of the Magic Cup if it was not available, such as a milk shake. An interview with Dietary Director #74 on 12/22/25 at 2:15 P.M. revealed that he was uncertain of when the facility had run out of Magic Cups, but that he had ordered some Magic Cups, which were expected on the next delivery.

Based on resident record review, staff interviews and review of a facility policy, the facility failed to have parameters in place for as needed pain medications. This affected one (Resident #3) out of two residents reviewed for pain management. The facility census was 59.Findings include:Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of vascular dementia and displaced fracture of the base of the neck of the right femur.Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that he was assessed as having a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicative of intact cognitive status.Review of Resident #3's physician orders dated 08/24/25 revealed that he had an order for Tylenol, a non-narcotic analgesic oral tablet 325 milligram (mg), give 650 mg by mouth every four hours as needed for pain. There were no specified parameters in place for the medication.Review of Resident #3's physician orders dated 08/26/25 revealed that he had an order for Oxycodone with Acetaminophen, an opioid analgesic 5-325 mg oral tablet, give one tablet by mouth every four hours as needed for pain. There were no specified parameters in place for the medication.Review of Resident #3's Medication Administration Record (MAR) revealed that he received as needed Oxycodone-Acetaminophen oral tablet 5-325 mg as needed for pain for a pain level of three on a pain scale of zero to ten, ten being the worst pain, on 10/10/25, on 10/11/25 for a pain level of five, on 11/17/25 for a pain level of five, on 11/22/25 for a pain level of five, 11/30/25 for a pain level of five, 12/07/25 for a pain level of four, 12/09/25 for a pain level of five, and 12/18/25 for a pain level of five.Review of Resident #3's MAR revealed that he received as needed Tylenol oral tablet 325 mg, 650 mg by mouth for a pain on 10/15/25 for a pain level of six, and on 12/04/25 for a pain level of six.An interview with Licensed Practical Nurse (LPN) #169 on 12/17/25 at 2:41 P.M. revealed that for residents who were prescribed two as needed pain medications, she would expect to quantify the pain level using a pain level scale from one to ten. She would expect the order to specify when to give each as needed pain medication based on the pain level scale and the parameters set forth in the order.An interview with the Director of Nursing (DON) on 12/17/25 at 2:51 P.M. confirmed that Resident #3 did not have parameters for pain levels in his two as needed pain medications. The DON revealed that she would expect the non-opioid analgesic to be used typically for a pain scale of one to five and the opioid analgesic to be typically prescribed for a pain scale of six to ten; however, the orders for the pain parameters would come from the physician.Review of the September 2021 facility policy titled Administering Medications revealed that medications shall be administered in a safe manner as prescribed.An interview with the Administrator on 12/17/25 at 3:01 P.M. revealed that the facility did not have a pain medication management policy.

Based on record review and interviews, the facility failed to implement pharmacy recommendations signed by the provider in a timely manner. This affected one resident (#49) of five reviewed for unnecessary medications. The facility census was 59.Findings include:Review of Resident #49's medical record revealed an admission date of 07/27/23 and diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction on the right dominant side, chronic pain, hyperlipidemia, hypertension, mood disorder due to know physiological condition, and alcohol abuse uncomplicated.Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed Resident #49 required a wheelchair for mobility and was independent with wheelchair mobility, was continent of both bladder and bowel, had occasional pain of five out of ten on the pain scale (zero was no pain and ten was the worst pain the resident could imagine), and received opioid pain medication.Review of Resident #49's physician's orders revealed an order dated 12/03/24 for trolamine salicylate external cream 10% (a pain relieving cream) with instructions to apply topically to left wrist every eight hours as needed for left wrist pain and an order dated 02/10/25 for diclofenac sodium external gel 1% (a pain relieving gel) with instructions to apply 4 grams to the affected area topically every six hours as needed for pain.Review of Resident #49's pharmacy note to the attending physician/prescriber dated 12/05/25 revealed the pharmacist recommended the trolamine salicylate external cream 10% and diclofenac sodium external gel 1% be evaluated for continued need or discontinuation as they had not been used in the past 60 days. Further review of the pharmacy note to the attending physician/prescriber revealed the note was signed by Nurse Practitioner (NP) #200 and marked to indicate the NP agreed with the pharmacist and the trolamine salicylate external cream 10% and diclofenac sodium external gel 1% should be discontinued. NP #200's signature was undated. The note was made available to surveyors on 12/18/25.Review of Resident #49's medication administration record (MAR) and treatment administration record (TAR) for December 2025 revealed the orders for trolamine salicylate external cream 10% (a pain relieving cream) with instructions to apply topically to left wrist every eight hours as needed for left wrist pain and an order dated 02/10/25 for diclofenac sodium external gel 1% (a pain relieving gel) with instructions to apply 4 grams to the affected area topically every six hours as needed for pain were present and active on the MAR and TAR as of 12/22/25.In an interview on 12/22/25 at 3:37 P.M. the Director of Nursing (DON) confirmed Resident #49's pharmacy note to the attending physician/prescriber dated 12/05/25 was signed by NP #200 and indicated the trolamine salicylate external cream 10% and diclofenac sodium external gel 1% should be discontinued. The DON stated that she did not recall when NP #200 had signed the pharmacy note since NP #200 did not date the note when she signed it. The DON further confirmed the trolamine salicylate external cream 10% and diclofenac sodium external gel 1% had not been discontinued.

Based on record review, review of facility investigations, interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected three residents (#28, #50, and #69) out of nine residents reviewed for medication administration. Facility census was 59. Findings include: 1. Review of the medical record revealed Resident #28 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included mononeuropathy of the right lower leg, pain in right knee, and type two diabetes. Review of Resident #28's physician order dated 11/24/25 revealed Resident #28 was ordered Pregabalin (a medication used to treat nerve pain) 150 milligrams (mg) capsules three times a day, due at 6:00 A.M., 2:00 P.M., and 10:00 P.M. Review of Resident #28's controlled drug record revealed on 11/26/25 at 4:00 A.M. Licensed Practical Nurse (LPN) #96 signed out five Pregabalin 150 mg capsules. Review of Resident #28's Medication Administration Record (MAR) revealed on 11/26/25 at 6:00 A.M., Pregabalin was not documented as administered. Review of Resident #28's facility medication error report dated 11/26/25 at 10:05 A.M. revealed a nurse reported that five Pregabalin 150 mg capsules were signed out of the controlled drug record on 11/26/25 at 4:00 A.M. Review of Resident #28's nursing note dated 11/26/25 at 7:27 P.M. revealed on 11/26/25 at approximately 10:00 A.M. Registered Nurse (RN) #123 was at the medication cart when Resident #28 reported not feeling well. Resident #28 stated she thought the increased dose of Pregabalin might be the culprit. Resident #28 had been taking Pregabalin 100 mg three times a day and the dosage had been increased to 150 mg when the doctor visited on 11/24/25. RN #123 checked the controlled drug record and saw five Pregabalin had been signed out on 11/26/25 at 4:00 A.M. The Nurse Practitioner (NP) was notified, and new orders were received for a completed blood count and comprehensive metabolic panel to be completed. Resident #28's vitals were to be checked every hour for four hours, then every two hours times two, and every four hours times four. The resident was also ordered normal saline intravenously at 30 milliliter (ml) an hour. The resident's level of consciousness was to be monitored and the afternoon and bedtime doses of Pregabalin on 11/26/25 were to be held. Resident #28 reported being dizzy and was assisted to bed. An interview on 12/22/25 at 10:08 A.M. with the Director of Nursing (DON) verified on 11/26/25 at 4:00 A.M. Resident #28 was administered 750 mg of Pregabalin instead of ordered 150 mg. The DON stated LPN #96 was unsure why she administered five capsules of Pregabalin to Resident #28. The DON also verified the Pregabalin was not scheduled to be administered at 4:00 A.M. and that it was also not signed off as administered.Review of the undated policy titled Administering Medications revealed medications shall be administered in a safe and timely manner, and as prescribed. If a dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 2. Review of the medical record revealed Resident #50 was admitted on [DATE] with diagnoses that included vascular dementia, anxiety disorder, idiopathic peripheral autonomic neuropathy, polyneuropathy, and polyarthritis.Review of Resident #50's plan of care dated 02/21/25 revealed Resident #50 had the potential for pain related to chronic pain syndrome. Interventions included to administer medications per physician orders and to monitor for side effects and effectiveness.Review of Resident #50's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively intact. Review of physician orders revealed Resident #50 was ordered Tramadol (to treat moderate to moderately severe pain) 50 milligrams (mg) twice a day at 7:00 A.M. and 7:00 P.M., Levaquin (antibiotic) 500 mg daily at 7:00 A.M., and Prednisone (corticosteroid) 40 mg daily at 7:00 A.M.Review of Resident #50's progress noted dated 11/26/25 at 8:30 A.M. revealed the nurse administered medications during the morning medication pass. The nurse noticed that night shift nurse (Registered Nurse (RN) #155) had signed out the narcotics (Tramadol) but there was not a time documented. This resulted in medication errors. Review of Resident #50's medication administration record (MAR) revealed the day shift nurse administered Resident #50's Tramadol, Levaquin, and Prednisone on 11/26/25 at the 7:00 A.M. administration time. Review of the controlled drug record revealed Resident #50 was administered Tramadol 50 mg on 11/26/25 at 5:50 A.M by Registered Nurse (RN) #155 and at 8:23 A.M. by Licensed Practical Nurse (LPN) #163.The facility investigation dated 11/26/25 revealed RN #155 stated she thought she had signed of the medication on the MAR. RN #155 was educated on ensuring the appropriate documentation was completed with medication administration. The root cause of the medication error was RN #155 failed to sign the MAR which caused the oncoming nurse to administer the medication for an additional dose. The Certified Nursing Practitioner (CNP) was notified, and new orders were received for Resident #50's level of consciousness and vital signs to be monitored every hour for four hours, then every two hours times two, and then every four hours times two. An electrocardiogram (test that records the electrical activity of the heart) was ordered to be completed on 11/26/25. A comprehensive blood count and basic metabolic panel were also ordered to be completed on 11/26/25 and 11/28/25.An interview on 12/22/25 at 10:08 A.M. with the Director of Nursing (DON) verified Resident #50 was administered Levaquin, Prednisone, and Tramadol by the nightshift nurse, RN #155, and day shift nurse, LPN #163, on 11/26/25. 3. Review of the medical record revealed Resident #69 was admitted on [DATE] with diagnoses that included osteogenesis imperfecta, fracture of lower end of right femur, chronic pain syndrome, and osteoarthritis. Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was cognitively intact. The MDS also revealed Resident #69 received scheduled pain medications and no as needed pain medication. Review of physician orders revealed Resident #69 was ordered Pregabalin (used to treat nerve pain) 200 milligrams (mg) twice a day at 7:00 A.M. and 7:00 P.M. Resident #69 was also ordered Tramadol 50 mg twice a day at 7:00 A.M. and 7:00 P.M. Review of the Medication Administration Record (MAR) revealed Resident #69 was administered Pregabalin 200 mg and Tramadol 50 mg by Licensed Practical Nurse (LPN) #94 on 11/26/25 at the scheduled 7:00 A.M. time. Review of the controlled drug record revealed Resident #69's Pregabalin 200 mg and Tramadol 50 mg were administered on 11/26/25 at 6:10 A.M. by Registered Nurse (RN) #155 and at 8:26 A.M. by LPN #94.Review of Resident #69's progress note dated 11/26/25 at 8:30 A.M. revealed the nurse (LPN #94) was administering medications during the morning medication pass. LPN #94 noticed that night shift nurse (RN #155) had signed out the narcotics at 6:10 A.M. resulting in medication errors since the medication was not signed off on the MAR. New orders received to monitor Resident #69's level of consciousness and vitals every hour for four hours, then every two hours times two, then every four hours times two. Review of the facility investigation dated 11/26/25 revealed the nurse (LPN #94) was administering medications during the morning medication pass and noticed the night shift nurse (RN #155) had signed out narcotics at 6:10 A.M. for Resident #69. RN #155 did not sign the MAR that the medications were administered. The root cause of the medication error was the nurse failed to sign the MAR which in turn caused the oncoming nurse to administer the medication for an additional dose. An interview on 12/22/25 at 10:08 A.M. with the Director of Nursing (DON) verified on 11/26/25, Resident #69 was administered Tramadol and Pregabalin by the nightshift nurse, RN #155, and by the day shift nurse, LPN #163.Review of the undated policy titled Administering Medications revealed medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must initial the resident's MAR after giving the medication.

Based on observation, staff interviews, review of the menu spreadsheet, and review of facility policy, the facility failed to provide and serve pureed bread as planned on the menu. This affected two out of two residents (Resident #8 and #13) who received pureed diets in the facility. The facility census was 59 residents.Findings include: Review of the planned pureed diet spreadsheet for 12/18/25 revealed that a #16 scoop of pureed bread was to be served with the lunch meal on 12/18/25. Observations of the preparation of the pureed diets on 12/18/25 from 10:02 A.M. to 10:17 A.M. revealed that no pureed bread was prepared for the pureed diets. An interview with [NAME] #117 on 12/18/25 at 11:51 A.M. confirmed that no pureed bread was made for the pureed diets on 12/18/25 for lunch, and no pureed bread substitute was served. [NAME] #117 stated that it does not work well. An interview with Registered Dietitian #300 on 12/18/25 at 12:22 P.M. revealed that if bread was unable to be prepared properly, she would expect a pureed bread substitute to be served instead.

Based on observation, medical record review, review of a facility Self-Reported Incident (SRI) and investigation, review of the facility's abuse policy titled Abuse, Neglect and Misappropriation of Property, and interviews with staff, residents and the authorities, the facility failed to ensure Resident #2 was free from an incident of resident-to-resident abuse. This resulted in Immediate Jeopardy and physical and psychosocial harm on 04/21/24 at approximately 7:45 A.M., when Resident #2, was physically abused/assaulted by Resident #3. Resident #3 struck Resident #2 multiple times resulting in two facial lacerations with bleeding, a laceration to the lower lip, and multiple hematomas (bruises) to the resident's bilateral arms, upper portion of her breasts, and upper chest wall. The incident occurred in the dining room where there were no staff present. Resident #2 also sustained psychosocial harm as a result of the incident, verbalizing her fear of reoccurrence, asking for her room to be inspected for the presence of Resident #3, with no evidence of psychosocial support following the incident resulting in Resident #2 isolating herself from attending preferred activities and meals. Following the incident, Resident #2 was not provided timely medical/hospital evaluation and the facility failed to notify the physician, failed to timely notify the authorities, and failed to ensure appropriate interventions were implemented to ensure resident safety. This affected one resident (#2) of six residents reviewed for abuse. The facility census was 58. On 05/02/24 at 3:56 P.M. the Administrator, Director of Nursing (DON), Regional DON #702, and [NAME] President of Clinical Operations #703 were notified Immediate Jeopardy began on 04/21/24 when Resident #3 initiated a physical altercation with Resident #2, striking Resident #2 multiple times resulting in two facial lacerations with bleeding, a laceration to the lower lip, and multiple hematomas (bruises) to the resident's bilateral arms, upper portion of her breasts, and upper chest wall. The incident occurred in the dining room where there were no staff present. The facility failed to provide appropriate interventions to prevent further verbal and/or physical interactions between other residents and Resident #3, failed to make any staffing changes related to staffing/supervision of cognitively impair residents and/or residents with physical/verbal behaviors while in the dining room prior to breakfast and failed to ensure Resident #2 received timely and appropriate aftercare following the resident-to-resident physical abuse. The Immediate Jeopardy was removed on 05/02/24 when the facility implemented the following corrective actions: On 05/02/24 at 11:20 A.M. 1:1 supervision was initiated for Resident #3 with one staff member assigned for supervision of the resident. Additional staff were added to the shifts (as needed) to ensure monitoring occurred until the resident's discharge. The following staff provided 1:1 supervision through discharge on 05/03/24: State tested Nursing Assistant (STNA) #130, #148, #160, and Activities Staff #160. On 05/02/24 at 11:30 A.M. an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held. Regional DON #702 and VPCO #703 educated the Administrator, DON, Medical Director #701, Business Office Manager (BOM) #96, Therapy Manager #95, SSD #100, the ADON, LPN #132, Dietary Manager (DM) #92, Plant Operations (PO) #90, Activities Director #91 on the facility abuse policy, Centers for Medicare and Medicaid abuse reporting guidelines, future expectations with reporting abuse and completing investigations. Topics also discussed during the meeting were resident behaviors and care planned interventions as well as the facility removal plan. QAPI committee meetings would be held weekly for weeks, beginning 05/02/24 then monthly for recommendations and further follow-up regarding the removal plan based upon evaluation of audits and observations. Audits would continue to be submitted to the QAPI committee for review and to ensure compliance goals. QAPI committee reserved the right to modify or extend monitoring times according to outcomes. The Administrator was responsible for the oversight of this plan to ensure ongoing compliance. Any issues identified thru the audits would be reviewed and revised thru the facility QAPI process. On 05/02/24 at approximately 12:00 P.M. the DON and Licensed Practical Nurse (LPN) #132 completed a record review for all 57 residents (the current census on 05/02/24) for behavioral diagnosis including but not limited to traumatic brain injury (TBI), dementia and schizophrenia with no newly identified residents at risk for resident-to-resident abuse through diagnoses. On 05/02/24 at 12:00 P.M. LPN #132 reviewed residents (Residents #51, #27, #49, #20, #60, #9, #17, #35, #32, #36, #13, #2, #8, #29, #38, #23, #64, #6, #54, and #58) determined to be at risk for potential aggressive behaviors to ensure care planned interventions were appropriate. On 05/02/24 at 12:11 P.M. Resident #3 was placed in a private room by Plant Director #158 and Medical Records #126. On 05/02/24 at approximately 1:00 P.M. the Director of Nursing spoke with Resident #6 (the resident who witnessed the incident between Resident #3 and Resident #2) to offer emotional/psychosocial support, but the resident declined. On 05/02/24 at approximately 4:30 P.M. facility resident profiles for residents at risk for potential aggressive behaviors (Residents #51, #27, #49, #20, #60, #9, #17, #35, #32, #36, #13, #2, #8, #29, #38, #23, #64, #6, #54, and #58) were updated to reflect care planned interventions to be followed when caring for a resident with a behavioral care plan by SSD #100, LPN #132 and/or the ADON. On 05/02/24 at 5:15 P.M. Resident #2 was evaluated by Physician #810 regarding the incident with Resident #3 via telehealth. The provider's 05/02/24 progress note indicated there were no lasting effects (as of this date) from the incident. There were no current updates made to the resident's care plan and no new orders were received. On 05/02/24 by 7:00 P.M. all 82 staff (17 nurses, 23 STNA, two Activity Aides, 14 Department Managers, two Agency Nurses, 12 therapy, seven dietary and five housekeeping/laundry) were educated by the Administrator, DON or ADON either in-person or by phone regarding the facility abuse policy and reporting abuse to the Administrator (the facility abuse coordinator). On 05/02/24 by 7:00 P.M. all nursing staff (17 nurses, 23 STNA and two agency nurses) were educated either in person or via phone on access to resident care plans by SSD #100, LPN #132, the DON, or the Assistant Director of Nursing (ADON). A hand-out was also provided regarding how to access the information and the staff who received education via phone will receive the hand-out on their next scheduled shift. Staff will also be required to show a return demonstration or recite the process on their next scheduled shift. The resident profiles are in the electronic medical record (EMR). Beginning 05/02/24 the facility implemented a plan that any facility initiated Self Reportable Incident(s) and facility investigation(s) would be escalated to regional support, Regional DON #702, and [NAME] President of Clinical Operations (VPCO) #703 for review to ensure the facility policy was followed. Beginning 05/02/24, a plan for Social Services Designee (SSD) #100 to conduct weekly psychosocial follow-up with Resident #2 was implemented to ensure no lingering effects from the incident had occurred. Follow up would be completed for four weeks. Beginning 05/02/24 the DON, ADON, and/or LPN #132 would review all new admissions for behavior risks. Auditing would be completed by the Director of Nursing/Assistant Director of Nursing and/or LPN #132 five days a week for the next eight weeks then three times a week for four weeks for all residents, which includes all new admissions. Beginning 05/02/24, the Director of Nursing, ADON and/or LPN #132 would review/audit all nursing staff documentation including progress notes, events, observations, and Care Assist documentation to ensure all residents with behaviors have care planned interventions to ensure safety. Auditing would be completed on all current residents five days a week for eight weeks, then three times a week for four weeks. On 05/03/24 at 4:45 P.M. Resident #3 was discharged to a sister facility related to the resident's behavioral health needs. On 05/06/24 at approximately 12:00 P.M. the Administrator, DON, Medical Director #701, Business Office Manager (BOM) #96, Therapy Manager #95, SSD #100, the ADON, LPN #132, Dietary Manager (DM) #92, Plant Operations (PO) #90, and Activities Director #91 conducted an audit (questionnaire) of current interviewable residents, whose Brief Interview for Mental Status (BIMS) score was eight and higher with no reported incidents of abuse and the residents interviewed indicated they felt safe within the facility. Non-interviewable residents (#27, #71, #47, #9 and #58), received a skin assessment on 05/02/24. Although the Immediate Jeopardy was removed on 05/02/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including schizoaffective disorder, bipolar type, anxiety, major depressive disorder, personality disorder, cognitive communication disorder, dysphagia (difficulty swallowing), heart failure, muscle weakness, and seizure disorder. Review of the care plan dated 08/07/20 revealed Resident #2 had verbal behaviors including making disruptive noises that were sometimes directed toward others, screaming at others, cursing, and yelling out [NAME] and moaning or humming. Interventions included sitting with the resident and diverting attention away from disruptive noises/screaming and supervising/monitoring at all meals due to the resident's poor self-monitoring and impulsivity with eating. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 09 of 15, indicating the resident had moderately impaired cognition. The MDS assessment revealed the resident had no psychosis or rejection of care. The assessment also indicated the resident had daily behavioral symptoms not directed toward others (examples given included verbal/vocal symptoms like screaming and disruptive sounds. Review of Resident #2's nursing progress note dated 04/21/24 at 7:45 A.M. (recorded as a late entry on 04/23/24 at 11:55 A.M.), authored by the DON, revealed STNA #102 brought Resident #2 up to her in a wheelchair and her assessment revealed bright red blood on the resident's face, hands, mouth, and clothes. The resident stated, I didn't do anything, Resident #3 attacked me. An abrasion was noted to the left cheek measuring approximately 2.0 centimeters (cm) by 0.5 cm by 0.1 cm and an abrasion was noted to the left side of the nose measuring approximately 1.0 cm by 0.5 cm x 0.1 cm. Areas were cleansed with wound cleanser and steri-strips were applied. Resident #2 was noted to be visibly upset after the altercation and requested to eat lunch in her room. The resident complained of pain and as needed (prn) medication was administered. Review of the Medication Administration Record (MAR) for April 2024 revealed Resident #2 was administered Tramadol 50 milligrams one tablet on 04/21/24 at 4:51 P.M. (somewhat effective) and again at 9:16 P.M. (effective). There was no mention of the pain medication administration in the nursing progress notes. Review of the MAR for April 2024 revealed the resident was administered Tramadol 50 mg on 04/22/24 at 7:45 A.M. (no assessment of the resident's pain) and no documentation of the resident's Tylenol administration on the MAR. Review of Resident #2's nursing progress note dated 04/22/24 at 12:56 P.M., authored by LPN #152, revealed Resident #2 was noted to have increased pain and did not want to go to the dining room for lunch. Tramadol prn was given this morning and Tylenol prn was given at noon. Review of Resident #2's nursing progress note dated 04/22/24 at 5:50 P.M. (recorded as a late entry on 04/23/24 at 2:59 P.M.), authored by LPN #152, revealed STNA alerted the nurse to come into Resident #2's room where scattered bruising was noted to the bilateral forearms and chest, related to the previous incident. The note indicated there were no complaints of pain or discomfort. Review of Resident #2's nursing progress note dated 04/22/24 at 8:45 P.M. (recorded as a late entry on 04/23/24 at 1:27 A.M.), authored by RN #110, revealed this RN was alerted by Nurse Practitioner (NP) #700 of Resident #2 having multiple injuries during an altercation with Resident #3. During assessment with NP #700, a scratch was noted to the left cheek, measuring approximately 12 cm and another scratch beside of it, measured approximately 4 cm, a laceration of the left side of the lip, two distinct fingerprint bruises to the right forearm, two bruises to the left forearm, two bruises to the left upper breast and two bruises to the left breast, a bruise to the left, flank area. Order received from NP #700 to cleanse the scratches and lip laceration and to apply triple antibiotic ointment to those areas daily and prn. An order was also received to obtain x-rays of the face and chest. The police were called due to resident-to-resident altercation and a police officer came and interviewed the residents. Review of Resident #2's progress note dated 04/22/24 at 9:00 P.M. (recorded as late entry on 04/23/24 at 1:13 A.M.), authored by NP #700, revealed Resident #2 was seen for a routine/regular visit. During assessment, Resident #2 was observed to have two scratches on her face, measuring approximately two to three inches in length with dried blood noted. Bruising to the bilateral arms and anterior chest, and a laceration to the inside of the bottom, left, lateral lip was noted. Resident #2 stated she was in a fight with another resident at the facility on the morning of 04/21/24. Resident disclosures and injuries were reported to the facility RN and DON. Injuries and skin assessment performed with RN #110. Attempted to notify attending physician/medical director #701 with message left requesting a call back. New treatment orders for an x-ray of the facial bones due to trauma/visible injury, a chest x-ray due to visible injury and pain, wound care to abrasions/scratches to face with wound cleanser and antibiotic ointment to be applied. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including diffuse traumatic brain injury (TBI) with loss of consciousness, major depressive disorder, and mood disorder, anxiety disorder, and muscle weakness. Review of the care plan dated 12/13/22 revealed Resident #3 had a diagnosis of anxiety and depression and experienced instances of feelings of dread/apprehension, little interest or pleasure in doing things, behavioral symptoms such as yelling/cursing at others, manipulation and making inappropriate comments. Interventions included to monitor/report signs and symptoms of anxiety, restlessness, pacing, poor impulse control, and fear/apprehension. Review of the care plan dated 12/20/22 revealed the resident had a memory/recall problem related to cognitive loss, history of TBI, experienced behavioral symptoms, and will yell/curse at others. Interventions included redirecting resident when entering unsafe areas. Review of the care plan dated 12/27/22 revealed the resident had behavior problems related to attention seeking, was non-compliant with the smoking policy and protocols, had physically burned another person during a smoke break, hid cigarettes on her person, was verbally aggressive at times with other residents and staff, made false statements regarding staff and other residents, and was not easily directed. Interventions included to observe for triggers of inappropriate behaviors and alter environment as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating intact cognition. The MDS assessment revealed the resident had no psychosis or rejection of care. Record review revealed Resident #3 had a history of behaviors, including the following incidents: On 01/21/23 (recorded as late entry on 01/22/23 at 7:15 P.M.), authored by RN #110, revealed this nurse was alerted by two residents there was an incident out in the smoking area. Upon investigation, Resident #3 became angry and verbally abusive to Resident #13 and STNA #169. Resident #3 continued to cuss at both individuals and then ultimately tried to burn Resident #13 with a cigarette, when STNA #169 tried to protect Resident #13, Resident #3 burned STNA #169 numerous times on purpose. Resident #3 confirmed she was trying to hurt both individuals and stated she was cussing and trying to burn people with her cigarette because she was mad at them for telling her to move out of the doorway as other residents were trying to go back inside to get out of the cold weather. Review of Resident #3's nursing progress note, dated 04/15/24 at 5:18 A.M., authored by RN #131, revealed when STNA went into room to check the resident and tried to get the resident up, when Resident #3 started swinging and kicking at the STNA. STNA came and got this nurse to assist. Resident #3 kept kicking and yelling that she don't give a {expletive} if she was wet and was not getting up. The resident was not laying in a wet bed but continued to fight. The resident's roommate was awakened by her yelling. Review of Resident #3's nursing progress note, dated 04/21/24 at 2:11 P.M. (recorded as late entry on 04/23/24 at 1:13 P.M., authored by the DON, revealed the resident was noted to be sitting in the lobby discussing the altercation with other residents. This nurse redirected the resident, and the re-direction was unsuccessful. The note indicated will continue to monitor. Review of Resident #3's nursing progress note, dated 04/22/24 at 9:56 P.M. (recorded as late entry on 04/23/24 at 6:34 P.M.), authored by RN #110, revealed NP #700 asked this RN to go with her to see Resident #3 and interview her related to the altercation with Resident #2. Resident #3 admitted to grabbing, hitting, and scratching Resident #2 because she was upset with her. Resident #3 stated Resident #2 smacked her in the left eye twice, however, no injuries were observed. Review of a facility Self-Reported Incident (SRI), tracking number 24658, with a discovery and submission date of 04/21/24, revealed an allegation/suspicion of physical abuse, with the initial source of the allegation being a resident victim and a resident witness, was reported to the State Survey Agency. The SRI indicated on 04/21/24 at 7:45 A.M. in the dining room, Resident #2 alleged Resident #3 attacked her. There were no staff present during the alleged attack. The only witness was Resident #6. Facility interview with Resident #3 revealed Resident #2 attacked her by pulling her oxygen off and saying, I'm gonna kill you, {expletive}. Facility interview with Resident #2 revealed she didn't do anything, and Resident #2 attacked her. The SRI indicated the initial skin inspection of Resident #2 revealed scratches to the left cheek and left side of her nose, with no other injuries noted. The following day, on 04/22/24, bruises to the chest and bilateral forearms were noted. Resident #2 requested to eat lunch in her room on the day of the allegation due to being fearful of another attack by Resident #3. Facility staff walked with Resident #2 to the dining room daily to ensure she felt safe. The SRI noted a 72-hour psychosocial evaluation was completed (the facility was unable to provide evidence this was completed), and Resident #2 showed no signs or symptoms of adverse reactions related to the event unless she was reminded of the allegation; when this happened, she would state that she was scared, but showed no signs of uneasiness, fearfulness, tearfulness, and attempts to walk to the dining room with staff accompanying her. The facility investigator was listed as the DON. Review of Resident #6's witness statement, dated 04/21/24 (without the time documented), indicated the statement was verbally given to the DON and the ADON and revealed Resident #2 came over and sat down and started moaning when Resident #6 and Resident #3 asked her to stop. Resident #2 said, you're not my boss. Resident #3 went over to Resident #2 and Resident #2 said, I'm gonna kill you (expletive) and took Resident #3's oxygen off. Resident #3 then scratched Resident #2. Review of Resident #2's witness statement, dated 04/21/24 (without the time documented), indicated the statement was verbally given to the DON and the ADON and revealed Resident #2 stated that she did not do anything, and Resident #3 attacked her. Review of Resident #3's witness statement, dated 04/21/24 (without the time documented), indicated the statement was verbally given to the DON and the ADON and revealed Resident #2 told Resident #3, I'm gonna kill you {expletive}. No other information was provided regarding the investigation. Interview on 04/29/24 at 1:50 P.M. with STNA #101 revealed she was assigned to care for Resident #2 on the next day (on 04/22/24) following the resident-to-resident altercation. STNA #101 stated after she toileted Resident #2, she noticed several bruises on the resident's chest and breast, and immediately notified LPN #152, who took pictures of the bruises and reported the bruising to the DON. STNA #101 further stated that following the incident with Resident #3, Resident #2 had cried and verbalized fear of going to the dining room or common areas alone. She shared the resident verbalized her fear the following day and her fear continued. STNA #101 stated that following the incident, Resident #2 mainly eats meals in her room and would only eat in the dining room if staff stays with her the entire time. Observation of Resident #2 on 04/29/24 at 1:54 P.M. with STNA #101, revealed seven greenish/purple-colored bruises, varying in size, located on the bilateral chest wall and upper breast area were noted on Resident #2. There was a hematoma noted on the right forearm, and scattered bruising noted to both forearms. Two separate lacerations were observed, one on the left side of the resident's nose, and the other on the left cheek. At the time of the observation, interview with Resident #2 revealed the resident voiced she did not feel safe leaving her room because she was afraid to get hit again by Resident #3. Resident #2 was tearful and stated to the surveyor, I'm scared. On 04/30/24 at 11:05 A.M., an interview with the DON revealed she was administering medications on the morning of 04/21/24 at approximately 7:45 A.M. (she was working as a floor nurse due to staffing needs) when STNA #102 brought Resident #2 to her from the dining room. The DON revealed she observed a scratch on Resident #2's left cheek and the side of her nose. The DON stated Resident #2 told her that Resident #3 attacked her and that she didn't know why, because she didn't do anything. The DON stated Resident #2 often moans and the moaning probably bothered Resident #3. The DON stated no staff were present in the dining room because breakfast had not been served yet. The DON confirmed several residents including Resident #2 and Resident #3 often go to the dining room before breakfast and were typically unsupervised until breakfast was served. The DON stated, this is their home, we can't stop the residents from going to the dining room. The DON confirmed she did not obtain a witness statement from STNA #102 and was unsure of what happened following the altercation between the residents and prior to Resident #2 being brought to her in a wheelchair by STNA #102. The DON stated following the incident, she notified the on-call physician, but could not recall the provider's name, and did not document the notification in the resident's medical record. The DON stated her skin assessment on 04/21/24 of Resident #2 following the altercation did not include any bruising of the resident's arms, chest, or breasts, or lip laceration and only indicated two scratches on the resident's face. The DON stated when she was later informed of the bruising and lip laceration, she attributed the injuries to the altercation between Resident #2 and Resident #3 and did not believe them to be injuries of unknown origin. On 04/30/24 at 11:30 A.M., interview with Resident #6 revealed he was waiting for breakfast along with Resident #2 and Resident #3 on the morning of 04/21/24. Resident #6 stated Resident #2 was moaning when Resident #3 told her to shut up. Resident #2 replied, make me. Resident #3 went around the table toward Resident #2 and continued telling her to shut up. Resident #3 swung and missed at first, and then Resident #2 tried to pull Resident #3's oxygen off, when Resident #3 scratched Resident #2's face and hit her. Resident #6 revealed there were no staff present in the dining room and Resident #2 went to the kitchen for help because her face was bleeding, and she was crying. The resident could not recall which staff responded to the incident. On 04/30/24 at 2:24 P.M., an interview with Social Services Director (SSD) #100 confirmed he had not followed-up or interviewed Resident #2 or Resident #3 following the incident that occurred on 04/21/24. SSD #100 further stated he had not followed up with either resident because the DON reported to him that she had followed up with both residents. SSD #100 stated Resident #2 came up to him in the hallway (he was unable to recall when this occurred) and showed him her mouth and stated he told the resident, That's terrible, however, there was not a direct conversation about the altercation at that time. On 04/30/24 at 3:34 P.M., interview with the DON revealed on 04/22/24 NP #700 freaked out when she saw Resident #2's bruises and then reported them to RN #110. The DON stated RN #110 took it upon herself to obtain witness statements from all the employees who were working in the facility on the evening of 04/22/24. The DON stated she didn't know why RN #110 obtained the witness statements when the employees were not working at the time of the incident and did not witness the incident between Resident #2 and Resident #3. The DON further revealed NP #700 was no longer working for the facility because she resigned a couple of days following the incident. The DON confirmed the only investigation documentation of the incident was the SRI investigation and report submitted to the State agency. The DON revealed her investigation concluded that abuse did not occur. The DON stated she did not consider the incident to be abuse because she did not think Resident #3 acted willfully and did not intend to injure or hurt Resident #2. The DON further confirmed following the incident, the only resident interviews obtained were from the two residents involved in the altercation and the resident witness. The DON confirmed she did not conduct any additional resident interviews regarding abuse, and other than the skin assessments completed for Resident #2 and Resident #3, no additional skin assessments were completed for non-interviewable residents, and other than the staff interviews obtained by RN #110, no additional staff had been interviewed regarding abuse or the incident. The DON further confirmed Resident #2 and Resident #3's psychiatric providers had not been notified of the altercation and there had been no follow-up from psychiatry for either resident following the incident. On 04/30/24 at 3:35 P.M., an interview with Resident #3 revealed she was in the dining room when Resident #2 was running her mouth and tried to hit her but didn't. Resident #3 stated she told Resident #2 she would make her shut up and then hit her. Resident #3 stated Resident #2 started crying and was bleeding, and then went to the kitchen and told them what had happened. Resident #3 stated a staff member asked her what happened during the incident, but she was unable to recall who had asked. On 04/30/24 at 3:45 P.M., an interview with Dietary Worker (DW) #191 revealed she and DW #190 were getting ready to serve breakfast when Resident #2 came to the kitchen door with blood dripping from her face. DW #191 stated she got a towel for the resident and Dietary Worker #190 went to get a nurse. DW #191 asked Resident #2 what happened, and she said, she hit me and beat me up. When DW #191 asked the resident who beat her up, she pointed to Resident #3. DW #191 then asked Resident #3 what had happened, and Resident #3 said, I hit her because she tried to hit me. DW #191 stated she didn't believe Resident #3, and thought Resident #2 probably irritated Resident #3, and then she hit her and scratched Resident #2. DW #191 stated she has heard Resident #3 tell Resident #2 to shut up before. DW #191 verified when she came out of the kitchen into the dining area, there were no staff present. DW #191 further stated the residents were usually in the dining room without staff until the food was ready to be served, and then staff comes to serve the trays. DW #191 stated every morning the residents come to sit in the dining room, often for one to two hours. DW #191 stated Resident #2 would often get bored and come to the kitchen and ask for coffee, and this calmed her down and helped with her moaning. DW #191 revealed STNA #102 was the aide who came following the incident and helped and cleaned Resident #2. DW #191 revealed Resident #2 would not come to the dining room by herself anymore since the incident happened, and told her, That lady is out there, and I'm scared she will hit me. DW #191 stated Resident #2 would only come to the dining room if an aide was with her but would sit away from the other residents. DW #191 stated, It's sad because she's scared to come alone now. DW #191 shared Resident #2 had enjoyed coming to the dining room every day. On 05/01/24 at 8:40 A.M., an interview with DW #190 revealed she was working in the kitchen on the morning of the incident. DW #190 stated she had heard Resident #3 tell Resident #2 on multiple occasions to shut up and be quiet because of her moaning. On 05/01/24 at 9:40 A.M., an interview with the Administrator confirmed the facility's investigation should have included staff interviews, and all residents should have been interviewed regarding abuse and any resident who could not be interviewed should have had a skin assessment completed. The Administrator further confirmed residents were unsupervised in the dining room when the altercation occurred between Resident #2 and Resident #3. On 05/01/24 at 2:20 P.M., an interview with Resident #14 revealed she often sits in the dining room before breakfast and had witnessed Resident #3 get very irritated with Resident #2's moaning and had heard Resident #3 tell Resident #2 to shut up or that she will make her shut up. Resident #14 stated she knew something was going to happen between the residents and had been worried because she was afraid Resident #3 was going to hurt someone. Resident #14 further stated, this is going to happen again because there is nobody in the dining room to watch them. Resident #14 stated she is afraid of Resident #3 because she doesn't trust her. On 05/01/24 at 2:38 P.M., an interview with NP #700 revealed on the evening of 04/22/24, she went into Resident #2's room for a scheduled, routine visit. NP #700 revealed after she turned the light on, she immediately noticed lacerations on the resident's cheek and nose, both with dry, crusted blood, and a swollen left lip. Resident #2 reported to her that she had gotten into a fight with Resident #3. NP #700 stated the re [TRUNCATED]

Based on review of the medical record, facility Self-Reported Incident (SRI), facility investigation, police report and facility policy and procedure and interview with staff, resident and legal guardian the facility failed to ensure one resident (Resident #1) was free from sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious emotional harm on 09/07/19 when Resident #2 was observed with Resident #1's breast in his mouth and his hand down her pants. Resident #1 expressed fear, and a feeling of being assaulted at the time of the incident. The facility census was 53. On 09/23/19 at 4:47 P.M. the Administrator, Regional Registered Nurse (RN) #34 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 09/07/19 at 1:30 P.M. when Resident #2 was found in Resident #1's room engaged in nonconsensual sexual activity. The Immediate Jeopardy was removed on 09/24/19 when the facility implemented the following corrective action: · On 09/07/19 following the incident Resident #2 was placed on one-on-one staff supervision and his room was moved to a different part of the facility away from Resident #1. The one-on-one (1:1) supervision continued for Resident #2 until the resident was discharged from the facility on 09/11/19. Resident #2 did not return to the facility following his discharge. · On 09/07/19 following the incident, Resident #1 was transported to the emergency room for assessment. The resident returned to the facility on [DATE] at 1:00 P.M. · On 09/07/19 at approximately 2:09 P.M. Maintenance Director #44, who had been notified of the incident by State tested Nursing Assistant (STNA)) #32, notified the Administrator of the incident of sexual abuse involving Resident #1 and Resident #2. The Administrator reported the allegation of sexual abuse involving Resident #1 and Resident #2 to the State Agency and to the local sheriff department and an investigation was initiated. · On 09/07/19 following the incident Licensed Practical Nurse (LPN) #31 and LPN #41 assessed Resident #1 and Resident #2. No concerns were identified. LPN #31 obtained a statement from Resident #1 and Resident #2 as part of a facility investigation regarding the sexual incident that had occurred between the two residents. · On 09/07/19 between 2:09 P.M. and 4:35 P.M. LPN #31 obtained witness statements from STNA #32, Housekeeper #30 and LPN #31, the three staff members who had observed the incident. The Administrator notified Regional Registered Nurse (RN) #34 and the Director of Nursing (DON) of the incident. · On 09/07/19 between 2:09 P.M. and 4:35 P.M. the DON conducted medical record reviews to identify like residents, with no other residents identified who were at risk for sexual abuse. · On 09/08/19 the Administrator obtained an additional statement from Housekeeper #30, the employee who first witnessed the incident on 09/07/19. · On 09/09/19 the DON, RN #42 and LPN #43 completed skin assessments for all additional current residents who were not interviewable (residents who had a Brief Interview for Mental Status (BIMS) score of less than 11). Thirteen (13) total residents had skin assessments completed. No concerns were identified. · On 09/09/19 the Administrator and RN #34 conducted abuse interviews for all additional current residents who were interviewable (residents who had a BIMS score of 11 or greater). Thirty-eight (38) residents were interviewed. No concerns were identified. · On 09/13/19 Resident #1 had a follow up visit by the psychiatric nurse practitioner with no psychosocial concerns identified. · Beginning on 09/23/19 the DON initiated staff education for all staff related to the facility abuse policy and procedure. All staff were required to complete a post test with a 100% pass rate required. A plan to continue education each shift until all staff members were educated was implemented. As of 09/23/19; 50 of 80 staff members, including contracted staff had received the education. · On 09/24/19 the DON provided disciplinary action and re-education to LPN #31 and Housekeeper #30 related to the facility abuse policy and procedure and the incident that occurred between Resident #1 and Resident #2 on 09/07/19. · On 09/24/19 the Administrator implemented a plan to complete abuse competency tests on five staff members three times per week for four weeks and then randomly on five staff members once a week for four weeks. The results of the competency tests will be reviewed weekly for four weeks by the facility Quality Assurance committee. If compliance is maintained, a plan for the tests to be reviewed monthly was identified. A plan was also developed if compliance was not maintained to determine root cause analysis and modification of the plan. · On 09/24/19 the Administrator implemented a plan for all new hires to be required to pass the Abuse competency test as part of their orientation. · On 09/24/19 the Administrator implemented a plan for the DON and Assistant Director of Nursing (ADON) to monitor compliance through daily clinical meetings Monday through Friday and reviewing resident behavior alerts, weekly Risk Meetings and monthly Quality Assurance Performance Improvement meetings (QAPI). · On 09/24/19 an ad hoc QAPI meeting was conducted with the interdisciplinary team, which included the Medical Director, Administrator, DON, Regional RN #34, the dietary manager, chaplain, admissions/marketing director, medical records employee, Maintenance Director #44, the Minimum Data Set nurse and the assistant business office manager to review the survey findings and to discuss the facility plan of action. Although the Immediate Jeopardy was removed on 09/24/19 the deficiency remains at Severity Level II (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of completing staff re-education and implementing their corrective action. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #1 had a court appointed legal guardian. Review of the Probate Court Letter of Guardianship form revealed on 01/10/17 a court appointed guardian was issued to Resident #1 due to the resident being deemed incompetent. The guardianship was noted to be in place for an indefinite time period. Review of a plan of care, dated 12/28/18 revealed Resident #1 was at risk for behaviors. The care plan reflected the resident had behavioral problems including being physically abusive and aggressive, socially and sexually inappropriate and had a history from other nursing homes of having sex with other residents. Interventions included to report to physician changes in behavioral status, intervene immediately as needed to protect the rights and safety of others, approach in a calm manner, divert attention, remove from situation and take to another location as needed. Review of Resident #1's Minimum Data Set (MDS) 3.0 assessment, dated 06/06/19 revealed Resident #1 was cognitively intact and independent for bed mobility, transfers and ambulation with a walker. Review of Resident #1's behaviors revealed the resident had verbal behaviors directed towards others; e.g. threatening others, screaming at others, cursing at others.) and other behavioral symptoms not directed at others; e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds. Review of Resident #1's nursing progress notes revealed the following entries related to sexual contact: On 03/24/19 the resident denied sexual contact with other residents. She was educated that if she would like to have sexual contact with other residents it had to be consensual, had to be in a nonpublic area and she must notify staff. On 03/28/19 the resident ' s guardian revealed the resident was not to have sexual relations with other residents. Record review revealed Resident #1 had a current plan of care developed related to impaired cognitive skills due to mild cognitive impairment. The care plan revealed the resident had inattention and disorganized thinking that comes and goes. Interventions included to use brief, simple, consistent words, cues and statements and report unanticipated changes in cognitive status to physician. Review of Resident #2's closed medical record revealed the resident was admitted to the facility on [DATE] and was discharged on [DATE] to another long-term care facility. The resident had [DIAGNOSES REDACTED]. Review of Resident #2's documented behaviors revealed the resident would frequently reject care. A plan of care, dated 05/24/19, revealed Resident #2 engaged in voluntary consensual sexual activities with other residents as evidenced by holding hands, kissing, sexual contact (private parts) and had multiple female friends he had these relations with. Interventions included ensure both residents were their own responsible party and had not been deemed incompetent by a physician. The care plan interventions revealed if there was a question regarding the ability to make decisions, contact either resident's physician and family to evaluate the situation, ensure relations were consensual and indicated consent must be active, not passive. The care plan also indicated it was a matter of whether or not the other resident said yes, not whether or not she said no or put up resistance, provide a private environment, educate the resident on the risks associated with sexual behaviors. On 09/07/19 Resident #2's plan of care was updated to include a room change and 1:1 direct staff supervision. Review of Resident #2's nursing progress notes revealed the resident had the following sexual history: On 03/24/19 education was given to Resident #2 regarding sexual behaviors. On 05/20/19 the resident was observed holding hands with a peer for an extended period of time, no other physical contact was observed. On 05/22/19 the resident was educated on the need for privacy and being respectful of others when spending time with female peers. A note dated 05/24/19 revealed the resident was educated on 05/23/19 to seek privacy when spending time with peers in a sexual manner. A note on 06/14/19 revealed on 06/13/19 the nurse and social service director met with the resident in his room to discuss recent behaviors, being sexually inappropriate in front of other residents, and refusing assistance from staff. The note indicated the resident verbalized understanding. Review of the MDS 3.0 assessment, dated 07/02/19, revealed Resident #2 had intact cognition. The assessment revealed the resident required extensive assistance from one staff for bed mobility and transfers, and extensive assistance set-up only for locomotion on the unit via wheelchair. Review of a facility self reported incident (SRI), tracking number 0 dated 09/07/19 and timed 4:50 P.M. revealed a male resident (Resident #2) was witnessed touching a female resident (Resident #1) in her private areas. The male resident (Resident #2) was removed from the room. The SRI revealed, Resident #1, assessed with [REDACTED].#2 around her. The SRI indicated Resident #1 did not appear anxious or distraught but did mention her private area hurt. There were no physical signs or marks related to the incident. Following the incident, Resident #2 was placed on 1:1 staff supervision, his room was moved to the opposite end of the facility and the staff were searching for alternative placement for him. A review of the facility investigation, dated 09/07/19 revealed Resident #1 was observed to be touched in the private parts by another resident (Resident #2) in her room. The residents were immediately separated by staff (STNA #32). Resident #1 was examined by LPN #31 and LPN #41 and sent to the local emergency room (ER). A review of Resident #1's witness statement (typed and received by the Administrator), dated 09/07/19 revealed Resident #2 was in her room beside her bed and pulled her close, she woke up and he stated to her, What are you doing sleeping all day? which scared her and she wasn't expecting it. Resident #2 then put his hand down her pants and put his mouth on her breast. Resident #1 indicated it lasted about five to 10 minutes and she didn't know what to do. The resident indicated it hurt her when he touched her private area, he didn ' t penetrate her, he had never touched her before the incident, and she thought she should go to the hospital. A review of Resident #2's witness statement (typed and received by the Administrator), dated 09/07/19 revealed Resident #2 stated he didn't know what the Administrator was talking about when asked about the incident between him and Resident #1. He was presented with the accusation, the staff observations, and notified that the local authorities would be coming, and then he was asked if he wanted to change his story. Resident #2 then stated that Resident #1 asked him to come to her room and he then admitted to touching her. Review of a local hospital record, dated 09/08/19 revealed Resident #1 was sent to the hospital for reported sexual assault. Resident #1 stated another resident touched her vagina with his fingers and kissed her on the mouth. A pelvic exam was performed by the Sexual Assault Nurse Examiner (SANE) nurse. Resident #1 complained of mild tenderness to her vagina. The SANE nurse report, dated 09/08/19, revealed no abnormalities noted upon the skin examination, but that the assailant vaginally penetrated Resident #1's vagina with his fingers. The report revealed Resident #1 stated she was in her room, asleep, when she suddenly was shaken awake by Resident #2 and he was asking her, What are you going to do? Be in bed all day? He then turned her over and proceeded to bite her breasts and moved on to her private parts. She stated she was scared, he was yanking on her neck and kissing her. She further revealed he then put his hand down her pants and used his hand as a weapon. She revealed Resident #2 stopped when STNA #32 came in the room. On 09/23/19 at 8:15 [NAME]M. interview with Resident #1 revealed on the afternoon of 09/07/19 she was sleeping in her bed when she was woken up by Resident #2 touching her breasts, kissing her, putting his hand down her underwear (stating his fingers touched her private area), he was also yanking her towards him and she stated the interaction was not consensual. She stated he assaulted her, put her breast in his mouth and used his hand to screw her down there, while pointing to her vaginal area. She stated he hurt her and she told him to stop, but then she stated she was too scared to say anything. Resident #1 stated he was too aggressive and she was defenseless, so she didn't scream and yell for help. The resident stated STNA #32 saw it and he stopped the encounter and made sure she wasn't alone after the incident. Resident #1 stated this had never happened before, and it hadn ' t happened since. Resident #1 further revealed that after the incident she felt worthless, but she couldn ' t stop Resident #2, so she didn't try hitting or pushing him off. During the interview, Resident #1 revealed she was sent to the hospital and a rape kit was done. Resident #1 revealed she feels safe at the facility now that Resident #2 is gone. On 09/23/19 at 12:35 P.M. interview with Social Services (SS) #35 revealed Resident #1 and Resident #2 would hold hands occasionally and Resident #1 would show interest in Resident #2, but it wasn't all the time. She revealed she had spoken with Resident #1's guardian in the past about sexual behaviors and the legal guardian didn't want the residents to do more than hold hands. SS #35 revealed Resident #2 was educated multiple times on privacy to others and to go to his room to not do that behavior in the living room area, but he was never educated on who it was appropriate to have sex with or what consent was. Review of a room change notification form, dated 09/07/19 revealed Resident #2 was moved (to another room) due to observation and safety related to an SRI. Resident #2 was subsequently discharged from the facility on 09/11/19. A review of the local law enforcement report, dated 09/07/19 at 3:59 P.M. revealed the deputy interviewed Resident #1, Resident #2, and Resident #3. The report revealed STNA #32 had found Resident #2 with his mouth on Resident #1's breasts and he also had a hand down her pants. STNA #32 stopped the incident and instructed Resident #2 to return to his room. It further stated the Administrator informed the deputy that Resident #2 was an [AGE] year old man with no known mental issues and Resident #1 was a younger female with a handicap. Upon the deputy ' s interview with Resident #2, Resident #2 stated Resident #1's pants were down, and she had told him to touch her vagina, so he did. He also stated Resident #1 told him to suck on her breasts. Resident #2 then revealed Resident #1 asked him to go to the bathroom with her so they could have sex and he declined. Upon interviewing Resident #1, Resident #1 stated she was asleep in her room on her bed when she felt someone shaking her, and at first, she didn ' t know who it was, but then she woke up and his (Resident #2's) hands were down her pants and his mouth was on her breasts. She stated she didn ' t know why he was doing that, but she was scared and didn ' t know what to do. Resident #1 stated she never invited the resident into her room, and she never told him to stop because she was too scared. She revealed the interaction was not consensual. Resident #1 then inquired about a protection order and what was going to be done about Resident #2 because she had to walk past his room to go to the dining room for dinner. The deputy advised her Resident #2 would be moved so that she wouldn ' t have to be anywhere near him. Upon interview with Resident #3 (who was Resident #1's roommate), Resident #3 stated her privacy curtain was closed, and she was not able to see any physical interaction between Resident #1 and Resident #2. She denied hearing any negative vocalizations or requests to stop touching or anything similar. On 09/23/19 at 3:40 P.M., interview with the local law enforcement/deputy revealed he had interviewed Resident #1 following the incident on 09/07/19. The deputy revealed Resident #1 had voiced to him that she was sleeping and Resident #2 woke her up as he was touching her. He stated he had to send the information he obtained to the detective bureau as they had a few detectives who were specially trained for rape allegations. The deputy verified the content of the findings in the report noted above. On 09/23/19 at 3:51 P.M. an attempt to reach the assigned police detective was unsuccessful as the detective was unavailable. A voice mail message was left, however no return call was received. A review of Housekeeper #30's witness statement, dated 09/07/19 revealed from approximately 1:30 P.M. through 1:45 P.M. the housekeeper witnessed Resident #2 in Resident #1's room by her bed with his left hand on her breast, his other hand down her pants, and her breast exposed. She stated they didn't stop when she entered the room. She stated she took the bathroom trash, left the room and told LPN #31. The witness statement was updated on 09/08/19 to include that Resident #1 was awake and giggling and laughing, the residents were also whispering. On 09/23/19 at 11:39 [NAME]M. interview with Housekeeper #30 revealed when she went into Resident #1's room to clean the bathroom on 09/07/19 at around 1:30 P.M. or 1:45 P.M., Resident #1 was in bed, her shirt was up, and she could see the resident's breasts. Resident #2 was observed to have his left hand on her breast and right hand down her pants, and they were whispering and giggling so she placed a trash bag in the bathroom trash can, left the room, and told LPN #31. She revealed she wasn ' t sure exactly what to do, but she didn ' t want to go back into the room because she felt uncomfortable. The housekeeper denied she attempted to intervene or stop the incident. She stated she would expect if someone walked in the room, most people would stop doing something like that. Housekeeper #30 stated she never knew the residents had sexual behaviors before and she didn ' t want to stop them as it was their right to do. She further revealed she was not educated on the facility abuse policy recently, only when she was first hired (May 2019), but didn't recall all if it. She revealed she only thought Resident #2 had relations with Resident #4 and stated this consisted of hand holding. A review of LPN #31's witness statement, dated 09/07/19, revealed at approximately 1:45 P.M. he went into Resident #1 ' s bedroom to talk to the resident. She was awake lying in bed with Resident #2 in his wheelchair on the right side of the bed. There were no complaints from Resident #1, and there were no sexual behaviors observed at that time. The statement indicated LPN #31 suggested Resident #2 leave the room. On 09/23/19 at 11:15 [NAME]M. and 11:31 [NAME]M. attempts to reach LPN #31 via telephone were unsuccessful. A review of STNA #32's witness statement, dated 09/07/19 revealed at approximately 1:55 P.M. he went into Resident #1's room to get Resident #2 out of her room and Resident #2 had his hand down Resident #1's pants and had her breasts out and exposed with his mouth on her breast. Resident #1 stated to the STNA she was sleeping when this was happening. STNA #32 told LPN #31, the nurse on the floor. On 09/23/19 at 9:35 [NAME]M. interview with STNA #32 revealed on 09/07/19 he was told by LPN #31 to go to Resident #1's room to check on Resident #1 and Resident #2. As the STNA was getting closer to the room, he could see Resident #2 holding onto Resident #1's breast with his mouth on it and his other hand was down her pants. He stated Resident #1's eyes were shut and she was laying in bed on her side facing the wall (explained as if someone had put a pillow behind her back). Resident #2 was in his wheelchair and as soon as STNA #32 entered the room, Resident #2 immediately stopped and left the room. STNA #32 then told LPN #31. STNA #32 revealed Resident #1 thanked him for removing Resident #2 from her room. He stated Maintenance Director (MD) #44 was calling the Administrator for an unrelated incident so MD #44 notified the Administrator of this incident. On 09/23/19 at 12:07 P.M. interview with Resident #1's court appointed legal guardian revealed she had been appointed legal guardian for Resident #1 a couple years prior due to the resident's mental illness and [DIAGNOSES REDACTED]. The legal guardian revealed she had been notified of the incident that occurred on 09/07/19 between Resident #1 and Resident #2 and revealed Resident #1 was not supposed to have any sexual contact while residing in the nursing facility. On 09/23/19 at 12:25 P.M. interview with the Administrator revealed he had made previous observations of Resident #2 and Resident #4 holding hands together but there was never any inappropriate nonconsensual touching that he was aware of. During the interview, the Administrator verified the facility completed an SRI and investigated an allegation of sexual abuse involving Resident #1 that occurred on 09/07/19. He further stated he believed Resident #1 could make decisions on her own, but confirmed she was not her own legal guardian and confirmed Resident #1's legal guardian had specifically requested Resident #1 not be sexually active with any residents at the facility. On 09/23/19 at 4:40 P.M. interview with the DON, Administrator and Regional RN #34 again confirmed Resident #1's legal guardian had specifically requested Resident #1 was not to have sexual contact with anyone. During the interview, the administrative staff verified Housekeeper #30 should have immediately intervened when she entered Resident #1's room and observed Resident #2 touching the resident. The administrative staff also verified LPN #31 had also entered Resident #1's room but failed to determine what had occurred or was occurring between the two residents and only suggested Resident #2 leave the room. A review of facility policy titled Abuse, Neglect and Misappropriation of Property, dated (MONTH) 2019 revealed sexual abuse included but was not limited to, any physical contact with a resident ' s body that was not reasonably related to appropriate provision of ordered care or services. It further stated that every Stakeholder, contractor, and volunteer must intervene immediately, to the extent feasible and consistent with personal safety and the persons training, to prevent or interrupt an incident of abuse. It also revealed if a Stakeholder observed a resident exhibiting any form of abuse towards another resident, the Stakeholder would intervene immediately to interrupt the incident and remove and/or separate the residents involved and move them to an environment where the resident's safety could be assured. The DON and/or charge nurse would ensure that the residents did not have access to one another until the circumstances of the incident could be determined. This deficiency substantiates Control Number OH 008.

Based on observation, record review and staff interview the facility failed to prevent the development of a Stage III (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are to exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) pressure ulcer to Resident #21's coccyx, provide wound consults as recommended, seek changes of treatment for [REDACTED]. This affected two residents (Resident #21 and #37) of three residents reviewed for pressure ulcers. Actual Harm occurred when Resident #21, who was assessed to be at a low risk for development of a pressure ulcer developed a Stage III pressure ulcer to the coccyx that declined to a Stage IV (a full thickness tissue loss with exposed bone, tendon and muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.) pressure ulcer with tunneling which subsequently became infected without timely treatment. Findings include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 05/07/17 Braden Scale for Predicting Pressure Sore Risk revealed Resident #21 was at low risk for pressure ulcers, with a score of 21, with no sensory perception impairment, rarely moist, walks occasionally, no limitation in ability, adequate nutrition and no apparent problem with friction and shear. Review of the medical record revealed on 06/18/17 at 5:30 A.M. Resident #21 sustained a fall with a closed fracture of proximal end of right humerus. Following the fall/fracture, a new intervention for a Dycem to the recliner seat at all times and remove cushion to seat was implemented. On 07/05/17 an active risk for behavior problems revealed a problem of refusal to sleep in bed, sleeps in recliner. On 08/29/17 a Non-Pressure Skin Condition Record was initiated related to a pilonidal cyst (a cyst at the bottom of the tailbone) measuring 4.5 centimeter (cm) in length by 1.9 cm width with 1.1 cm depth. The cyst is common in people who sit a lot. The area had scant serous, serosanguinous exudate with dark pink/red tissue with blanchable surrounding skin with no pain. The record revealed the resident had a specialty bed mattress as needed, vitamin therapy and supplement. A physician's orders [REDACTED]. Apply [MEDICATION NAME] to wound bed and secure with foam dressing every third day and as needed. A 08/29/17 Braden Scale for Predicting Pressure Sore Risk revealed Resident #21 was at risk for pressure ulcers, score of 18, with no sensory perception impairment, occasionally moist, walks occasionally, no limitation in ability, very poor nutrition and no apparent problem with friction and shear. On 08/30/17 a referral was made for wound clinic services for 09/07/17. Physician orders [REDACTED]. On 09/04/17 the measurements were documented to be the same with scant/small amount serous, serosanguinous exudates with dark pink/red tissue with blanchable surrounding skin, specialty bed mattress as needed, vitamin therapy and supplements. The skin record revealed, Fistula is being treated. Resident non-compliant with dressing and reposition. Will go to wound clinic on 09/07/17. On 09/07/17 Resident #21 was seen at the wound clinic. There was no mention of a fistula or pilonidal cyst on the wound clinic assessment. The wound clinic assessed the area as a Stage III pressure ulcer measuring 4.0 cm in length by one cm width with 1.6 cm depth with no tunneling or undermining. There was a medium amount of exudate, serosanguinous and red brown color. Large amount of granulation 67-100%, red no necrosis or odor or slough. There was a non-viable tissue open wound/selective debridement, non-incisional with total area 4 square cm. and curette for [MEDICATION NAME], slough and skin. The pressure ulcer was stable post debridement and severity of tissue post debridement was limited to breakdown of skin. Physician orders [REDACTED].M. Encourage resident not to sit for long periods of time; low air loss mattress if resident will sleep in bed and a purple cushion for sitting. Cleanse coccyx wound with wound cleanser, pat dry, apply nickel thick dose of Santyl ointment to wound. Cover with dry gauze, secure with [MEDICATION NAME] border, change every day and as needed. May shower and cleanse wound with mild soap and water. On 09/07/17 the low air loss mattress was discontinued related to resident refusing to sleep in bed and the purple seat cushion was discontinued and changed to a gel cushion to recliner. The facility moved documentation of the coccyx from the non-pressure skin condition record to a Pressure Ulcer Record on 09/07/17. On 09/12/17 the measurements remained the same; the area was assessed to be a Stage III pressure ulcer with moderate amount of serosanguinous red brown drainage. Resident #21 was on the transport list for 09/21/17 to go to the wound clinic. However, the resident did not go to the appointment. There was no evidence as to why Resident #21 was not taken to the wound clinic appointment. On 10/02/17 the coccyx measured 4.3 cm in length by 2.1 cm width with 1.9 cm depth and was assessed to be a Stage III with moderate amount of serosanguinous and purulent drainage. Wound bed dark pink/red tissue and now has slough (moist yellow or gray necrotic tissue). The assessment indicated Resident takes dressing off area, throws in trash and put toilet paper in area. Area moist with sloughing to bed edges. The assessment documented the pressure ulcer had improved however there was now purulent drainage from the ulcer. On 10/10/17 the pressure ulcer deteriorated further measuring 6.0 cm in length by 5.0 cm width with 2.0 depth and moderate purulent drainage. On 10/17/17 the coccyx pressure ulcer measured 5.5 cm in length by 2.0 cm width with 1.9 cm depth with serosanguinous and purulent drainage, moderate amount. The wound bed was dark pink/red tissue and slough. The assessment indicated the pressure ulcer had improved however there was still purulent drainage from the ulcer without a change in treatment. On 10/27/17 a wound culture was ordered. The culture was ordered 30 days after the yellow slough was noted and 25 days after purulent drainage was first documented. There had been no treatment change to the wound since the 09/07/17 wound clinic visit. There was no evidence of the 09/21/17 missed follow up appointment at the wound clinic being rescheduled. On 10/27/17 there was an order to re-obtain the wound culture due to faulty collection kit. On 10/30/17 [MEDICATION NAME] (an antibiotic) was initiated for seven days for the pressure ulcer wound, 28 days after purulent drainage was first documented. The results of the 10/30/17 wound culture showed light growth of Escherichia coli and heavy growth of [DIAGNOSES REDACTED] Aureus. The doctor was notified 10/30/17. On 11/07/17 a new Pressure Ulcer Record was initiated for a Stage III right ischium facility acquired pressure ulcer measuring 2.1 cm in length by 2.4 cm width with 0.2 cm depth with small to moderate serous/serosanguinous drainage with the wound bed normal for skin, pink tissue and dark pink/red tissue. It indicated the physician, family and dietary were notified on 11/08/17. The narrative read area found. Treatment started. No pain or discomfort noted. Reposition every two hours, non-compliant with care and no odor. On 11/10/17 the weekly skin assessment identified a new open area to right gluteal crease between the buttock and upper thigh. On 11/10/17 there was an order to refer to Resident #21 to a new wound clinic. On 11/15/17 Resident #21 had a consult at the outside wound clinic. The wound clinic assessed resident #21's skin impairments as follows: a. An area to the right ischium was staged a Stage II pressure ulcer measuring 2.0 cm in length by 2.3 cm width with 0.1 cm depth with small, serosanguinous exudate. Granulation is large, pink; necrosis is small, yellow, wet. Wound margins are distinct. periwound is slightly chaotic and hyper pigmented. b. The sacral/coccyx ulcer measured 4.6 cm in length by 1.0 cm width with 2.0 cm depth. There was undermining at 12 o'clock of 2.5 cm. Exudates were large, serous. Granulation was large, pink. Necrosis was small, yellow, wet. Wound margins were distinct. Periwound was slightly hyper pigmented. There was some bone palpated in the base of the wound. Resident (#21) did have limited mobility. The area was assessed by the wound clinic as a Stage IV pressure ulcer. The assessment indicated the treatment with an oral antibiotic. Bone was palpated in the pressure area and an x-ray of the pelvis was done. Orders were given to pack the area with [MEDICATION NAME] silver, NoSting and a foam adhesive. Change every three days and as needed. Will switch to wound vac with black foam, [MEDICATION NAME] covering the bone that was exposed , NoSting, VAC drape, 150 mmHg change three times a week and as needed if no abnormality on x-ray. Recommended that (resident) not be on her bottom for more than 20 minutes at a time while in chair and that should be with meals. She needs a waffle or off-loading cushion to chair. Change position every two hours while in bed. Recommend a dietary consult due to low BMI of 16.5. According to the person who came with her she does have some type of cushion on her chair which she will throw out. She sits constantly and will a lot of times put tissues up in her wound and is very non-compliant. Follow up in one month. On 11/15/17 orders to discontinue the waffle cushion and encourage using gel cushion. Check placement of gel cushion every shift. Check wound vac placement every shift for dislodgement and excessive soiling. [MEDICATION NAME] AG to be used instead of [MEDICATION NAME] AG to right ischium. Change to have [MEDICATION NAME], then black foam, then wound vac. Discontinue Santyl treatment. Between 11/17/17 and 11/20/17 the wound treatment was changed three times. On 11/22/17 and order for a [MEDICATION NAME] was obtained. On 11/23/17 the result was low at 13. On 12/01/17 resident was admitted to Hospice care. The labs, weekly weights and wound clinic follow up were discontinued. Hospice Registered Nurse to do dressing changes on Mondays. Since going to the wound clinic, the change of treatment 11/15/17, and the administration of antibiotics for the infected pressure ulcer of the coccyx, the Stage IV pressure ulcer had improved to 2.5 cm x 0.4 cm x 0.2 cm with scant serous drainage on 01/30/18. The right ischium had improved to 1.2 cm x 1.0 cm x 0.2 cm on 01/23/18. On 01/30/18 there was a decline to 1.2 cm x 1.0 cm x 0.5 cm and the treatment was changed to calcium alginate. The low air loss mattress was being signed off every shift since the order date in September through the discontinued date of 12/15/17 when in fact the mattress had never been placed on the resident's bed. Review of the November 2017, December 2017 and January 2018 behavior and administration records revealed the resident was documented as having no behaviors. During observation of the dressing change 01/31/18 at 1:45 P.M. Licensed Practical Nurse (LPN) #52 said the coccyx dressing had come off that morning and Hospice had to bring more supplies. Observation revealed a blood spotted napkin in the recliner next to Resident #21. LPN #52 indicated Resident #21 sticks it back where the coccyx ulcer is. Observation of Resident #21's fingers revealed her fingernails were long and jagged with dark debris under the nailbeds. The right index finger nail was broken. LPN #52 verified the resident takes off her pressure ulcer dressings and sticks tissues down the back of her pants onto the pressure ulcer On 02/01/18 at 10:10 A.M. the DON said they discontinued the ordered low air loss mattress because Resident #21 did not sleep in bed. The DON clarified the order for the seat cushion to gel cushion instead of a purple cushion. The DON verified the staff was signing off every shift the mattress was on the bed when it was not. The DON verified the resident had a Stage II and a Stage IV pressure ulcer on 12/01/17 and the MDS 3.0 assessment was miscoded. The Mood and Behavior section documented the resident had no mood or behaviors. The DON verified the MDS and the treatment sheet both indicated the resident had no behaviors but stated this was also not correct indicating she had refusal of care and depression. On 02/01/18 at 1:01 P.M. the DON indicated in July 2017 Resident #21 started sleeping in the recliner and refusing to sleep in bed. The pressure reducing cushion to the chair was not utilized until after Resident #21 developed a pressure ulcer to the coccyx on 08/29/17. The DON further verified the facility had an appointment on the transport sheet on 09/21/17 for Resident #21 to go to the follow up wound clinic appointment. The DON verified she did not go to the appointment. The DON verified there was no record as to why she did not keep the appointment and no record the appointment was rescheduled. The DON verified the coccyx pressure ulcer became infected. On 09/26/17 the pressure ulcer started to show signs of deterioration. On 10/02/17 the pressure ulcer had purulent drainage. There was not a culture ordered until 10/27/17. An antibiotic was ordered 10/30/17 for light growth of Escherichia coli and heavy growth of [DIAGNOSES REDACTED] Aureus. Resident #21 did not have a wound clinic visit until 11/15/17 when the coccyx pressure ulcer was staged as a Stage IV with undermining that had not been assessed by the facility. The treatment to the coccyx stayed the same from the 09/07/17 wound clinic visit until Resident #21 again visited a wound clinic on 11/15/17 related to deterioration of the pressure ulcer and the presentation of a second pressure ulcer. The DON verified the ulcer had gone from a Stage III to a Stage IV without a dressing treatment change. On 02/01/18 at 1:27 P.M. interview with Wound Nurse #58 revealed she doesn't know why Resident #21 did not return to the wound clinic. She verified the ulcer had purulent drainage without a treatment change. On 02/01/18 at 1:40 P.M. interview with Resident #21's physician the Medical Director revealed he did not know or couldn't picture the resident. The physician indicated he did not recall a resident with pressure ulcers. 2. Record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had orders to float heels and to apply a foam boot to right foot while in bed for skin prevention. Observation on 01/31/18 at 2:35 P.M., of Resident #37 with STNA #13 and the resident's mother (who was a registered nurse) verified the resident was lying in bed and there was no evidence of a foam boot on the right foot and the resident's heels were not floated off the bed. The resident's mother reported Resident #37 had a Stage IV pressure ulcer in the past and she had bought a special white boot on her own, which she provided to the facility. However, she had not seen it for a while. STNA #13 verified there was no white or blue foam boot in the resident's room or in laundry. Observation on 02/01/18 at 9:57 A.M., of Resident #37 with STNA #35 revealed the resident was lying in bed. There was no foam boot on the right foot and the heels were not floated off the bed. STNA #37 verified the findings.

Based on medical record review, policy review, medical director interview and staff interview, the facility failed to ensure residents were monitored for [MEDICAL CONDITION] and fluid overload. This affected two residents (Resident #74 and Resident #79)of three residents reviewed for weight monitoring. Harm occurred to Resident #74 when the facility failed to monitor, implement interventions and notify the physician of the resident's 17% weight gain between 01/20/15 and 02/10/15, and the resident was admitted to the hospital with [REDACTED]. Harm occurred to Resident #79 when the facility failed to monitor, implement interventions and notify the physician of the resident's 14% weight gain between 01/30/15 and 02/12/15, and the resident was admitted to the hospital with [REDACTED]. Findings include: 1. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 01/22/15 revealed the resident was independent for daily decision-making, was 64 inches tall and weighed 202 pounds (#). The resident had no known weight gain. Review of the Nursing Admission Information assessment dated [DATE] revealed Resident #74 had [MEDICAL CONDITION] to the right lower extremity. There was no documented evidence of the extent of the [MEDICAL CONDITION]. Review of Resident #74's Daily Skilled Nurse's Notes revealed the following: On 01/20/15, 01/25/15 and 02/14/15, the resident had generalized [MEDICAL CONDITION] with no documented location or extent. There was no documented evidence the physician or family was notified. On 02/03/15 and 02/05/15, no [MEDICAL CONDITION] was documented. On 02/05/15, the resident was started on [MEDICATION NAME] for left lower leg [MEDICAL CONDITION] with +2 [MEDICAL CONDITION]. The daughter was notified of the new order for [MEDICAL CONDITION]. Review of Resident #74's admission physician orders, dated 01/15/15 revealed monthly weights were ordered. Review of the resident's Vital Signs and Weight Record dated 01/20/15 through 02/10/15 revealed the following weights: On 01/20/15, 202 #. On 01/25/15, 214#. On 02/03/15, 225#. On 02/05/15, 219#. On 02/10/15, 237#. Review of the Nutritional Progress Notes dated 02/12/15 revealed Resident #74 had [MEDICAL CONDITIONS] and a weight gain of 35 pounds since admission. Daily weights were ordered. Review of the daily skilled nurse's notes dated 01/15/15 through 02/11/15 revealed no comprehensive assessment of the resident's weight gain or family/ physician notification until 02/12/15. Review of the Communication Form and Progress Note (SBAR) dated 02/14/15 revealed the family demanded the transfer of the resident to the hospital due to increase in fluid retention and decreased urinary output. The resident's condition at the time of transfer included: shortness of breath, a distended abdomen with urinary output in the last 24 hours of 100 milliliters, a weight of 233#, and a blood pressure of 142/43. Review of the hospital physician discharge summary, dated 02/26/15 revealed Resident #74 was diagnosed with [REDACTED]. On 03/17/15 at 4:38 P.M., interview with Medical Director #14 revealed he was to be notified when a resident gains five pounds in three days. Medical Director #14 verified he was not notified of the resident's weight gain between January 2015 to March 2015. Medical Director #14 verified the resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. 2. Medical record review revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] and diagnosed with [REDACTED]. Review of the 5-day MDS 3.0 assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making, was 59 inches tall, weighed 112 pounds and was not on a physician prescribed weight gain regimen. Review of Resident #79's Nursing Admission Information assessment dated [DATE] revealed no [MEDICAL CONDITION] and the resident had a history of [REDACTED]. Review of the admission physician orders [REDACTED]. Review of Resident #79's Vital Signs and Weight Record dated 01/30/15 through 02/12/15 revealed the following weight increases: On 01/30/15, 104#. On 02/02/15 and 02/03/15, 110#. On 02/04/15, 112#. On 02/05/15 and 02/06/15, 113#. On 02/07/15, 115#. On 02/08/15 and 02/10/15, 116#. On 02/09/15, 117#. On 02/11/15, 118#. On 02/12/15, 119#. Review of the medical record revealed no documented evidence Resident #79 was weighed daily as ordered on [DATE], 02/01/15 or 02/13/15. Review of the Radiology Report dated 02/12/15 included cardiomegaly (enlarged heart size). Review of the SBAR Communication Form and Progress Note dated 02/15/15 revealed Resident #79 had complaints of shortness of breath and fluid retention since 02/11/15 that had gotten worse. Resident's weight on 02/14/15 was 119# and on 02/15/15 the resident weighed 122#. Resident #79 did not receive [MEDICATION NAME] (diuretic) at 8:00 A.M. as ordered due to pharmacy and insurance issues. The resident and family stated she had been retaining fluid since 02/11/15 and had seen an increase in the retention over the past few days. The certified nurse practitioner (CNP) was notified, ordered to give [MEDICATION NAME] when it arrived this evening, apply lower extremity compression hose and re-evaluate the resident in the morning. The family and resident felt it was in the best interest of the resident to go to hospital. Resident #79 was transferred to the emergency room via squad for evaluation. Review of Resident #79's Daily Skilled Nurse's Notes revealed the following: No documented evidence the physician or family was notified of the resident's weight gain between 02/02/15 and 02/12/15. No documented evidence the physician or family was notified the development of [MEDICAL CONDITION] (location and amount of [MEDICAL CONDITION] was not documented) on 02/06/15, 02/11/15 or 02/12/15. Review of the Actual/Potential Cardiovascular Problems care plan dated 02/09/15 revealed interventions included to report any change of condition to the physician, monitor the lower extremities for any pain or swelling, administer medications as ordered and weigh monthly. On 03/17/15 at 4:01 P.M., interview with the DON verified Resident #79 gained 15 pounds between 01/30/15 and 02/12/15 and developed [MEDICAL CONDITION] on 02/06/15, 02/11/15 and 02/12/15 without physician or family notification. The DON also verified the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Change in a Resident's Condition or Status policy revised February 2014 revealed the facility shall promptly notify the resident, attending physician and representative of changes in the residents medical/mental condition and/or status. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the Weight Monitoring System policy, undated, included residents were to be weighed according to the physician order [REDACTED]. This deficiency substantiates Complaint Number OH 283.

Based on medical record review, review of Registered Nurse (RN) #100 ' s personnel file, review of staff in-service records and staff interview, the facility failed to provide necessary care and services when staff failed to immediately implement cardiopulmonary resuscitation (CPR) and activate emergency medical services (EMS) for one resident found without vital signs and was designated as a full code. This resulted in Immediate Jeopardy for one (Resident #70) who had expired at the facility. The facility identified 28 residents who required full resuscitative measures in the event of a cardiopulmonary arrest. The facility census was 69 residents. On [DATE] at 10:32 A.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 9:45 A.M. when RN #100 found Resident #70 without a pulse or respirations. RN #100 did not initiate CPR or activate the EMS. Resident #70 required full resuscitation (full code) with an active order initiated on [DATE] for a full code status. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: ? From [DATE] through [DATE] the DON conducted in-services with all 19 licensed nursing staff employed by the facility either in person or via telephone related to resident Code Status. ? On [DATE] the DON conducted an audit of all sixty nine resident records and ensured all code status/advance directive information was in place. The DON identified 28 residents who were requesting full resuscitation (CPR) measures implemented. ? On [DATE] the Administrator provided a written plan to complete audits of 10 different resident records per week to ensure code status was present in the chart and to ensure the residents' code status had a corresponding physician order. Also, the nurse manager will conduct 10 random interviews of 10 different staff members weekly to ensure staff is aware of what to do in the event they would see a resident with difficulty breathing, not breathing and/or not responsive. This will be conducted on an ongoing basis. The Administrator will conduct monthly audits of the tracking tools for compliance. This education component will be added to the new hire orientation packet. ? On [DATE], review of a Disciplinary Action Form in RN #100's personnel file revealed the DON terminated employment of RN #100 for failure to comply with standard nursing procedures in regard to the event of [DATE] for Resident #70. RN #100 was terminated for failure to administer CPR or activate EMS when Resident #70 was found without vital signs. ? On [DATE], the DON conducted in-services with all 11 therapy staff, 30 State-tested Nurse Aides (STNA), ten housekeeping/laundry staff, seven dietary staff, two activity staff, four office staff, two transportation staff and one volunteer employed by the facility either in person or via telephone on changes in condition and reporting. ? On [DATE] the surveyor interviewed two Licensed Practical Nurses (LPNs #102 and #103) and two RNs (#104 and #105). All four nursing staff demonstrated knowledge of where to find the code status for residents and their responsibilities to ensure each resident's correct code status was checked and followed. Interviews with STNAs #106 and #107, Admissions Director (AD #108), Dietary Staff (DS #109) and the one Administrative Staff (AS #110) revealed they were knowledgeable of what to do if there were a change in condition or they found a resident unresponsive. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (No actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as an insufficient amount of time had lapsed between the date of the incident of Immediate Jeopardy on [DATE] and the date of the on-site investigation on [DATE] to determine the facility had implemented ongoing audits and monitoring of residents code status as per the corrective plan developed by the facility. Findings include: Review of the medical record of Resident #70 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's current physician orders for [DATE], revealed Resident #70 had an active order initiated [DATE] for a full code status. Review of the nursing progress notes dated [DATE] at 1:29 P.M. revealed Resident #70 complained of being short of breath with oxygen saturation at 98% on two liters of oxygen. Lung sounds were diminished, audible wheezing was noted. The resident had an order for [REDACTED]. Review of the nursing progress notes dated [DATE] revealed the following: At 2:20 P.M. Resident #70 complained of shortness of breath and chest pain in the mid to left breast area. A breathing treatment was provided. At 2:24 P.M., the physician was notified of the chest pain and advised to send the resident to the emergency room , however the resident refused. At 2:30 P.M. the physician ordered [MEDICATION NAME] (for indigestion) which was effective and revealed the resident's pain to a number 4 (on a 1 to 10 scale). There were no nursing progress notes from 2:30 P.M. to 10:37 P.M. Review of the nursing progress note dated [DATE] at 10:37 P.M. revealed the doctor ordered sublingual [MEDICATION NAME] (a medication used to dilate the blood vessels and relieve chest pain), but the resident refused and asked for [MEDICATION NAME] instead. Resident #70 revealed the pain was a five out of 10 and decreasing. Review of the nursing progress note dated [DATE] at 8:30 A.M. revealed Resident #70 took his morning medications without complications and had no concerns at that time. Further review of nursing progress notes dated [DATE] at 9:45 A.M. revealed STNA #99 alerted RN #100 that she needed assistance with Resident #70. The note stated the resident had used his urinal and when he sat back into the chair, his bilateral extremities began shaking. The note also indicated the resident was kept safe during the [MEDICAL CONDITION] activity and oxygen was applied as it was dislodged during the shaking. Continued review of the nursing progress note revealed Resident #70 was sitting in the recliner at the bedside, shaking activity ceased, his pupils were fixed, drooling was noted, a gray ash color noted to the skin and vitals were absent immediately. At this time RN #100 did not administer CPR nor did RN #100 call 911 for emergency transport or assist in spite of the active physician's order stating the resident as a full code. Review of the documented interview of RN #100 by the DON on [DATE] at 12:15 P.M., revealed when asked by the DON what Resident #70's code status was, she could not answer and stated she thought she had looked at the wrong chart because afterward she realized he was a full code. RN #100 acknowledged she had not looked at the physician's order to verify code status and she told the other nurse on duty the resident was a do not resuscitate comfort care (DNRCC) code status. Review of a Disciplinary Action Form in RN #100's personnel file revealed on [DATE] the DON terminated RN #100 for failure to comply with standard nursing procedures in regard to the event of [DATE] for Resident #70. Specifically, RN #100 was terminated for failure to administer CPR or activate EMS when Resident #70 was found without vital signs. Interview with the Physician #97 on [DATE] at 10:37 A.M. revealed Resident #70 had been hospitalized prior to admission to the nursing facility for cardiac issues and the resident had been advised he was no longer a candidate for any more cardiac treatment. Physician #97 stated Resident #70 died from an acute [MEDICAL CONDITION] Infarction (MI). RN #104 called and informed the physician on [DATE] of the resident having chest discomfort and he offered to have the resident transported to the hospital at that time, but the resident refused. Interview with Physician #97 revealed he felt Resident #70 was having cardiac symptoms at that time. The physician indicated he received a call from LPN #99 on [DATE] and was told Resident #70 had no vital signs and he was a do not resuscitate, however we (indicting the physician and the facility) found out later RN #100 made a clerical error. Interview with LPN #98 on [DATE] at 7:50 A.M. revealed she was halfway down the hall when RN #100 was waving and yelled for help. LPN #98 went into Resident #70's room and RN #100 left the room. LPN #98 revealed she could see the resident had expired and she yelled out to RN #100 asking for the code status. RN #100 yelled back a DNRCC. Later, RN #100 looked in the computer and found out Resident #70 was a full code. Interview with STNA #99 on [DATE] at 8:00 A.M. revealed she was serving breakfast trays when Resident #70 had turned on his call light. When she answered the call light, Resident #70 was having some difficulty breathing, but was talking and asked to use the bathroom. STNA #99 asked if he would rather use the urinal instead of going to the bathroom since he was short of breath and he agreed. STNA #99 revealed she stood Resident #70 up to use the urinal and when he sat back down his breathing got worse, his skin was clammy and he was shaking. STNA #99 yelled out for the nurse and Resident #70 was breathing heavier. STNA #99 yelled for the nurse again and RN #100 came. Then Resident #70's eyes rolled back in his head and closed. RN #100 yelled out for another nurse (LPN #98), RN #100 went to check the code status and then said Resident #70 was a DNRCC. Review of the facility policy and procedure and interview with the Director of Nursing (DON) on [DATE] at 8:24 A.M. revealed the facility had no policy in place specifically for a full code status or cardiopulmonary resuscitation. The DON also verified that Resident #70 was admitted on [DATE] and had a full code status in place, on [DATE] Resident #70 had a [MEDICAL CONDITION], CPR was not initiated, EMS (emergency medical service) was not activated and Resident #70 died . This deficiency substantiates allegations contained in complaint #OH 690.