Every finding on record at Roseview Nursing and Rehabilitation Center

Based on record reviews and interviews the facility failed to notify 1 (#1) of 3 sample resident's RP (responsible party) of a change in a resident condition. The facility failed to notify resident #1's RP of new orders for medications including an antipsychotic was initiated without their knowledge.Findings:Review of resident #1's physician orders revealed the following:Divalproex sodium (Depakote) 250 mg (milligram) by mouth twice daily, start date 05/12/2026.Risperidone (Risperdal) 0.5 mg by mouth twice a day, start dated 05/19/2026.Review of the facility's Resident and Family Notification Guidelines (CMCO 01-26) revealed in part the notification of a resident and the resident representative of changes in the resident's condition is the primary responsibility of the nurse assigned to the resident. Any order change, addition or discontinuance (i.e. antibiotic started, dosage changes to medications, ankle bracelet applied, etc.).During an interview on 06/09/2026 at 2:00 p.m. S2 Charge Nurse reported she was the nurse that took the order for the Depakote. S2 Charge Nurse reported she did not notify resident #1's RP and she should have.During an interview on 06/09/2026 at 3:00 p.m. S1 DON reported the RP was not notified when the new orders for Depakote and Risperdal was prescribed. S1 DON reported the RP should have been notified.

Based on record reviews and interviews, the facility failed to monitor 1(#1) of 3 sample residents for possible adverse consequences reviewed for unnecessary medications. The facility failed to provide monitoring for behaviors and possible adverse consequences or side effects related to the use of the antipsychotic medications Seroquel and Risperdal for resident #1.Findings:Review of resident #1's medical records revealed diagnoses that include dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance, delusional disorders, psychotic disturbance, mood disturbance and agitationReview of resident #1's current Physician orders revealed the following orders:05/19/2026 Risperidone oral tablet 0.5 mg (milligram). Give one tablet by mouth two times a day related to dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance.04/14/2026 Seroquel oral tablet 12.5 mg. Give one tablet by mouth two times a day related to delusional disorders.Review of resident #1's most recent completed Quarterly MDS (minimum data set) dated 05/01/2026 revealed Section N-medications, high risk drug class's antipsychotics.Review of resident #1's Comprehensive Plan of Care revealed the following problems with some of the interventions: The resident uses psychotropic medications related to receiving anti-psychotic medications related to dementia. Some of the interventions are to monitor for side effects and effectiveness every shift. Behavioral monitoring every shift, document. Monitor/document/report as needed any adverse reactions of psychotropic medications. Monitor/record occurrence for target behavior symptoms and document per facility protocol.During an interview on 06/09/2026 at 2:00 p.m. S2 Charge Nurse reported the nurses should have documented the behaviors and possible side effects related to the use of the antipsychotic medications and they did not.During an interview on 06/09/2026 at 2:45 p.m. S3 Corporate Nurse reported reviewed resident #1's records and there was no documentation of monitoring behaviors or side effects related to the use of the antipsychotics.

Based on record reviews and interviews, the facility failed to provide adequate supervision to prevent accidents and ensure the residents' environment remained free of hazards for 1 (#1) of 4 sampled residents reviewed for facility transportation. The facility failed to:1. Ensure Resident #1 was properly secured with shoulder and lap belt in the facility van,2. Ensure Resident #1 was assessed following a fall on the van, and3. Ensure Resident #1's fall was promptly reported and documented.Findings:Review of Facility's Policy and Procedures, in part revealed:Accident/Incident Reports (undated): Policy: When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. An accident/incident report and the appropriate documentation will be completed by the end of the shift. Questions about what constitutes an accident/incident should be immediately directed to the DON or the shift supervisor. Purpose: To assure appropriate follow-through on all accidents/incidents. To study the cause of accidents and incidents and to give guidance for corrective/preventative action. Procedure: 1. Do not move the resident until a licensed nurse evaluates the resident's condition. 2. Notify the nurse in charge. 3. Licensed Nurse - Administer any necessary first aid .Complete a thorough head to toe assessment of the resident for possible injury, including range of motion. 7. Notify the resident's physician - receive orders for follow-through. 9. Complete an accident/incident report. 10. Note the location and the time of the incident, the names of the witnesses, and the exact circumstances of the incident. 11. Obtain a descriptive statement of incident from the resident involved.Falls (undated): Procedure: 1. Resident will not be moved until a licensed nurse evaluates and has ascertained resident's condition. 2. Notify the nurse in charge. 5. Notify physician for further orders. Follow nursing interventions if required. 8. Fill out incident/accident form.Review of Resident #1's medical records an revealed an admit date of 09/13/2019 with the following diagnoses including in part: type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified glaucoma, acquired absence of left leg below the knee, acquired absence of right leg below the knee and muscle wasting and atrophy not elsewhere classified.Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 15 indicating cognitively intact. Further review revealed impairment on both sides of lower extremities and device used is a wheelchair, Review of Resident #1's comprehensive care plan revealed high risk for falls related to bilateral amputee and wheelchair bound.Review of facility's incident log for the past 4 months failed to reveal an incident dated 01/08/2026 for Resident #1.Review of Resident #1's S7NP notes dated 01/23/2026 revealed in part: .He reports during transport he was not buckled properly and driver had to hit the brakes, and he came out of his secured seat .S7NP discussed transportation incident with S2DON who S4Complainant reported they were aware of the incident, as well as administration . NP was not made aware .During a telephone interview on 02/23/2026 at 11:25 a.m. S4Complainant reported on 01/08/2026 as she rode in the facility transport van with Resident #1, S3CNA/Van Driver was speeding and slammed on the brakes causing Resident #1 to fly out of his wheelchair. S4Complainant further reported Resident #1 was initially facing forward in his wheelchair and once he flew out he was on the floor facing the back of the van. S4Complainant reported S3CNA/Van Driver pulled over, they opened the back of the van, used the ramp to get Resident #1 back in his wheelchair which took about 30 minutes and then took him to the doctor's appointment. S4Complainant further reported the chest strap was not in place placed during Resident #1's transport. S4Complainant reported upon arrival back to the facility S3CNA/Van Driver told S1Administrator and S2DON what happened. S4Complainant reported once Resident #1 returned to the facility he was not assessed and had bruises on his nubs.During an interview on 02/23/2026 at 12:45 p.m. S8LPN reported she was not informed Resident #1 had fallen on the van and therefore, an assessment was not completed.During an interview on 02/23/2026 at 1:50 p.m. S5CNA reported on 01/08/2026 she accompanied Resident #1 when he fell on the van. S5CNA further reported after Resident #1's wheelchair was secured, she turned around and noticed his chest strap wasn't on and then S3CNA/Van Driver slammed on the brakes and Resident #1 came out of his wheelchair and fell on the floor. S5CNA reported S3CNA/Van Driver pulled the van over and got him back in his wheelchair. S5CNA further reported the incident should have been reported and S3CNA/Van Driver said she was going to report the incident.During an interview on 02/23/2026 at 3:00 p.m. S3CNA/Van Driver reported on 01/08/2026 Resident #1 fell while being transported to an appointment. Resident #1's wheelchair was buckled down on the bottom in the front and back but the chest strap was not placed across him. S3CNA/Van Driver further reported they were coming to a light, she put on the brakes and the next thing she knew Resident #1 was on the floor sitting on his butt. S3CNA/Van Driver reported it is the van driver's responsibility to strap the resident in and the CNA goes behind and checks. S3CNA/Van Driver reported after Resident #1 fell she pulled over and they put him back in his wheelchair. S3CNA/Van Driver reported once they returned to the facility S2DON and S1Administrator were notified. S3CNA/Van Driver acknowledged she did not call the fall in to the facility when it happened and should have.During an interview on 02/24/2026 at 8:20 a.m. S6Corporate Nurse reported S3CNA/Van Driver should have pulled over, called the facility so the nurse could go and assess Resident #1 before moving him and proceeding to the appointment. S6Corporate Nurse confirmed the facility should have documented the incident.During an interview on 02/24/2026 at 8:35 a.m. S2DON reported on 01/08/2026 S3CNA/Van Driver returned from dropping off Resident #1 for an appointment and reported there was an incident on the van. S2DON further reported S3CNA/Van Driver indicated Resident #1 was taken to his appointment. S2 DON further reported S3CNA/Van Driver told her she was stopping at a red light and Resident #1 slid out of the wheelchair. S2DON indicated S3CNA/Van Driver reported the chest strap and a lap safety belt that hook into each other was not on Resident #1 when he fell out of the wheelchair. S2DON further reported S3CNA/Van Driver should have pulled over, called the facility so Resident #1 could be assessed for injuries before moving him. S2DON acknowledged an incident report should have written and was not. S2DON further acknowledged Resident #1's nurse was not notified the day of the incident and should have been.During an interview on 02/24/2026 at 12:30 p.m. S2 DON reported the van driver was responsible for securing a resident and resident's wheelchair in the van for transport.During an interview on 02/24/2026 at 1:30 p.m. Resident #1 reported on 01/08/2026 he was being transported to the eye doctor by S3CNA/Van Driver and S5CNA and S4Complainant were also on the van. Resident #1 further reported the back and front straps were placed on the wheelchair but when they started to put on the chest strap across his chest it didn't work. Resident #1 reported they didn't tell anyone the strap was not working and left to go to doctor's office anyway with no chest strap in place. S3CNA/Van Driver was driving and stepped hard on the brakes causing Resident #1 to fall forward and onto the floor. S3CNA/Van Driver pulled over and S3CNA/Van Driver, S5CNA and S4Complainant tried to help him up but he was too heavy so they took his wheelchair out of the van and lined it up on the ramp so he could scoot into wheelchair. Resident #1 reported once settled in his wheelchair S5CNA and S4Complainant realized the chest strap didn't work because it was not snapped in and attached. Resident #1 further reported they proceeded to the appointment without the strap across his chest or lap. Resident #1 reported once he returned to the facility no one came to check on him and ask if he was okay.During an interview on 02/24/2026 at 3:05 p.m. S1Administrator reported S3CNA/Van Driver reported on 01/08/2026 Resident #1 slid out of his wheelchair on the van and he crawled back into his wheelchair. S1Administrator further reported he looked at the van and was informed the staff did not use the strap across the chest and should have. S1Administrator acknowledged an incident report should have be written.

Based on record review and interviews, the facility failed to ensure the daily van safety checklist was accurately documented for 1 (#1) of 3 (#1, #2, #3) residents reviewed for transport. Findings:Review of facility's daily van safety checklist revealed, in part: Must be used for every transport - whether leaving the facility or returning to facility. Was shoulder and lap seat belt secured correctly on the resident? Were seatbelts and wheelchair straps re-checked after initial strapping? Report any unsafe condition to the Administrator (i.e. equipment failure, van maintenance issue, etc.) If No, corrective action.Review of facility's daily van checklist dated 01/08/2026 revealed S3CNA/Van Driver transported Resident #1 and all questions answered yes (Was shoulder and lap seat belt secured correctly on the resident?), Unsafe conditions NA.During an interview on 02/24/2026 at 3:05 p.m. S1Administrator reported staff on the van did not use the strap across the chest of Resident #1 during transport on 01/08/2026 and should have. While reviewing the daily van safety checklist, S1Administrator confirmed S3CNA/Van Driver's documentation was inaccurate. Further review revealed the shoulder and lap belt was documented as secured and was not contributing to the incident on 01/08/2026.During an interview on 02/24/2026 at 3:25 p.m. S3CNA/Van Driver reported the daily van safety checklist dated 01/08/2026 should have been checked no for the question: was shoulder and lap seat belt secured correctly on resident? at the time of Resident #1's transport in the van.

Based on record reviews, observations and interviews, the facility failed to provide services that met professional standards for 2 (#12 and #20) of 9 residents reviewed for accident hazards and supervision. The facility failed to ensure there were no medications at the bedside.Findings:Review of the facility's undated self-administration of medication policy revealed in part:Policy:It is the policy of this facility that each resident has the right to self-administer medications, but is the responsibility of the interdisciplinary team to determine that it is safe prior to the resident exercising that right.Procedure:2. If the resident wishes to self-administer medications, the Interdisciplinary Team must assess the resident's overall ability to safely administer his/her own medications. Resident #12Review of Resident #12's medical record revealed an admission date of 12/03/2020 with diagnoses that included allergic rhinitis and chronic systolic (congestive) heart failure. Further review revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating no cognitive impairment. Review of Resident #12's physician's orders on 01/05/2025 revealed an order dated 09/02/2025 for fluticasone propionate nasal suspension 50 MCG(micrograms)/ACT(activated); 1 spray in each nostril two times a day related to allergic rhinitis. Further review failed to reveal an order for self-administration of medication. Review of Resident #12's medical record on 01/05/2026 failed to reveal an assessment for self-administration of medication. An observation on 01/05/2026 at 8:45 a.m. revealed a nasal spray medication labeled fluticasone on Resident #12's bedside table.An observation on 01/05/2026 at 2:50 p.m., with S4 ADON (Assistant Director of Nursing) revealed a nasal spray medication labeled fluticasone was on Resident #12's bedside table.During an interview on 01/05/2026 at 2:50 p.m., S4 ADON confirmed Resident #12 did not have an order for self-administration of medication for fluticasone and/or an assessment for self-administration of medication, therefore medication should not have been left at the bedside.Resident #20Review of Resident #20's medical record revealed an admission date of 03/12/2019 with diagnoses which included hypertensive urgency, psychotic disorder with delusions due to known physiological condition, and constipation. Further review revealed a BIMS (Brief Interview of Mental Status) 14, indicating no cognitive impairment.Review of Resident #20's physician's orders on 01/05/2025 failed to reveal an order for docusate sodium.Review of Resident #20's medical record on 01/05/2026 failed to reveal an assessment for self-administration of medication. An observation on 01/05/2026 at 7:45 am revealed a bottle of medication labeled docusate sodium on Resident #20's bedside table.An observation on 01/05/2026 at 2:45 p.m. revealed a bottle of medication labeled docusate sodium on Resident #20's bedside table.An observation on 01/05/2026 at 2:46 p.m. with S4 ADON revealed a bottle of medication labeled docusate sodium was on Resident #20's bedside table. During an interview on 01/05/2026 at 2:46 p.m., S4 ADON confirmed Resident #20 did not have an order for docusate sodium, an order for self-administration of medication and/or an assessment for self-administration of medication, therefore medication should not have been at the bedside.

Based on record review, observations and interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#7 and #9) out of 3 residents reviewed for respiratory services. The facility failed to ensure proper storage of respiratory equipment. Findings:Review of the facility's undated oxygen administration (concentrator or tank) policy revealed in part:Policy:Humidifier bottles, cannulas and oxygen tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. When not in use, cannula or mask should be placed in a plastic bag.Resident #7Review of Resident #7's face sheet revealed an admit date of 12/13/2025 with the following diagnoses, but not limited to heart failure, paroxysmal atrial fibrillation, shortness of breath, and COPD (chronic obstructive pulmonary disease) with (acute) exacerbation.Review of Resident #7's January 2026 physician orders revealed an order dated 10/31/2025 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligram)/3ML(milliliter); 1 vial inhale orally every 8 hours as needed for SOB (shortness of breath) related to COPD with (acute) exacerbation per handheld nebulizer. Review of Resident #7's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 9 indicating moderately impaired cognition. Observation on 01/05/2026 at 8:37 a.m. revealed Resident #7's nebulizer was on top of personal fridge with mask and tubing not in a plastic bag. Observation on 01/05/2026 at 10:37 a.m. revealed Resident #7's nebulizer was on top of personal fridge with mask and tubing not in a plastic bag. Observation on 01/06/2026 at 12:35 p.m. with S4 ADON (Assistant Director of Nursing) revealed Resident #7's nebulizer was on top of personal fridge with mask and tubing not in a plastic bag.During an interview on 01/06/2025 at 12:35 p.m. S4 ADON confirmed Resident #7's nebulizer mask and tubing was not stored properly. S4 ADON reported Resident #7's nebulizer mask and tubing should be stored and labeled in a plastic bag when not in use. Resident #9Review of Resident #9's medical record revealed an admission date of 10/30/2025 with the following diagnoses which included obstructive sleep apnea (adult) and chronic diastolic (congestive) heart failure.Observation on 01/05/2026 at 10:03 a.m. revealed a bi-pap (bi-level positive airway pressure) machine on Resident #9's bedside table and bi-pap face mask was not in a plastic bag and undated.Observation on 01/06/2026 at 2:15 p.m. revealed a bi-pap machine on Resident #9's bedside table and the face mask was not in a plastic bag and undated.Review of Resident #9's January 2026 physician orders revealed an order dated 11/12/2025 to apply bipap machine; at bedtime related to obstructive sleep apnea (adult) and remove per schedule.During an interview on 01/06/2026 at 2:15 p.m., S6 LPN (Licensed Practical Nurse) confirmed Resident #9's bi-pap mask was not in a plastic bag and undated on Resident #9's bedside table.During an interview on 01/06/2026 at 2:25 p.m., S1 DON (Director of Nursing) confirmed Resident #9's bi-pap mask was not in a plastic bag and dated.

Based on record review and interview, the facility failed to ensure 4 (#1, #2, #3, and #4) of 4 glucometers used in the facility were maintained in safe operating condition for residents with orders for blood glucose monitoring. S1 DON (Director of Nursing) reported the facility had 29 residents in the facility who required blood glucose monitoring with the facility's glucometer. Findings: Review of the facility's undated Glucometer Information Sheet revealed:The EvenCare 2 Glucometer is the glucometer that is in use at this facility.2. Control testing of this glucometer is to be completed at least daily. Usually the facility night shift completes this task using the EvenCare 2 Glucometer Control Testing Instructions and documenting those results accordingly on the approved control testing log.Any control reading that is out of range and the nurse is not able to figure out the cause immediately (battery needs to be changed in glucometer, the control solution is out of date, etc.) will not be used to test a resident's blood sugar until the glucometer is repaired or repeat control tests are within normal limits. Review of December 2025 Glucometer Quality Control Log revealed the following, in part:Glucometer #1 -12/03/2025 - High control reading was written over and appeared to be 232 and marked as within range. Acceptable range for high control solution was 170 to 230. No comments were documented.12/07/2025 - High control reading was 163 and marked as within range. Acceptable range for high control solution was 170 to 230. No comments were documented.Glucometer #2 - 12/16/2025 - Low control reading was 74 and marked as within range. Acceptable range for low control solution was 41 to 71. No comments were documented.12/25/2025 - Low control reading was 78 and marked as within range. Acceptable range for low control solution was 41-71. No comments were documented.Glucometer #3 - 12/17/2025 - High control reading was 147 and marked as within range. Acceptable range for high control solution was 168 to 228. No comments were documented.12/17/2025 - Low control reading was 32 and marked as within range. Acceptable range for low control solution was 40 to 70. No comments were documented.12/24/2025 - High control reading was 163 and marked as within range. Acceptable range for high control solution was 168 to 228. No comments were documented. Glucometer #4 -12/10/2025 - Low control reading was 71 and marked as within range. Acceptable range for low control solution was 40 to 70. No comments were documented. Review of November 2025 Glucometer Quality Control Log revealed, in part:Glucometer #1 -Documented high and low checks were recorded for 30 days. The log failed to reveal lot numbers, expiration dates and the acceptable ranges for the low and high control solutions. No comments were documented.Glucometer #2 - 11/02/2025 - High control reading was 154 and marked as within range. Acceptable range for high control solution was 159 to 215. No comments were documented.11/04/2025 - Low control reading was 68 and marked as within range. Acceptable range for low control solution was 37 to 67. No comments were documented.11/23/2025 - High control reading was 1 and marked as within range. Acceptable range for high control solution was 159 to 215. No comments were documented.Glucometer #3 -11/02/2025 - High control reading was 163 and marked as within range. Acceptable range for high control solution was 167 to 225. No comments were documented.11/06/2025 - High control reading was 298 and marked as within range. Acceptable range for high control solution was 167 to 255. No comments were documented.11/10/2025 - High control reading was 165 and marked as within range. Acceptable range for high control solution was 167 to 225. No comments were documented.11/27/2025 - High control reading was 164 and marked as within range. Acceptable range for high control solution was 167 to 225. No comments were documented. Glucometer #4 -11/13/2025 - High control reading was 220. No indication of whether this reading was within range. Acceptable range for high control solution was 157 to 215. No comments were documented.11/17/2025 - High control reading was 220. No indication of whether this reading was within range. Acceptable range for high control solution was 157 to 215. No comments were documented. During an interview on 11/07/2026 at 11:35 a.m. S1 DON reviewed the November 2025 and December 2025 Glucometer Quality Control Logs for Glucometers #1, #2, #3, and #4 and confirmed there were illegible control values which could have been out of range and out of range control values without any comments to indicate how the out of range result was handled. S1 DON further reported the November 2025 Glucometer Control Log for glucometer #1 had no documented high or low control solution lot numbers, expiration dates, or acceptable ranges documented to verify the high and low controls done. S1 DON further reported all control values should have been legible, if controls were out of range the comments should have included what the staff member did to check controls to verify in range.

Based on record reviews, an observation and interview the facility failed to ensure 1 (#7) of 1 resident reviewed for food received a mechanically soft diet as ordered by physician. Review of facility Menu Matrix revealed mechanically soft diet was described as mostly for dysphagia; ground meats with soft foodsReview of Resident #7's face sheet revealed an admission date of 12/13/2025 with a diagnosis of dysphagia (oropharyngeal phase). Review of Resident #7's January 2026 physician orders revealed an order dated 09/13/2025 for a regular NSOT (no salt on tray) diet, mechanical soft texture, regular/thin consistency. Review of Resident #7's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 9 indicating moderately impaired cognition. Review of Resident #7's swallowing/nutritional status revealed Resident #7 held food in mouth/cheeks or had residual food in mouth after meals, coughed or choked during meals or when swallowing medications, and had complaints of difficulty or pain when swallowing. Further review of Resident #7's Quarterly MDS revealed Resident #7 was ordered a mechanically altered diet which required change in texture of food or liquids. Review of Resident #7's care plan revealed Resident #7 had potential for oral pain, oral irritation, and difficulty chewing related to use of dentures. Resident #7 has top dentures with interventions for NSOT mechanical soft diet.Observation on 01/06/2026 at 12:35 p.m. with S4 ADON (Assistant Director of Nursing) revealed Resident #7 was served chicken and sausage gumbo with rice, lettuce and tomato salad, garlic bread with peach cobbler for dessert. During an interview on 01/06/2026 at 12:35 p.m. S1 DON (Director of Nursing) reviewed Resident #7's lunch meal ticket for a mechanical soft diet and confirmed Resident #7 should have been served a mechanical soft diet. During an interview on 01/07/2026 at 9:30 a.m. S7 SLP (Speech Language Pathologist) reported Resident #7 had a diagnosis of dysphagia, with swallowing and chewing issues. S7 SLP reported Resident #7 should be on mechanical soft diet with grounded meats. During an interview on 01/07/2026 at 9:45 a.m. S8 Dietary Manager confirmed Resident #7's diet was mechanical soft with grounded meats and Resident #7's chicken and sausage was not prepared correctly; chicken and sausage was chopped and should have been grounded.

Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 1 of 2 residents reviewed for hospitalization. The facility failed to notify the Office of the State Ombudsman of the emergency transfer and provide the resident and their RP (responsible party) written notice which specified the duration of the bed-hold policy at the time of transfer to the hospital for Resident #23. Findings:Review of the facility's Emergency Transfer Log for October 2025 fail to reveal Resident #23 was entered on the log notifying the State's Long-Term Care Ombudsman of the emergency discharge to the hospital 10/21/2025. Further review failed to reveal Resident #23 and their RP was given written notice which specified the duration of the bed-hold policy at the time of transfer to the hospital.The facility's Emergency Transfer Log read in part, the document will be emailed to the Office of the State Ombudsman by the 15th of each month that include the location of transfer, written notification date to resident, transfer date, date return to facility and reason for transfer. Review of Resident #23's records failed to reveal documentation the facility had provided a bed hold policy to the resident or their RP at the time of the discharge to the hospital.During an interview on 01/06/2026 at 4:45 p.m. S5 Corporate Nurse reported the Office of State Ombudsman was not notified of Resident #23's emergency transfer. S5 Corporate Nurse further reported a bed hold policy was not completed. S5 Corporate Nurse reported the State Ombudsman should have been notified and a bed hold policy should have been completed by Social Service and they were not.

Based on observations, interview and record review the facility failed to follow recognized infection control practices to prevent the development and transmission of infection for 1(#23) out of 2 (#23, #76) residents observed with an indwelling Foley catheter. The facility failed to ensure the Foley catheter collection bag did not touch the floor (#23). Findings: Observation on 01/05/2026 at 09:30 a.m. revealed Resident #23's Foley catheter collection bag hanging from the frame of the bed laying on the floor. Further observation revealed a puddle of malodorous urine on the floor along the foot of the bed. During an interview on 01/05/2026 at 09:30 a.m. S3 Restorative Aid reported after observing Resident #23's Foley catheter bag on the floor, it should not have been on the floor. During an interview on 01/05/2026 at 09:40 a.m. S2 LPN (Licensed Practical Nurse) reported Resident #23's Foley catheter bag should not have been on the floor.Review of the facility's Catheter Management Policy (undated) revealed in part: Policy: Catheter Management is the routine care administered when an indwelling urinary catheter is in place. This routine care protects the resident from infection, injury, and promotes comfort. The procedures included in this policy the following: cleaning the genitalia and insertion site of the catheter (urethral or suprapubic). Catheter irrigation to ensure patency, and care of the closed drainage system. Procedure: Maintain closed drainage system: Watch for kinking in the tubing that can interfere with patency and free flow of urine. Never allow the bag or tubing to touch the floor.Review of Resident #23 records revealed diagnoses that include neurogenic bladder, urinary tract infection, and cognitive communication deficit. Review of Resident #23's current Physician Orders revealed an order date 12/31/2025 Macrobid Oral Capsule 100 milligrams (Nitrofurantoin) Give 1 capsule by mouth at bedtime related to urinary tract infection, site not specified, indefinitely. Review of Resident #23's Comprehensive Plan of Care revealed a focus that the resident had a Foley catheter for neurogenic bladder. Goals for the resident was to remain free from catheter-related trauma through review date. Interventions included catheter care as ordered, monitor urine for color and condition and document. Change catheter as ordered per medical doctor. Ensure drainage tubing is kink free. Monitor and document output as per facility policy.

Based on record review and interview the facility failed to inform the resident's responsible party/representative (RP) of a resident's change in condition for 1 (#35) of 2 residents (#10, #35) reviewed for falls. The facility failed to ensure the RP was notified of a resident's fall (#35). Findings: Review of the facility's Resident and Family Notification Guidelines (undated policy) presented by the facility revealed in part: Notification of resident and the resident representative of changes in the resident's condition is the primary responsibility of the nurse assigned to the resident. List below are scenarios of when such notification is to occur and be documented as occurring in the nurse's notes. Your documentation should include the name of the resident representative that you spoke with not just the relationship. Any accident, injury, or if an incident report is completed. Review of the facility's Incident Report for Resident #35 revealed Resident #35 had an unwitnessed fall on 12/01/2025 in the resident's room. Resident #35 was found on the floor by a CNA (Certified Nursing Assistant) between the bed and the air condition unit to the left side of the bed. Resident #35 reported, The sheet was wet, and I was trying to move it. No injuries noted, resident was alert and oriented, hospice notified. Further review of the report and Resident #35's nurse's notes failed to reveal notification of the RP. During an interview on 01/05/2026 at 9:30 a.m. Resident 35's RP complained the facility never notified her of the falls Resident #35 had. Resident #35's RP reported the facility reported they did not have to notify the RP they only had to notify hospice. Review of Resident #35's record revealed the RP as a (Friend) and contact type, Family Representative - Financial #1 POA (Power of Attorney). During an interview on 01/07/2025 at 10:30 a.m. S1 DON (Director of Nursing) reported if a resident has hospice, hospice will notify the RP if a resident had a fall or any changes in their condition. S1 DON confirmed hospice did not notify Resident #35's RP of the falls. S1 DON reported and agreed notifying Resident #35's RP of a change in condition is ultimately the facility responsibility and not hospice.

Based on record reviews and interview the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 3 (#30, #45, and #76) of 32 residents reviewed for Advance Directives. Findings:Review of Resident #30's medical record revealed an admit date of 05/22/2024. Further review of Resident #30's medical record revealed an incomplete Advanced Directives Checklist signed and dated 05/22/2024 failed to indicate whether Resident #30 or Resident #30's responsible parties were given information on formulating an advanced directive. Review of Resident #45's medical record revealed an admit date of 05/02/2024. Further review of Resident #45's medical record revealed an incomplete Advanced Directives Checklist signed and dated 05/02/2024 failed to indicate whether Resident #45 or Resident #45's responsible parties were given information on formulating an advanced directive. Review of Resident #76's medical record revealed an admit date of 12/16/2025. Further review of Resident #76's medical record revealed an incomplete Advanced Directives Checklist signed and dated 06/27/2024 failed to indicate whether Resident #76 or Resident #76's responsible parties were given information on formulating an advanced directive. During an interview on 01/06/2026 at 11:15 a.m. S5 Corporate Nurse reviewed Resident #30, Resident #45 and Resident #76's Advanced Directive Checklist and confirmed the form was incomplete and did not indicate whether information on formulating an advance directive was provided .

Based on observations, record review and interviews, the facility failed to ensure a resident was free from neglect during ADL (activities of daily living) care. The facility failed to ensure S4 CNA (Certified Nursing Assistant) asked for assistance for a two person assist before providing incontinence care which resulted in a fall with injuries for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for neglect.The deficient practice resulted in an immediate jeopardy for Resident #1 on 07/25/2025 at approximately 10:30 a.m. when Resident #1 fell out of the right side of the bed during incontinent care when S4 CNA (Certified Nursing Assistant) failed to ensure a two person assist was used during incontinent care to prevent Resident #1 from falling out of the bed. S4 CNA did not ask for assistance before providing ADL care and Resident #1 fell from the bed resulting in multiple injuries. Resident #1 was sent to a local hospital on [DATE] at 10:47 a.m. via stretcher and was admitted due to his injuries. Review of the hospital records dated 07/25/2025 revealed Resident #1 was diagnosed to have a questionable non-displaced fracture to the right maxillary wall, non-displaced right posterior 12th rib fracture, and a remote T(thoracic)5 vertebral body compression fracture.The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation.Findings:Abuse and Neglect Policy with a revision date of 04/02/2025.Purpose: The purpose of the Abuse/Neglect policy is to comply with the seven - step approach to abuse and neglect detection and prevention:1). Screening 2.) Training 3.) Prevention 4.) Identification 5). Investigation 6.) Protection 7.) Reporting and ResponsePolicy: It is the policy of the facility that each resident will be free from abuse. This facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including .Each resident has the right to be free from mistreatment, neglect, and misappropriation of property.Definition: Abuse and neglect exist in many forms and to varying degrees. G. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.I. Serious Bodily Injury: The term serious bodily injury is defined as any injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. Review of Resident #1's medical record revealed an initial admission date of 03/27/2024 with diagnoses, which included in part, ataxia following other non-traumatic intracranial hemorrhage, essential tremor, muscle wasting and atrophy of left lower leg and right lower leg, weakness, contracture of muscle, multiple sites and aphasia. Review of Resident #1's Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated BIMS (Brief Interview of Mental Status) could not be completed due to resident was rarely/never understood. Further review of the Quarterly MDS assessment revealed Resident #1 had upper and lower extremity impairments to both sides, dependent with eating, oral hygiene, toileting hygiene, and shower/bathe self. Resident #1 was dependent for mobility in rolling left and right. Resident #1 was always incontinent of bowel and bladder and dependent on staff for ADL care. Further review revealed Resident #1 did not return to the facility after his hospitalization on 07/25/2025. Review of Resident #1's comprehensive care plan revealed in part, Resident #1 was at high risk for fall related to neurocognitive disorder and required total care with bedbound status. Further review of the comprehensive care plan revealed Resident #1 had an ADL deficit and required two person assist with all ADLs and transfers.Review of the facility's Incident Log for the past 3 months revealed Resident #1 had a witnessed fall on 07/25/2025.Review of S4 CNAs signed witness statement (undated) revealed: I went to Resident #1's room to check and see was he wet. He was soaked in pee and bowel movement. I looked on the hall to see if there were available aides. I didn't see any so I decided to change Resident #1. His bed was soaked with urine so I had to change, I grabbed my linen to put on his bed. I turned him and put the linen on the bed. I grabbed my pamper and pad. Resident #1 moved a little and hit the floor. I didn't have any time to catch him.Review of Resident #1's nurse's notes dated 07/25/2025 at 11:44 a.m. revealed S3 LPN (Licensed Practical Nurse) was called to Resident #1's room. Upon entering the room, Resident #1 was lying flat and face first on the floor to the right side of the bed between the air unit and bed. S3 LPN was informed by S4 CNA that while she was performing incontinent care and went to turn Resident #1, Resident #1 rolled off the bed to the floor. Redness was noted to the left cheek, left side of forehead, right cheek, right upper back, both knees, right lower leg and back of head. The ambulance was notified and Resident #1 was transferred out of the facility via stretcher to a local emergency room.Review of Resident #1's hospital record dated 07/25/2025 revealed in part, a chief complaint of Resident #1 fell out of the bed while rolled by staff. Bruising noted to left cheek and upper back. Further review revealed Resident #1 had bruising to the left side of his face, backside of his neck, right side of his shoulder, and both knees. Review of Resident #1's CT (Computed Tomography) scans revealed: questionable non-displaced fracture to the right maxillary wall, non-displaced right posterior 12th rib fracture, and a remote T5 vertebral body compression fracture. During an interview on 08/11/2025 at 8:30 a.m. S1 Corporate Nurse reported Resident #1 was sent to the hospital with major injuries due to the fall incident on 07/25/2025. S1 Corporate Nurse further confirmed Resident #1 was a two person assist and S4 CNA did not call for assistance and performed care without having another person assist her resulting in Resident #1's fall from the bed.Observations made on 08/11/2025 throughout the facility revealed resident rooms were checked for resident wall care plans and all had resident specific wall care plans located on the wall above the resident's bed, on bright orange paper and in bold letters if the resident was a one or two person assist. An observation on 08/12/2025 at 9:15 a.m. revealed S10 CNA and S12 CNA reviewed Resident #3's wall care plan and acknowledged Resident #3 was two person assist with transfers. Resident #3's wall care plan was located on the wall, above Resident #3's bed, on an orange sheet of paper with bold letters. Resident #3 was transferred from her bed to a Geri-Chair via Hoyer lift using two person assist without difficulty. Resident #3 was non-verbal but awake and looking around the room. Resident #3 was in no apparent distress during the transfer. Resident #3 was transferred safely from the bed to the Geri-chair, with 2 person assist as instructed on the wall care plan.Attempted phone calls made to S4 CNA on 08/12/2025 at 10:53 a.m., 12:26 p.m., and 2:21 p.m. were unsuccessful. During an interview on 08/12/2025 at 11:15 a.m. S3 LPN reported seeing Resident #1 face down on the floor between the air unit and the bed. S3 LPN reported Resident #1 was a two person assist with everything; he could not move his legs or his trunk. S3 LPN reported Resident #1 had tremors and could not move his arms good. S3 LPN further confirmed Resident #1's wall care plan was located on the wall above the bed stating Resident #1 required two person assist. During an interview on 08/12/2025 at 11:18 a.m. S2 DON (Director of Nursing) confirmed there was a sign above Resident #1's bed notifying staff Resident #1 was a two person assist with all ADLs. S2 DON confirmed S4 CNA did not follow the wall care plan which resulted in Resident #1's fall with injuries on 07/25/2025. Attempted phone call made to S4 CNA on 08/13/2025 at 10:48 a.m. and was unsuccessful.During an interview on 08/13/2025 at 1:20 p.m. S5 CNA Supervisor reported S4 CNA had experience working with Resident #1 and knew Resident #1 was a two person assist with all ADL care and should have asked for assistance before providing ADL care to Resident #1. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. During an interview on 08/13/2025 at 11:00 a.m., S1 Corporate Nurse confirmed the following corrective actions put into place were completed on 07/28/2025. The facility implemented the following actions to correct the deficient practice beginning on 07/25/2025 with a completion date of 07/28/2025:1. In-services were immediately started by S2 DON on 07/25/2025 on that afternoon and evening shift. S2 DON came back to the facility on the 10P-6A shift on 07/25/2025 and met with licensed and unlicensed staff to review care plans on the wall and following them with each resident encounter. 2. S4 CNA did not provide care to other residents at the facility after this event but was asked to remain at the facility to be interviewed by S2 DON and was present at the staff meeting that afternoon when topics relevant to this event were discussed at length. S4 CNA then left the facility following the meeting. S4 CNA was asked by S2 DON to return to the building on 07/26/2025 to talk with the S2 DON. At this point the facility knew the seriousness of the injuries sustained by Resident #1 and S4 CNA was officially suspended. S4 CNA had not provided care to other residents since 07/25/2025 at approximately 10:30 a.m. S4 CNA was officially terminated on 07/27/2025 for not following facility protocol with care. 3. In-services were done on following care plans on the wall began after the incident on 07/25/2025 and continued on 07/26/2025 and 07/27/2025 to licensed and unlicensed nursing staff by nursing administration.4. Staff education continued on 07/28/2025 on the following subjects: Following the care plans on the wall for resident care. Pre and post-tests to license and unlicensed nursing staff on assistance with bed mobility and following the plans on the wall was initiated on 07/28/2025. The administrator and assistant administrator also presented education to the licensed and unlicensed nursing staff beginning on 07/28/2025 regarding the seriousness of the care plans on the wall information and how not following that information could be grounds for termination. 5. Evaluation of all the facility care plans on the wall were completed by nursing administration on 07/26/202, 07/27/2025, and 07/28/2025, even though the care plan on the wall on Resident #1's room was accurate for residents at the facility. The wall care plan updating continues when changes occur to resident abilities and medical status.6. Monitoring of CNAs staff performing care to see if they are following the care plan on the wall instructions while performing resident care was implemented on 07/25/2025 by nursing administration. This monitoring will continue 2-3 times a week for the next 6 weeks then monthly thereafter until compliance is maintained. Nursing administration is actually going into resident's rooms during care to see if the care plan on the wall is being followed by the CNA's providing care. Corrective action and immediate education is provided by nursing administration if care is not being provided according to the care plan on the wall. 7. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the QAPI (Quality Assurance and Performance Improvement) Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implement as needed.Validation of Past Noncompliance:The facility corrective actions were confirmed through onsite interviews, observations and record reviews.Review of the facility's in-services dated 07/25/2025, 07/28/2025 and 07/29/2025 revealed the facility in-serviced licensed and unlicensed staff, including CNAs, on paying attention to the resident's wall care plan in the resident's room located on the wall above the bed. The facility enforced if the wall care plan stated the resident required two person assistance, to make sure two persons assisted. Review of the Bed Mobility/ADL Care Monitor sheets revealed monitoring was put in place on 07/25/2025 after the incident. Monitoring was done by S2 DON. Further review of the Bed Mobility/ADL Care Monitor sheets revealed they continued monitoring through 07/28/2025 and then the monitoring pages were updated on 07/29/2025 to include more detailed specific information to ensure residents which required two person assist were included and if care was completed without injury. Review of the facility's QAPI meetings dated 07/28/2025, 07/29/2025, 07/30/2025, 08/05/2025, and 08/07/2025 revealed facility ensured wall care plans were discussed, the wall care plans were posted, and the staff were following the wall care plans.Observations made on 08/11/2025 throughout the facility revealed resident rooms were checked for resident wall care plans and all had resident specific wall care plans located on the wall above the resident's bed, on bright orange paper and in bold letters if the resident was a one or two person assist. Review of trainings revealed, on 07/28/2025, the facility put in place a pre-post- and answer bed mobility test and following the plans on the wall. All CNAs have taken the test and passed.During an interview on 08/12/2025 at 9:00 a.m. S10 CNA Restorative Aide, reported she attended an in-services on resident wall care plans and was aware to first review the wall care plan before care was provided. S10 CNA Restorative Aide reported the wall care plan indicated if the resident was a one or two person assist with transfers, lifts, or ADL care. S10 CNA further reported if she had any questions about a resident, she would ask a nurse and all transfers were two person when a lift was used. An observation on 08/12/2025 at 9:15 a.m. revealed S10 CNA and S12 CNA reviewed Resident #3's wall care plan and acknowledged Resident #3 was two person assist with transfers. Resident #3's wall care plan was located on the wall, above Resident #3's bed, on an orange sheet of paper with bold letters. Resident #3 was transferred from her bed to a Geri-Chair via Hoyer lift using two person assist without difficulty. Resident #3 was non-verbal but awake and looking around the room. Resident #3 was in no apparent distress during the transfer. Resident #3 was transferred safely from the bed to the Geri-chair, with 2 person assist as instructed on the wall care plan.During an interview on 08/12/25 at 9:30 a.m. S13 CNA reported she attended an in-service regarding resident wall care plans above resident beds. S13 CNA reported she knew to review the wall care plans prior to resident care and to know if the resident is a one or two person assist. S13 CNA further reported if there were any questions, the nurse would clarify. S13 CNA knew to ask assistance when a two person assist was required for any type of care. During an interview on 08/12/2025 at 9:42 a.m. S11 CNA reported she attended an in-service on resident wall care plans. S11 CNA was knowledgeable in reviewing the wall care plans upon entering a resident's room. S11 CNA reported the wall care plans, above the resident's bed, indicate whether a resident required one or two person assist with care. S11 CNA further reported if she was not sure, she would ask the nurse.During an interview on 08/12/2025 at 2:05 p.m. S15 CNA reported she was trained on the resident wall care plans. S15 CNA further reported she attended an in-service on bed mobility and the number of persons required to assist residents with ADLs. S15 CNA reported each resident had a wall care plan on the wall above the bed and CNAs were to follow that wall care plan. S15 CNA further reported a CNA should always ask for assistance if a resident was a two person assist with ADLs. During an interview on 08/12/2025 at 5:00 p.m. S14 CNA reported she attended in-services on resident wall care plans and knew to look at the sign on the wall to see if the resident was a one or two person assist. S14 CNA understood to never attempt to move or transfer a resident alone if the resident was a two person assist.During an interview on 08/13/2025 at 8:32 a.m. S7 CNA reported she attended the in-service on Bed Mobility and turning schedule. S7 CNA further reported the meeting included how important it was to use two person assist if the wall care plan indicated two person assist. If there was not another CNA to help, she would call the nurse or a supervisor to help and never attempt two person assist care alone. During an interview on 08/13/2025 at 8:33 a.m. S8 CNA reported he attended the in-service regarding wall care plans and the importance of following the wall care plans. S8 CNA further reported he checked the wall care plans upon entering a room and checked if the resident was a one or two person assist. If the resident was a two person assist, S8 CNA reported he would ask for assistance and never attempt to move or change a resident without another person to assist. During an interview on 08/13/2025 at 8:39 a.m. S9 LPN reported she attended the in-service on bed mobility and wall care plans which included to check residents wall care plans located above the resident's bed. S9 LPN reported she would assist CNAs when needed for residents requiring two person assist patient care. During an interview on 08/13/2025 at 8:59 a.m. S2 DON reported S4 CNA was suspended right after the incident. S4 CNA stayed for the in-service on wall care plans and left after that. S2 DON reported S4 CNA did not care for any residents after the incident with Resident #1. S2 DON further reported S4 CNA was called to the facility the next day to sign papers on termination for not following the company policy.

Based on record review and interview, the facility failed to follow a resident's plan of care for 1 (#1) of 3 (#1, #2, #3) sampled residents. Findings:Review of Resident #1's medical record revealed an initial admission date of 03/27/2024 with diagnoses, which included in part, ataxia following other non-traumatic intracranial hemorrhage, essential tremor, muscle wasting and atrophy of left lower leg and right lower leg, weakness, contracture of muscle, multiple sites and aphasia. Review of Resident #1's Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated BIMS (Brief Interview of Mental Status) could not be completed due to resident was rarely/never understood. Further review of the Quarterly MDS assessment revealed Resident #1 had upper and lower extremity impairments to both sides, dependent with eating, oral hygiene, toileting hygiene, and shower/bathe self. Resident #1 was dependent for mobility in rolling left and right. Resident #1 was always incontinent of bowel and bladder and dependent on staff for ADL (Activities of Daily Living) care. Review of Resident #1's comprehensive care plan revealed in part, Resident #1 was at high risk for fall related to neurocognitive disorder and required total care with bedbound status. Further review of the comprehensive care plan revealed Resident #1 had an ADL deficit and required two person assist with all ADLs and transfers.Review of S4 CNAs (Certified Nursing Assistant) signed witness statement (undated) revealed: I went to Resident #1's room to check and see was he wet. He was soaked in pee and bowel movement. I looked on the hall to see if there were available aides. I didn't see any so I decided to change Resident #1. His bed was soaked with urine so I had to change, I grabbed my linen to put on his bed. I turned him and put the linen on the bed. I grabbed my pamper and pad. Resident #1 moved a little and hit the floor. I didn't have any time to catch him.Review of Resident #1's nurse's notes dated 07/25/2025 at 11:44 a.m. revealed S3 LPN (Licensed Practical Nurse) was called to Resident #1's room. Upon entering the room, Resident #1 was lying flat and face first on the floor to the right side of the bed between the air unit and bed. S3 LPN was informed by S4 CNA that while she was performing incontinent care and went to turn Resident #1, Resident #1 rolled off the bed to the floor. During an interview on 08/13/2025 at 1:20 p.m. S5 CNA Supervisor reported S4 CNA had experience working with Resident #1 and knew Resident #1 was a two person assist with all ADL care and should have asked for assistance before providing ADL care to Resident #1. During an interview on 08/12/2025 at 11:18 a.m. S2 DON (Director of Nursing) confirmed there was a sign above Resident #1's bed notifying staff Resident #1 was a two person assist with all ADLs. S2 DON confirmed S4 CNA did not follow the wall care plan on 07/25/2025 and use one person assist and should have used two person assist during ADL care for Resident #1.

Based on record reviews, interviews, and video footage the facility failed to protect the resident's right to be free from verbal abuse by a staff member for one (Resident #1) of three (#1, #2, #3) sampled residents. Findings: Review of Resident #1's record revealed an admitted [DATE] with diagnoses including in part. ESRD (End Stage Renal Disease), history of falling, fluid overload, anemia in chronic kidney disease, anxiety disorder, lack of coordination, cirrhosis of the liver, COPD (Chronic Obstructive Pulmonary Disease), viral hepatitis C without hepatic coma, muscle wasting and atrophy . Review of Resident #1's MDS (Minimum Data Set) dated 10/16/2024 revealed a BIMS (Brief Interview of Mental Status) of 15 which wound indicate the resident was cognitively intact. Review of the facility's Employee Statement dated 10/28/2024 revealed S2 DON (Director of Nursing) interviewed Resident #1. Resident #1 reported S3 CNA (Certified Nursing Assistant) came into her room complaining about having to provide incontinent care. During an interview on 11/04/2024 at 1:32 p.m. Resident #1 stated S3 CNA came into her room one day and said, I guess I have to change your sh---y a-- diaper again. During a telephone interview on 10/29/2024 at 4:30 p.m. Resident #1's RP (Responsible Party) reported the staff were unprofessional. On 10/24/2024 Resident #1 fell in her room, called the RP and the RP heard S3 CNA say, Shut the f--k up, you haven't been on the floor that long. Stop lying on me. Review of the facility's video footage with audio on 10/24/2024 revealed the following: At 4:30 a.m. S6 LPN (licensed practical nurse) was in the hallway with med-cart when Resident #1 screamed out. S6 LPN looked inside the door and told S4 CNA and S5 CNA Resident #1 was on the floor and they both went to the room. At 4:34 a.m. S3 CNA entered Resident #1's room. At 4:35 a.m. S3 CNA, S4 CNA, and S5 CNA left Resident #1's room and they walked towards the camera. Audio revealed S3 CNA talking loudly in the hall. Some curse words were said by S3 CNA. S3 CNA went back to Resident #1's room at 5:19 a.m. and came out of room at 5:21 a.m. Then S3 CNA entered Resident #1's room again at 5:36 a.m. and exited at 5:39 a.m. S3 CNA had supplies in hand, which appeared to be diaper and pads. During a telephone interview on 10/30/2024 at 2:00 p.m. S3 CNA reported on 10/24/2024 Resident #1 was on the phone telling her daughter she was on the floor. S3 CNA told Resident #1 to tell the truth, don't be lying on her. S3 CNA reported Resident #1 was telling her daughter she was on the floor when she was in her wheelchair. During an interview on 10/30/2024 at 3:15 p.m. S2 DON reported Resident #1's RP called S2 DON on 10/24/2024 to report S3 CNA cursed at Resident #1. S2 DON interviewed S3 CNA and S3 CNA did say that she said to Resident #1, Why are you lying, you were not on the floor long? S2 DON reported the language used by S3 CNA violated company policy and they terminated her.

Based on record review, interview, and facility camera footage, the provider failed to ensure services were provided to meet professional standards of quality by failing to complete a full head to toe assessment with vital signs after a resident fall prior to being moved from the floor to a wheelchair for one (Resident #1) of three (#1, #2, #3) residents reviewed for falls. Findings: Review of the facility's policy for falls (Nursing G-10 p. 1), Policy: To provide emergency care. Procedure: 1. Resident will not be moved until a Licensed Nurse has ascertained resident's condition. 2. Assess resident for any abnormalities: i.e., a. Deformed, discolored or painful body parts. b. Open wounds, hemorrhaging. c. Vitals (Vital Signs). d. State of consciousness . Review of Resident #1's record revealed an admitted [DATE] with diagnoses including, in part, ESRD (End Stage Renal Disease), history of falling, fluid overload, anemia in chronic kidney disease, anxiety disorder, lack of coordination, cirrhosis of the liver, COPD (Chronic Obstructive Pulmonary Disease), viral hepatitis C without hepatic coma, muscle wasting and atrophy . Review of Resident #1's MDS (Minimum Data Set) dated 10/16/2024 revealed a BIMS (Brief Interview of Mental Status) of 15 which wound indicate the resident was cognitively intact. Resident #1 required one person assistance for bed mobility, transfers, and toileting. Review of Resident #1's progress notes revealed the following, in part: Incident note dated 10/24/2024 at 3:32 a.m. by S1 LPN (Licensed Practical Nurse) entered note time 7:10 a.m.: CNA called downed the hall and stated resident was on the floor when entering resident was laying on left side on the side of the bed with wheelchair beside resident. Wheelchair noted not locked. Resident was assessed and resident was crying out complaining of left hip pain. ROM (Range of Motion) done resident was able stand and transfer to wheelchair. 10/24/2024 at 12:12 p.m.: Stat x-ray of the left hip. 10/24/2024 at 2:40 p.m.: Received ___ IMAGING results related fall and complains of left hip pain. Findings: No acute fracture or dislocation is identified. Mild joint space reduction of the hip noted. Bony mineralization and the visualized portion of the pelvis are unremarkable. Impressions: No acute findings. Degenerative changes, mild joint space reduction of the hip noted. Notified resident of results. 10/24/2024 at 5:33 p.m.: While CNA's were changing resident writer was notified to resident's room to assess resident's right leg. Writer noted right hip swollen and resident c/o pain. Writer notified NP (Nurse Practitioner), ordered stat x-ray for right hip. --- IMAGING notified. S2 DON (Director of Nursing), and Daughter notified. Pain medication given. Blood pressure 134/64, pulse 81, respirations 18, temperature 99.0 Fahrenheit. 10/24/2024 at 9:27 p.m.: Resident refused ___ IMAGING and stated she wants to go to the hospital. Writer notified NP, NP gave order to send out for evaluation. Resident's daughter and S2 DON, notified, _____ Transportation notified for transport. Resident was transported to hospital at 7:25pm. 10/28/2024 at 4:40 p.m.: Resident returned to facility at 2:30 p.m. via ____ Transportation from hospital, Diagnosis, displaced right peri-trochanteric femur fracture. Resident is in stable condition, in bed resting quietly requesting inflated mattress from hospital be taken off, stated it's uncomfortable. Writer notified CNA's to remove inflated mattress. Review of resident #1's comprehensive care plans included the following, in part: At high risk for falls related to lack of coordination; 02/02/2023 resident lost footing wearing slides while ambulating with walker, no injuries noted, educated on proper shoes to wear. 06/16/2023 resident wheelchair bound, non-ambulatory related to overall decline in physical function since Diagnosis of ESRD. She has increased weakness, debility, and decreased ROM. Anti-anxiety med use 05/16/2024 ambulating with four wheel walker with limited assistance. Non-compliant with asking for assistance 10/02/2024. Supervision with four wheel walker ambulation. 10/24/2024 actual fall when forgot to lock wheelchair brakes- PT/OT in place and notified, stat left hip x-ray ordered, education to lock brakes during transfers. Sent out to hospital for complaint of right hip pain. Daughter called and reported resident has fractured right hip. Interventions included ensure proper footwear, falling star program, keep assistive devices in reach, make sure pathways are clear, resident uses wheelchair for mobility, and needs staff propelling most distances . Review of Resident #1's hospital discharge record revealed the following in part: Discharge 10/28/2024 Patient is a [AGE] year old female .who experienced a ground level fall onto her hip, experienced pain, inability to bear weight, loss of ROM prompting her to seek medical care . Hospital course- Patient with multiple medical problems, nursing home resident. admitted with fall and right femur fracture. She underwent ORIF (Open Reduction and Internal Fixation) . Discharge Diagnosis- Femoral fracture, diabetes, alcoholic cirrhosis, coronary artery disease, hypertension, chronic kidney disease, and Anemia. During an interview on 10/30/2024 at 12:21 p.m., Resident #1 reported she had a fall when she was trying to get into her wheelchair and wound up with a right hip fracture. Two CNAs (S4 CNA and S5 CNA) came in and helped her up to wheelchair after the fall. Review of the facility's video footage with audio on 10/24/2024 revealed the following: At 4:30 a.m. S6 LPN (licensed practical nurse) was in the hallway with med-cart when Resident #1 screamed out. S6 LPN looked inside the door and told S4 CNA and S5 CNA Resident #1 was on the floor and they both went to the room. S6 LPN entered Resident #1's room [ROOM NUMBER]:34:24 a.m. and exited from the room at 4:34:50 a.m. (26 seconds). During an interview on 11/06/2024 at 6:20 a.m. S6 LPN reported on 10/24/2024 at 4:30 a.m. she heard Resident #1 holler and then went to door and saw Resident #1 on the floor. S6 LPN indicated she called out for the CNAs (S4 CNA and S5 CNA) to come to Resident #1's room. S6 LPN verified that she did not complete an assessment for Resident #1 before they moved Resident #1. S6 LPN verified she held the wheelchair in place while S4 CNA and S5 CNA got Resident #1 into the wheelchair. During an interview on 11/06/2024 at 6:35 a.m. S1 LPN reported on 10/24/2024 S6 LPN told S1 LPN that Resident #1 had fallen on the floor. S1 LPN verified when she got in Resident #1's room the resident was sitting in her wheelchair. S1 LPN verified S4 CNA and S5 CNA had gotten Resident #1 off the floor and placed her in a wheelchair. S1 LPN indicated she completed an assessment while Resident #1 was in the wheelchair and Resident #1 complained of left hip pain. S1 LPN verified Resident #1 should have had a full assessment prior to being moved. During an interview on 11/06/2024 at 7:00 a.m. S4 CNA reported she got to the room and Resident #1 was on the floor. S4 CNA indicated her and S5 CNA got Resident #1 off the floor and into her wheelchair while S6 LPN held the wheelchair in place. S4 CNA verified when any resident has a fall they call for the nurse to come and assess the resident, then after assessment is completed they will move the resident off of the floor if the nurse says it is ok to move. If a resident has an injury, a staff member is to remain in room with the resident until EMS (Emergency Medical System) arrives. During an interview on 11/06/2024 at 7:45 a.m. S5 CNA reported S6 LPN called out for help when Resident #1 fell to the floor. S5 CNA then indicated her and S4 CNA got Resident #1 off of the floor and into wheelchair while S6 LPN was holding wheelchair steady. S5 CNA verified that a nurse was supposed to do an assessment before moving a resident off the floor. During an interview on 11/06/2024 at 8:30 a.m. S2 DON verified a full head to toe assessment was to be completed for any resident that had a fall before being moved from the floor. S2 DON further indicated Resident #1 should have had a full assessment before being moved from the floor.

Based on record reviews, observations and interviews the facility failed to provide necessary care and services in accordance to the professional standards of practice and the resident's plan of care for 2 (#39, #90) of 2 (#39, #90) residents reviewed for respiratory care. Findings: Review of the facility's current Oxygen Administration (Concentrator or Tank) Policy revealed in part: Policy: Humidifier bottles, cannulas and O2 tubing will be changed at least once weekly and dated. Resident #39 Observation on 10/23/2023 at 9:00 a.m. revealed resident #39 sitting on bedside with O2 (Oxygen) in use via nasal cannula (NC) at 2.5L (liters)/minute (M) by oxygen concentrator and an attached humidification bottle dated 10/13/2023. Review of resident #39's medical record revealed an admitted [DATE] with diagnoses that include in part chronic pain, hypertension, dependence on supplemental oxygen, atrial fibrillation (a-fib), and chronic ischemic heart disease. Review of resident #39's Physician orders revealed in part: 03/23/2023 Change O2 tubing/humidifier bottle and clean filter every week on Thursday. 03/07/2021 O2 at 2L/M per NC PRN (as needed) during the day for SOB (short of breath). If ineffective after five minutes notify MD (medical doctor). 03/16/2021 O2 at 2L per NC every HS (bedtime) for obstructive sleep apnea Resident #90 An observation on 10/23/2023 at 8:10 a.m. revealed resident #90 with O2 in use via nasal cannula at 2L/M per concentrator and an attached humidification bottle dated 10/13/2023. Review of resident #90's medical record revealed an admitted [DATE] with diagnoses that include in part Paroxysmal atrial fibrillation, chronic pain, chronic pulmonary embolism, dependence on supplemental oxygen, and angina pectoris. Review of resident #90's Physician orders revealed in part: 10/13/2023 O2 at 2L per NC continuously for a-fib. 10/12/2023 Change O2 tubing/humidifier bottle and clean filter every week on Fridays. During an interview on 10/23/2023 at 11:00 a.m. S4 RN (Registered Nurse)/Charge Nurse confirmed resident #39's and 90's oxygen humidification bottle were dated 10/13/2023. S4 RN/Charge Nurse further reported according to policy, the humidification bottles should have been changed by the night nurse on Thursday and had not been. During an interview on 10/23/2023 at 11:45 a.m. S3 DON reported according to facility policy, the oxygen humidification bottles for residents using oxygen should be changed and dated by the nurse on Thursday nights and as needed.

Based on record review and interview, the facility failed to develop a baseline care plan to include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care by not developing a care plan within 48 hours of admission for 1 (#201) of 1 (#201) resident baseline care plan reviewed for dialysis and nutrition. Findings: Review of resident #201's record revealed an admitted [DATE] with diagnoses in part: chronic pain, ascites, surgical wound care, and hypertensive chronic kidney disease stage 5 requiring dialysis. Review of resident #201's physician orders revealed in part orders dated: 10/21/2023 Dialysis on Tuesday, Thursday, Saturday at . 10/17/2023 Nepro, give one (1) by mouth every bedtime. Document percentage of intake. 10/17/2023 Diet: Mechanical soft, Renal limit tomatoes, potatoes, oranges and bananas to no more than 3 times weekly. Review of resident #201's record failed to reveal a baseline care plan that included the care and treatment associated with dialysis and the resident's special diet and nutritional needs. During an interview on 10/25/2023 at 10:20 a.m. S1 Minimum Data Set Nurse confirmed resident #201 failed to have a baseline care plan developed for dialysis and nutritional needs and should have.

Based on observation, record review and interview the facility failed to ensure a resident's person centered plan of care was reviewed and revised to include approaches and interventions to address the resident's need for O2 (Oxygen) for 1 (#90) of 23 sampled resident's care plans reviewed. Findings: An observation on 10/23/2023 at 8:10 a.m. revealed resident #90 with O2 in use via NC (Nasal Cannula) at 2L (liters)/ M (minute) per concentrator. Review of resident #90's medical record revealed an admitted [DATE] with diagnoses in part Paroxysmal atrial fibrillation (a-fib), chronic pain, chronic pulmonary embolism, dependence on supplemental oxygen, and angina pectoris. Review of Physician orders revealed in part: 10/13/2023 O2 at 2L per NC continuously for a-fib. 10/12/2023 Change O2 tubing/humidifier bottle and clean filter every week on Fridays. Review of resident #90's comprehensive care plan failed to reveal resident #90 was care planned for use and care of Oxygen. During an interview on 10/24/2023 at 11:30 a.m. S2 Corporate Nurse reviewed resident #90's physician orders and care plan and confirmed resident #90 had not been care planned for the use of oxygen and should have been.

Based on interviews, record reviews, and observations the facility failed to provide adequate supervision for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for risk of elopement. The deficient practice resulted in Immediate Jeopardy for Resident #1 on 07/31/2023 at 8:00 p.m. when Resident #1 exited through the dining room door of the facility. On 7/31/2023 the facility was notified by a concerned community citizen that Resident #1 was found outside approximately 300 feet from facility near a railroad track 12 minutes after Resident #1 exited the facility. On 07-31-2023 at 8:21 p.m., Resident #1 returned to the facility assisted by S3 [NAME] Clerk and S4 LPN (licensed practical nurse). Facility staff immediately notified S2 DON (Director of Nursing), Resident #1's doctor, and S1 Administrator of incident. Resident #1 was assessed and had no injuries when found by S4 LPN. The Immediate Jeopardy continued for 12 other residents who were at risk for wandering until 08/10/2023 when the dining room door hinge was repaired to ensure the door closed completely. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Finding: Review of the facility's Wandering or Missing Resident Policy dated 05/2023 revealed in part, a department or resident care staff which identified a wandering resident is missing must notify all staff of the missing resident by announcing on the public address system, Code W and residents name. Any staff member becoming aware of a resident not being at a designated area or activity shall proceed to notify the charge nurse, director of nursing and the administrator. Review of resident #1's medical record revealed an admitted [DATE] with a diagnosis of but not limited to Depressive Episodes, Dementia, History of Falling, Cognitive Communication Deficit. Review of the resident #1's Yearly MDS (Minimum Data Set) dated 07/21/2023 revealed in part, resident #1 had a BIMS (Brief Mental Status Interview) score of 3 indicating severe impairment and wandering behavior occurred 7 days of the 7 day look back period, and resident #1 received anti-depressant medication for 7 days of the 7 day look back period. Review of resident #1's August 2023 Physician's Orders revealed in part: 08/17/2021-Visual Checks for resident location every 1 hours 08/17/2021-Wander alert bracelet on resident for elopement precautions at all times, bracelet located on residents right leg 08/17/2023- Check Wander alert bracelet daily to ensure band is intact and transmitter is functioning properly. Review of Resident #1's current Comprehensive Care Plan revealed Resident #1 was care planned for wandering and use of wander alert bracelet with interventions including visual check for resident location every hour, wander alert bracelet on resident for elopement precautions and check wander alert bracelet daily to ensure band is intact and transmitter is functioning properly. Review of Resident #1's elopement risk assessment with start and end date of 08/17/2021 revealed Resident #1 was found to be at risk for elopement. Review of resident #1's progress notes revealed in part: 07/31/2023 at 11:24 p.m. by S4 LPN. Writer was notified by [NAME] Clerk that a lady noticed a person walking down ___ Rd and asked if we were missing a resident, she described the resident that fit her description. Writer and [NAME] Clerk left the facility and found resident standing a couple of feet past the rail road tracks. Lady that notified us about resident came and offered to transport resident back to facility. [NAME] clerk accompanied resident back to the facility. Head to toe assessment done, administrator notified, director of nursing and nurse practitioner notified. During an observation on 08/16/2023 at 3:45 p.m. of the facility's surveillance video from 07/31/2023, revealed Resident #1 walking out of the facility's dining room door alone on at approximately 8:00 p.m. Further review of facility surveillance video revealed at 8:12 p.m. a concerned community citizen walked into the facility's front door and alerted staff of a resident out of the facility and staff ran out of the facility. At 8:21 p.m. resident #1 was seen being assisted back into the facility by staff. During an interview on 8/14/2023 at 2:15 p.m. S3 [NAME] Clerk reported on 07/31/2023 at approximately 8:00 p.m. the dining room door alarm went off and she overhead paged for a staff member to go and check the dining room door alarm. S3 [NAME] Clerk further reported S5 Front Door Screener checked the dining door and reset the alarm. A few minutes later a visitor came in the front door and described a resident who was outside of the facility walking on the street. I (S3 [NAME] Clerk) recognized the resident by the visitor's description. S4 LPN and I (S3 [NAME] Clerk) left the facility and located the resident down the street near the railroad track in some bushes unharmed and assisted the resident back inside of the facility. During an interview on 08/15/2023 at 1:35 p.m. S5 Front Door Screener stated, I was sitting at the front door when the ward clerk said to check the dining room door alarm. I went to the dining room door and looked out the door and did not see any resident. I closed the door and reset the alarm on the door and went back to my station at the front door. A few minutes later a visitor came into the facility and described a resident who was outside of the facility walking down the street. We immediately went to search for the resident. During an interview on 08/14/2023 at 2:30 p.m. S4 LPN reported, a lady had come to the facility and reported seeing a possible resident on the street out by the railroad tracks. We (S4 LPN and S3 [NAME] Clerk) went out and located the resident on the road near the railroad track and assisted the resident back inside of the facility. S3 [NAME] Clerk notified the administrator, and I (S4 LPN) notified the director of nurses. During an interview on 08/15/2023 at 8:30 a.m. S2 DON reported resident #1 had been assessed to be a wanderer and was at risk for elopement and wandered in the facility daily. S2 DON confirmed resident #1 had eloped from the facility through the facility's dining room door on 07/31/2023 at approximately 8:00 p.m. S2 DON confirmed the facility's dining room door did not close completely after a staff member had entered and required repairing for safety and supervision of residents. During an interview on 08/15/2023 at 2:00 p.m. interview with S5 Maintenance Supervisor and S1 Administrator reported upon examining the dining room exit door after resident #1's elopement, it was noted that the door did not close completely and remained about one-half inch open after being closed. S1 Administrator and S5 Maintenance Supervisor confirmed the dining room door had to be repaired to ensure resident safety and supervision. On 07/31/2023, the facility implemented the following actions to correct the deficient practice with completion on 08/10/2023: 1. Resident #1 was placed on close supervision and visual check every 1 hour. 2. Daily census checks on each resident. 3. All residents assessed for elopement risk and wandering risk. 4. Staff in-services regarding: monitoring door alarms to include checking outside and inside to find out who activated the alarm, door alarm audit sheet, wandering and missing resident policy and procedures and wander alert bracelet check and documentation. Emphasis on answering door alarms and assuring all wandering resident with and wander alert bracelet are accounted for. 5 All facility door codes were changed and staff were instructed only to enter and exit the facility through the front door. 6. 8/10/2023 the dining room door was repaired to ensure complete closure for safety. 7. A mock drill was completed by administrative staff in which door alarms were triggered and staff were observed following the facility protocol. 8. Monitoring of each door alarm is tracked daily by the ward clerk or nurse at the nurse's station. 9. This plan is monitored in the facility's daily Quality Assurance meetings with indefinite monitoring, changes will be made to current monitoring if issues arise.

Based on observation, record review and interview, the facility failed to provide adequate supervision and implement measures to prevent accidents/incidents for 4 of 5 sampled residents by failing to: 1. assess and implement measures to prevent further incidents when 2 residents exhibited an increase in aggressive behaviors toward each other (#1, #3) 2. ensure staff reported altercations between residents (#1, #3) Resident #3 suffered actual harm when resident #1 hit him with a trash can causing resident #3 to fall. Resident #3 sustained a deep laceration above his lip and a left hip fracture. 3. implement measure to prevent falls (#2, 5) The facility's census was 106 according to the Resident Census and Conditions Report. The report also indicated the facility had 34 residents with behavior symptoms. Findings 1. Residents #3 and #1 Review of resident #3's record revealed he was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of resident #3's most recent MDS assessment dated [DATE] revealed his cognitive skills for daily decision-making was assessed as "2" (moderately impaired) and he had a problem with his short and long term memory. He had persistent anger with self or others (up to five days a week). He exhibited wandering and socially inappropriate/disruptive behavior "3/1" (daily and was not easily altered). He was ambulatory at the time of the assessment. Review of resident #1's record revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of his most recent MDS dated [DATE] revealed his cognitive skills for daily decision-making was "2" (moderately impaired) and he had problem with his short term memory. He had persistent anger with self or others (up to five days a week). Review of #3's record revealed he was residing in another room at the facility until 7/26/10 when he was moved due to not getting along with his roommate. Resident #3 was moved to resident #1's room which is shared by four residents (#1, #2, #3 and #5). Review of resident #3's nurse's note dated 8/28/10 revealed the resident was found sitting on the floor in a puddle of blood. A deep laceration was noted above his lip. When the resident was asked what happened, he stated, "my roommate hit me with the trash can". Resident #3 was sent to a local emergency room , treated and returned to the facility. Review of the Report of Consultation from the local emergency room dated 8/28/10 revealed #3 had a [DIAGNOSES REDACTED]. Review of the nurse's notes dated 8/28/10 at 6:30 p.m. revealed report was received and the nurse wrote that resident #3 received 6 stitches to his face would not be having surgery due to being a poor candidate for surgery. Record review for resident #1 revealed a nurse's note dated 8/28/10 at 8:15 a.m. in which the nurse documented the following: the resident hit his roommate in the face with a trash can. The nurse wrote that the resident stated 'I was trying to knock his brains out'. Resident very agitated. The physician came to the facility and examined the resident. At 1:30 p.m., the resident was sent to a behavioral hospital. Further review of resident #1's record revealed 2 previous incidents which involved his roommates. On 7/3/10 at 2:50 p.m. the nurse documented she was called to resident #1's room. She wrote that the resident was cussing and the housekeeping supervisor #S9 said resident #1 threw a drawer over at another resident (#2), hitting him on his left side. The nurse documented the other resident did not have any injuries from the incident. She wrote that resident #1 stated he did not want anyone messing with his stuff. He stated someone was going through his drawers and it upset him and he wanted his lawyer. The nurse documented the physician was notified of the incident and he ordered an injection of Ativan 2 mg IM to be given. On 7/31/10 at 9:00 p.m., the nurse documented resident #1 got upset because another resident's (#5) wheelchair was parked by his his wheelchair, assuming that resident wouldn't pull his wheelchair out and he got belligerent with the other wheelchair and kind of pushed it out of the way in a heavy manner. Review of a statement written (attached to the 7/30/10 incident report) by the housekeeping supervisor #S9 dated 7/30/10 revealed the following: I .... (#S9) was in the ward where Mr. (NAME REDACTED) ..... (resident #1) resides. I was in the room looking for linen. I picked up washcloths off bedside table and Mr. (NAME REDACTED) .... (resident #2's) bed, when I turned around, Mr. (NAME REDACTED) ..... (#1) was cursing and throwing things. He took the top drawer from the bedside table and threw it as hard as he could. The drawer landed on Mr. (NAME REDACTED) .... (#2)'s stomach area. I went over and checked on Mr. (NAME REDACTED) .... (#2) and removed the drawer, called for the nurse and help to the room, Mr. (NAME REDACTED) ....(#1) was still cursing calling us names and throwing things. He was kicking and pushing the bedside table out the door of his room. He went out in the hall pushing things cursing and trying to hit people. Ms. (NAME REDACTED) ..... (#S11), Ms. (NAME REDACTED) ..... (#S15) and nurse (#S4) were also in the room, we backed up and stayed away from him. Ms. (NAME REDACTED) ....(#S4) was doing paperwork on him, #S11 and #S15 were cleaning the room. During an interview on 9/9/10 at 1:00 p.m., LPN #S3 stated on 8/28/10 she was paged to resident #1's room. She said resident #1 told her that he hit resident #3 with a trash can because he was always messing in his things. LPN #S3 further stated she was told that the evening before, resident #3 raised a fist at resident #1 because resident #3 was digging through resident #1's closet. She said she did not find this out until after the 8/28/10 incident. During an interview on 9/9/10 at 1:10 p.m. CNA #S10 stated "it doesn't take much for him (#1) to go off, any little thing can agitate him". He stated he had never seen resident #1 hit anyone before. He said he did not witness the incident, but he said resident #1 told him he felt threatened by resident #3 and the only thing he could find was a trash can. He stated he reported this to his supervisor #S8. On 9/9/10 at 1:15 p.m., the 7-3 shift CNA supervisor #S8 stated resident #1 gets a little agitated at times when someone gets in his way. He said the only time resident #1 hit anyone was when he hit resident #3 with the trash can. He stated he asked resident #1 about the incident. He stated the resident told him 'I was trying to tell him to get out of the doorway'. He said he was told that resident #3 was standing over resident #1 and that he threw the trash can because he thought the resident #3 was going to hit him. The CNA supervisor stated he talked to one of the nurses about it on the same day. He further stated resident #3 has not hit anyone, but he gets agitated and he also has a hearing impairment in one ear and he probably did not hear resident #1. During an interview on 9/9/10 at 1:25 p.m., the housekeeping supervisor #S9 stated one afternoon she asked the 3-11 shift CNA supervisor #S11 to go with her into resident #1's room. She stated resident #1 "will cuss at you out at the drop of a hat". She said when she went in the room, he started cussing and fussing and started kicking the bedside table, then yanked the drawer out and threw it. She said it landed on resident #2's stomach. She said resident #2 was laying in the bed. She said resident #1 tried to push the bedside table out the door. She was asked if resident #1 intentionally threw the drawer at resident #2. She stated "Sincerely, I don't think he was trying to hit ..... (#2). He's got one of those short fuses, he's got a temper. He comes down the hall fussing and cussing and he'll kick the yellow barrels". She said she had never seen him hit anyone, but he has threatened it. During an interview on 9/9/10 at 2:25 p.m. with CNA supervisor #S11, she stated on 8/27/10 on the 3-11 shift resident #1 picked up a wet floor sign and attempted to hit resident #3. She stated that she caught him and said "Oh no, don't you hit him" and he put the sign down. She further stated the incident had been reported to LPN #S7. On 9/9/10 at 3:00 p.m., CNA #S12 stated resident #1 "gets mad and gets an attitude". He stated residents #1 and #3 "have got into it before". He stated the two residents got into an argument couple of days before the incident with the trash can. He said resident #3 kept accusing resident #1 of going through his belongings and resident #1 told him he was not messing with his stuff. He stated "they were in each others face. I broke them up and I think I told ... ... (LPN #S4)". He further stated, "the next time ..... (LPN #S7) was here, resident #1 was going down the hall and resident #3 went up to him and was putting his finger in #1's face. Resident #1 got upset and picked up the wet floor sign and started to hit him". He said the incident was reported to LPN #S7. During an interview on 9/9/10 at 3:20 p.m. with resident #3 he was asked about the incident that occurred with resident #1 on 8/28/10. He stated he entered the doorway to his room and was standing there. Resident #3 stated that resident #1 picked up a trash can and hit him. He further stated "I didn't think we had a problem, I don't know why he hit me." An interview was conducted on 9/9/10 at 3:30 p.m. with the DON #S2 and Administrator #S1. The DON stated she was aware of the incident which resident #1 hit resident #3 with the trash can. When asked if they were aware of any other incidents between the two residents, both stated "no". The Administrator stated when there is an incident, an incident/accident report is filled out. When they were told about the other 2 incidents involving residents #1 and #3, the DON stated she remembered another incident in which resident #1 picked up a wet floor sign and threw it, but he didn't try to hit anyone, he just does not want anyone in his way. Neither the Administrator nor the DON was aware of the incident that occurred on 8/27/10 or the other incident described by CNA #S12 that occurred "couple of days" before the 8/28/10 incident. During an interview on 9/9/10 at 4:15 p.m., the MDS nurse LPN #S14 was asked if behavior incidents were reported to him. He stated the incidents were not reported to him unless the incident occurs during the assessment period, "they should tell me when a behavior occurs, they don't". He stated he was not aware of the incident in which resident #1 almost hit resident #3 with a wet floor sign. He said that during the care plan meetings, he asks the other staff if any one has had a significant change. On 9/10/10 at 11:50 a.m.., the SSD #S6 stated she conducted the investigation that involved resident #1 hitting resident #3 with the trash can. She stated she was not aware of the incident the night before. She said it never came up during her investigation. She stated she did not try to find out if there had been previous incidents. 2. Resident #2 Review of the incident/accident report book revealed resident #2 had the following falls: 5/20/10 at 10:00 a.m. - resident #2 was found on the floor between the bed and window attempting to get up. 6/27/10 at 12:45 p.m. - resident #2 was sitting on roller walker and slid to the floor. 6/28/10 at 10:50 a.m. - resident #2 was on floor. His roommate reported that the resident lost his balance, fell on floor and hit his head. A dime-sized bump was noted on the back of the resident's head. 7/5/10 at 11:15 a.m. - resident #2 fell on floor trying to go to the bathroom. 7/18/10 at 9:20 a.m. - resident #2 fell on floor, trying to go to bathroom. 7/27/10 at 10:00 a.m. - resident #2 was found laying supine on the floor. The resident reported that he was just laying on the floor, he did not fall and that he likes laying on the floor. 7/28/10 at 10:45 a.m. - resident #2 on floor naked sitting on buttocks. The resident reported he slipped and fell . 8/3/10 at 9:45 a.m. - resident #2 was found sitting on the floor next to the wheelchair. 8/28/10 at 4:45 p.m - resident #2 attempted to get out of wheelchair, the wheelchair was not locked and the resident slid out of the wheelchair to the floor. 9/6/10 at 12:05 p.m. - resident #2 was found on the floor near the bathroom. The resident reported he was trying to get out of the wheelchair to pee and landed on his knees. Review of a nurse's note dated 9/8/10 at 1:30 p.m. revealed the resident was in his wheelchair near the snack machine and he slid out of the wheelchair onto the floor. Review of resident's fall risk assessment dated [DATE] revealed a score of 13 (high risk). Review of the resident's current care plan dated July 2010 revealed a problem of potential for falls related to unsteady gait. The resident's falls were hand-written on the care plan, but the care plan failed to address new interventions to prevent further falls. Further review of the record revealed resident was referred to PT due to the falls on 7/5/10, 7/18/10 and 7/28/10. The resident started therapy on 8/7/10 and completed his treatment on 8/23/10 (total of 6 visits). Review of the PT note dated 8/23/10 revealed the resident's gait pattern continues to be slow and unsteady and patient remains at a high risk for falls without supervision. The note indicated the CNAs were instructed to ambulate the resident 2-3 times per week with the rolling walker instead of rolator, with constant supervision. During an interview on 9/10/10 at 9:00 a.m., CNA #S10 stated he had never ambulated resident #2 with a walker and was not aware of any type of exercise program for the resident. On 9/10/10 at 9:15 a.m., the MDS nurse LPN#S14 was asked about the procedure when a resident falls. He stated every time a resident falls, they are screened by therapy. He said the DON reviews the incident report and lets him know who has fallen and he has therapy screen the resident. During another interview on 9/10/10 at 9:50 a.m, the MDS LPN #S14 was asked what preventive measures had been implemented for each of resident #2's falls. He stated "I know he got therapy". He stated the interventions were supposed to be documented in the care plan, but they were not. When asked what had been done about the falls that occurred on 8/28/10, 9/6/10 and 9/8/10, after therapy was completed, he stated "I haven't done anything". He stated care plan meetings are held every Wednesday and falls are discussed. He said the team discusses what can be done to stop the falls. He stated there was no follow through regarding resident #2's falls. He further stated he was not aware of the recommendation made by PT on 8/23/10 to ambulate the resident with the walker. 3. Resident #5 Review of resident #5's nurse's notes dated 6/21/10 revealed the resident was seated in his wheelchair and fell backwards to the floor hitting his head. The resident was assessed by the nurse and had no injuries. Resident #5 was sent to a local emergency room and returned the same day in stable condition. Review of resident #5's nurse's notes dated 9/8/10 revealed the resident was seated in his wheelchair in the dining room at a table. The resident pushed back against the table, the wheelchair fell backwards to the floor, and resident #3 hit his head on the floor. The resident was assessed by the nurse and had no injuries. Review of resident #5's plan of care revealed tip bars had been placed on #3's wheelchair on 9/8/10. Further review of #3's record revealed no interventions had been put in place to prevent further falls after the fall on 6/21/10. During an interview on 9/10/10 at 10:05 a.m. with the MDS nurse #S14, he stated he did not know why interventions had not been put in place after resident #5 fell backwards in his wheelchair on 6/21/10. He further stated the tip bars had not been placed on the wheelchair until after the fall on 9/8/10. An observation on 9/9/10 at 1:10 p.m. revealed resident #5's wheelchair had tip bars on the back of his wheelchair. Further observation revealed the tip bars did not extend past the wheels to prevent the wheelchair from tipping over. During an interview on 9/9/10 at 4:30 p.m. with the Administrator #S1 and the MDS nurse #S14, after observing #5's wheelchair, both agreed the tip bars did not fit the wheelchair. The MDS nurse #S14 stated that he had applied the tip bars and he agreed they would not prevent the resident's wheelchair from tipping backwards.